Salter-Harris type III fracture-dislocation of the glenoid: a case report

Physeal lesions are common in children and are responsible for 15%-30% of all bony injuries.⁶ The Salter-Harris (SH) classification system (Table I), originally proposed by Salter and Harris in 1963,¹⁰ identifies various patterns of physeal lesions that are seen exclusively in skeletally immature children. The classification system has important implications regarding the treatment and prognosis of such injuries.⁶

Table I.

The SH fracture classification system¹⁰

SH	Description	Prevalence
Type 1	Fracture runs transversely through the physis, separating the epiphysis from the metaphysis.	5%
Type 2	Fractures extend from the transverse plane through the physeal plate proximally, resulting in a triangular segmental fracture of the metaphysis.	75%
Type 3	Intra-articular fractures that extend from the physis into the epiphysis, which may include damage to the articular cartilage. The fracture may also include 2 epiphyseal segments and can extend across the length of the physis.	10%
Type 4	Fracture traverses through the metaphysis, physis, and epiphysis.	10%
Type 5	Fractures are characterized by impaction/disruption of the physis and are often due to a crush or compression injury.	Rare

SH, Salter-Harris.

Long bones contain physeal lines located between the epiphysis and the metaphysis. This region is characterized by 4 zones and includes a layer of resting cells (containing lipids, proteoglycans, and glycogen), proliferating cells (primarily responsible for extracellular matrix production), and hypertrophic cells (containing maturation, degeneration, and provisional-calcification phases).⁷ The final zone is located closest to the metaphysis and is the most common site of physeal fractures, though the nature of the fracture is primarily dependent on the mechanism of injury.⁶

Common presentations of SH fractures include joint swelling, point tenderness over the physis, limited range of motion, sensation of instability, and inability to weight bear on the affected side. Signs of ligamentous laxity may present, which can lead to misdiagnoses targeting joint soft tissue pathologies. Aside from the expected prolonged pain and restricted joint mobility, misdiagnosed or mismanaged SH fractures can have profound implications on the natural development of the involved bone. The fracture site is prone to further injury and risks physeal arrest preventing bone growth. In addition, SH fractures can disrupt blood supply leading to post-traumatic avascular necrosis.^3,13 It is important to note that during a workup, normal ossification patterns in the adolescent shoulder can mimic a fracture in traumatic settings.²

SH type III fractures are intra-articular, extending from the physis to the epiphysis and often minimally displaced, necessitating the use of magnetic resonance imaging (MRI) or computed tomography for accurate diagnosis. While isolated soft-tissue injuries (eg, Perthes; Glenolabral Articular Disruption (GLAD); Anterior Labroligamentous Periosteal Sleeve Avulsion [ALPSA])^1,8,9,15 and similar SH type III proximal humerus fractures have been reported in literature,^4,5,12, 13, 14 the isolated fracture pattern is yet to be reported in the anterior glenoid of an adolescent patient. The following case report outlines the diagnosis, operative management, and clinical follow-up of a 13-year-old boy who suffered a traumatic SH type III fracture dislocation of his anterior glenoid. In doing so, this report aims to provide further insight into the management of previously unrecognized, healed physeal fractures presenting with persistent symptoms following unsuccessful conservative treatment.

Informed consent to the use of clinical details, imaging, clinical photos, and intraoperative videos for research purposes was given by the patient and their parent. Institutional review board approval was provided by Uniting Care Health Human Research Ethics Committee (2024.03.397).

A 13-year-old boy of normal body habitus (body mass index 18.7 kg/m²) presented to the Kenneth Cutbush Shoulder Clinic at Brisbane Private Hospital (Brisbane, Australia) in April 2021. He complained of left shoulder pain, limited range of motion, reduced strength, and recurrent anterior shoulder instability. The shoulder pain was global (8/10 at worst, 0/10 at rest/night) and exacerbated with overhead activity and active motion.

The patient suffered a traumatic first-time shoulder dislocation four years prior to presentation following a motocross accident in which he landed on his left shoulder and the bike collided with him on impact. The left shoulder dislocated anteriorly and reduced spontaneously moments prior to hospital presentation. The patient was treated conservatively with physiotherapy. However, he experienced a second dislocation while pushing a heavy gate open twelve months later. He would dislocate his shoulder on a further 4 occasions when falling off his bike over the next three years.

