Rapid Destruction of the Humeral Head Caused by Subchondral Insufficiency Fracture: A Report of Two Cases

Abstract

Rapidly destructive arthritis (RDA) of the shoulder is a rare disease. Here, we report two cases, with different destruction patterns, which were most probably due to subchondral insufficiency fractures (SIFs). Case 1 involved a 77-year-old woman with right shoulder pain. Rapid destruction of both the humeral head and glenoid was seen within 1 month of the onset of shoulder pain. We diagnosed shoulder RDA and performed a hemiarthroplasty. Case 2 involved a 74-year-old woman with left shoulder pain. Humeral head collapse was seen within 5 months of pain onset, without glenoid destruction. Magnetic resonance imaging showed a bone marrow edema pattern with an associated subchondral low-intensity band, typical of SIF. Total shoulder arthroplasty was performed in this case. Shoulder RDA occurs as a result of SIF in elderly women; the progression of the joint destruction is more rapid in cases with SIFs of both the humeral head and the glenoid. Although shoulder RDA is rare, this disease should be included in the differential diagnosis of acute onset shoulder pain in elderly female patients with osteoporosis and persistent joint effusion.

Rapid Destructive Arthrosis Due to Subchondral Insufficiency Fracture of the Shoulder: Clinical Characteristics, Radiographic Appearances, and Outcomes of Treatment

“…Rapid destructive arthrosis (RDA) is the marked destruction of a joint within months after the onset of symptoms [1]. This condition usually occurs in the hip and more rarely in the shoulder [2].…”

“…Very recently, subchondral insufficiency fractures (SIFs) of the shoulder have been described as a cause of rapid joint destruction [1,2,4,5]. SIF is a recently proposed concept and is thought to cause femoral head collapse associated with RDA of the hip [6,7].…”

“…It was thought to occur secondary to physiological stress applied to a weakened bone due to reduced bone mineralization, commonly seen in elderly women with osteoporosis [9]. Although the pathogenesis of RDA of the shoulder remains unclear, there have been several reports for RDA resulting from SIF of the shoulder [1,2,4,5]. Magnetic resonance imaging (MRI) plays an important role in the diagnosis of SIF, which is often inconspicuous on initial radiographs [6].…”

“…To the best of our knowledge, only 25 cases of RDA due to SIF of the shoulder have been reported as case reports or small case series [1,2,4,5,10,11]. Because of its rarity and related gaps in knowledge, this condition might be misdiagnosed as idiopathic destructive arthritis of the shoulder, osteonecrosis of the humeral head, Milwaukee shoulder syndrome, infectious arthritis, or osteomyelitis [12,13].…”

Editorial Commentary: “Just When I Thought I'd Seen Everything That Could Go Wrong?” (Often Overheard in the Surgeon's Lounge): Osteonecrosis of the Humeral Head After Arthroscopic Rotator Cuff Surgery

“…3 This complication has been described with rotator cuff surgery with metal anchors, 4,5 resorbable anchors (as in this series 6 ), no anchors (again, as in this series 7 ), and no arthroscopy at all. 8,9 It is also clear that it can occur with no surgery at all, 9 with no other etiologic factors, 10 as well as with a variety of disease states that may be difficult to ferret out, such as alcohol use or unrecognized or forgotten steroid use. The situation is further blurred by the entity of rapid destructive arthritis of the shoulder, which shares some, but not all, characteristics with osteonecrosis.…”