The patient is an avid Brazilian Ju Jitsu competitor that regularly engages in high-impact boxing and mixed martial arts activities. Five weeks prior to his presentation in clinic, he injured his shoulder at a training camp while tackling an opponent of heavy body habitus. The following week, he dislocated his shoulder while throwing a punch. The patient's past medical history was otherwise unremarkable consisting of turbinate reduction, septoplasty, and severe allergic rhinitis to various allergens. The patient did not take regular medications and reported no known drug allergies.

On examination, the patient was distressed and supported his pathological left arm with his dominant right arm. His active range of motion (AROM) was severely limited relative to his nonpathological side with 70° vs. 180° of abduction, 80° vs. 180° of forward flexion, 30° vs. 70° of external rotation, and internal rotation limited to pocket level vs. T7. Passive range of motion for forward flexion and external rotation were identical compared to the AROM. The patient experienced pain in the posterior shoulder when resisted external rotation at 0° abduction was performed. The belly-press test (forceful internal rotation at 0° abduction) also elicited pain. Speed's test assessing for the presence of bicipital (long head) tendinopathy or a superior labral tear was negative. Jobe's test, which assesses the presence of a supraspinatus lesion, was also negative. The anterior apprehension test was positive. The patient demonstrated moderate ligamentous laxity.

Preoperative visual analog scales assessed pain, while the Oxford Shoulder Score and Quick Disabilities of the Arm, Shoulder, and Hands (DASH) scores were used to assess the patient's functional limitations. The patient scored 16.8 on the Oxford Shoulder Score supporting his inability to engage in activities of daily living. The QuickDASH was only partially completed. However, full responses to the Sports Module of the QuickDASH indicated that the patient was unable to participate in mixed martial arts due to his recalcitrant shoulder pathology.

Imaging

The patient presented to the clinic with numerous MRI investigations since the inception of his injury in 2017. An initial MRI examination following the first dislocation in 2017 revealed a SH type III injury of the anterior-inferior glenoid with anterior displacement of the fractured fragment (Fig. 1). The fracture classification was evidenced by a fracture extending from the physis to the epiphysis with minimal anterior displacement of the fractured fragment. Important soft-tissue differential diagnoses, including isolated common glenoid labrum tears (eg, Perthes, GLAD, ALPSA) were excluded. Six months later, a serial MRI demonstrated healing of the SH fracture with significant bone formation along the anterior aspect of the glenoid (Fig. 2).

Figure 1.

MRI, September 2017. SH type III fracture of the left glenoid following a motocross accident. MRI, magnetic resonance imaging.

Figure 2.

MRI, March 2018. Six months after injury. Healing of the SH type III fracture of the left glenoid with callus formation. MRI, magnetic resonance imaging; SH, Salter-Harris.

Two additional MRIs were conducted in March and April 2021, immediately prior to presentation (Figs. 3 and 4). Radiological studies reported nonspecific bone marrow edema with lesser and greater tubercle and humeral epiphyseal involvement. Bone trauma at this level was suspected; however, the articular surfaces, glenohumeral joint line, and epiphyseal line were reported as within normal limits. The long head of the biceps tendon and the bicipital groove were intact. The subscapularis was reported to be within normal limits, with supraspinatus and infraspinatus enthesial attachments deemed satisfactory. There was no evidence of a rotator cuff tear, and the acromioclavicular joint was normal. The healed fracture pattern resembled a SH type III fracture of the anterior-inferior labrum with evidence of bony remodeling and a deficient anterior labrum.

Figure 3.

MRI without contrast, March 2021. Three and a half years after SH type III fracture of the glenoid and approximately 1 week after a traumatic left-shoulder dislocation in a Brazilian Ju Jitsu competition. Bone remodeling present. MRI, magnetic resonance imaging; SH, Salter-Harris.

Figure 4.

MRI arthrogram, April 2021. Three and a half years after SH type III fracture of the glenoid and approximately five weeks after a traumatic left-shoulder dislocation in a Brazilian Ju Jitsu competition. Axial slice demonstrates a deficient anterior labrum as evidenced by contrast effusion through the anterior-inferior glenohumeral joint. The inferior glenohumeral ligament is appreciable. Coronal slice demonstrates articular incongruity. MRI, magnetic resonance imaging; SH, Salter-Harris.

A computed tomography scan with 3D en-face comparative views between both shoulders demonstrated a more pronounced pear-shaped glenoid in the pathological shoulder consistent with the healed SH fracture pattern from four years prior (Fig. 5). A deficient anterior labrum consistent with his injury was noted. No obvious humeral avulsion of the glenohumeral ligament lesion, Hill-Sachs lesion, or labral tear was noted, and the rotator cuff appeared intact.

Figure 5.

CT without contrast, April 2021. Three and a half years after SH type III fracture of the glenoid and approximately five weeks after a traumatic left-shoulder dislocation in a Brazilian Ju Jitsu competition. (A) Bilateral 3D rendering of scapular anatomy with en-face view demonstrates the articular incongruity in the anterior-inferior left glenoid when compared to the right, nonpathological side. (B) Bilateral 3D rendering of humerus anatomy demonstrating consistency between both sides and confirming no Hill-Sachs lesion. SH, Salter-Harris; CT, computed tomography.

Diagnosis

The clinical findings, comprising of both medical history and examination, were consistent with a diagnosis of gross anterior instability. The imaging reports support this diagnosis, and allude to the presence of a deficient labrum secondary to recurrent dislocation and a remodeled SH type III fracture with articular incongruity.

Management

Surgical management was indicated for this patient given his recurrent shoulder instability, persistent debilitating pain and discomfort, a diagnosis of a previous SH type III fracture affecting the physeal plate and epiphysis of the glenoid, deficient anterior labrum, and the patient's desire to continue pursuing mixed martial arts. The patient was consented for an arthroscopic stabilization with the potential addition of a Remplissage procedure should a significant Hill-Sachs defect be found intraoperatively.

The patient had anterior subluxation of the joint with examination under anesthesia, though no posterior glide/instability was noted. Diagnostic arthroscopy found an anterior labrum deficiency and apparent lax anterior capsule. No obvious Hill-Sachs lesion was found. The rotator cuff and biceps tendons were intact. Mild bursitis within the subacromial space was noted.

Three Fibertack anchors (AR-3636-1; Arthrex, Naples, FL, USA) were inserted in the anteroinferior glenoid, and an anterior capsulolabral plication was performed to tighten the joint capsule (Fig. 6). The rotator interval was released and a bursectomy was performed. The surgical site was irrigated with a betadine lavage, and monocryl sutures (Art. No Y293H; Ethicon, Raritan, NJ, USA) were used to close the surgical site. The patient was discharged the following day and began physiotherapy. He was instructed to immobilize the limb in a sling full-time for six weeks, as evidenced in literature.⁷ He was not allowed to return to mixed martial arts training until a satisfactory result was attained at the 6-month postoperative review.

Figure 6.

Arthroscopic view. Three suture anchors (AR-3636-1; Arthrex, Naples, FL, USA) inserted anteroinferiorly in the G and a capsulolabral plication of the AC. HH is appreciable. G, glenoid; AC, anterior capsule; HH, humeral head.

Clinical follow-up

The patient presented in clinic for follow-up seven weeks postoperatively. He was discernibly happier, claiming his shoulder felt more secure. On examination, he had 90° of forward flexion, 90° of abduction, 0° of external rotation, and internal rotation to the level of the thoracolumbar junction. He had commenced active exercise physiotherapy by this stage, with the aim of conducting light strengthening after three months postoperatively.

At three months postoperatively, the patient presented pleased with his progress. On examination, he had 180° of forward flexion, 180° of abduction, 45° of external rotation, and internal rotation to the level of the thoracolumbar junction. His anterior apprehension test was negative. Given his marked improvement at this stage, the plan for physiotherapy was shifted from a range of motion approach to strengthening (including scapular strengthening exercises).

At six months, the patient had maintained his full forward flexion, abduction, and internal rotation range of motion while achieving an external rotation of 70°. The shoulder was stable, and the apprehension test remained negative. At this stage, he was encouraged to reintroduce light wrestling and shadow boxing.

At twelve months, the patient presented noting his shoulder had become sore more recently following the reintroduction of heavy workload pad hitting in sessions that spanned upward of 3 hours. On examination, his shoulder had full range of motion with good stability. A follow-up MRI reported an intact repair (Fig. 7). The patient was instructed to limit the workload on pad hitting and instead focus on the less contact heavy aspects of his mixed martial arts training in the interim.

Figure 7.

MRI, March 2022. Eleven months poststabilisation surgery. Healed pathology with intact repair is demonstrable. MRI, magnetic resonance imaging.

Patient-reported outcome measures were not measured in the postoperative assessments. The patient did not experience any complications following the surgical intervention, including evidence of periosteal layer entrapment, delayed healing, neurovascular compromise, or construct failure.

Discussion

The SH classification system pertains to fracture patterns involving the physis in children and adolescent populations. SH type III fractures are intra-articular in nature, by virtue of extending from the physis into the epiphysis. Epiphyseal involvement risks damage to the articular cartilage, which in turn can lead to post-traumatic arthritis.⁷ Other typical complications of physeal fractures include growth arrest, deformity, malunion, articular disfunction, and reduced range of motion.^7,11 However, as we have found in the diagnostic workup of this case, underappreciated healed SH type III glenoid fractures may present with recurrent shoulder instability. Effective management of this time-sensitive pathology is therefore warranted to mitigate the risk of complications and sequalae seen in this patient.

The successful management of isolated soft-tissue injuries such as GLAD^1,8 or ALPSA^9,15 has been reported. Similarly, SH type III fractures have been previously reported in shoulder surgery literature^4,5,12, 13, 14; however, these have focused on the fracture pattern in the proximal humerus. The patient in this case report experienced recurrent instability, frank dislocations, pain, and discomfort; all due to an underappreciated SH type III fracture that adversely altered the original glenoid architecture. To the best of the authors' knowledge, the underlying SH type III fracture pattern in the anterior-inferior glenoid responsible for recurrent shoulder instability is yet to be reported in literature.

This case report provides insight into the management of a patient presenting with common shoulder joint symptomatology with an underlying physeal fracture pattern. Surgical intervention was indicated due to progressive joint deterioration, accompanied by worsening symptoms and significant limitations in activities of daily living and sports participation. A capsulolabral plication with Fibertack anchoring was performed to tighten the joint capsule and stabilize the glenohumeral joint. The procedure netted a positive result, with the patient returning to full AROM comparable to the nonpathological side, as well as the eventual reintroduction of high-impact sporting endeavors.

This case highlights the importance of a robust history, examination, and investigation into a common presentation such as recurrent shoulder pain and instability. In this scenario, the patient was initially treated conservatively in the acute phase of his recovery following a traumatic shoulder dislocation. As a consequence of the unrecognized SH type III fracture, the patient experienced recurrent shoulder instability, pain, and discomfort. The conservative management approach resulted in years of recurring and recalcitrant symptomatology, which may have been preventable should a surgical opinion/intervention have been initially sought.

Evidence-based practice hinges on the presence of a robust literature base, which may include patient follow-up studies and case reports for uncommon presentations and/or pathologies. This study offers insight into the successful management of a previously unreported pathology. In doing so, it aims to clarify strategies for managing time-sensitive injuries to mitigate their risk of progression into more insidious sequalae. However, this study does not elucidate the appropriate management of the fracture in the acute setting. Therefore, the treatment algorithm derived from this case ought to be considered with caution in the immediate reduction of such physeal fractures.

Conclusion

We report the first case of an SH type III physeal fracture in the anterior inferior glenoid of a 13-year-old boy. Herein, we outline the diagnostic workup, successful treatment and management of an SH type III glenoid fracture, with demonstrated return to function following an arthroscopic stabilization, including Fibertack anchoring and anterior capsulolabral plication.

Disclaimers

Funding: No funding was disclosed by the authors.

Conflicts of interest: Kenneth Cutbush has served on the speaker’s bureau or has been paid an honorarium to present by Arthrex, Stryker, and Johnson and Johnson. He has received institutional support from Device Technologies, Arthrex, and Stryker. At the time of submission this author serves as the Scientific Secretary for the Australian Orthopaedic Association. He also reports stock ownership in Tetrous, receives fellowship program support from Device Technology, Zimmer Biomet, Johnson and Johnson, and Wright Medical. He receives research support from Zimmer Biomet, Wright Medical and Ausbiotech. The other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Patient consent: Obtained.