The Journal of Emergency Medicine, Vol. 45, No. 4, pp. e99–e102, 2013Copyright � 2013 Published by Elsevier Inc.

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http://dx.doi.org/10.1016/j.jemermed.2012.11.011

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ClinicalCommunications: Adults

SKIN DIMPLING AFTER A CLOSED PROXIMAL HUMERUS FRACTURE

Arun Aneja, MD,* Nicholas B. Jew, MD,† Matthew L. Graves, MD,* and Kendall McKenzie, MD‡

*Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, Mississippi, †University of Mississippi School ofMedicine, Jackson, Mississippi, and ‡Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi

Reprint Address: Nicholas B. Jew, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216

, Abstract—Background: Skin dimpling, also known asskin puckering, is a rare occurrence after closed proximalhumerus fractures. This finding is suggestive of incarcera-tion of the skin at the fracture site and may lead to necrosisand conversion to an open fracture. Objectives: Our goal isto describe our experience with skin dimpling after a proxi-mal humerus fracture to increase awareness and recognitionof this clinical presentation in the Emergency Department(ED). Case Report:We report a case of a 46-year-old womanwho presented to the EDwith left shoulder pain and swellingafter a fall. She was found to have skin dimpling over the an-terior aspect of the shoulder on further examination andwasdiagnosed with a proximal humerus fracture after imaging.Conclusion: Skin dimpling is an uncommon sign associatedwith proximal humerus fractures that can help in diagnosisand determining course of treatment. Devastating soft tissueinjury can occur if the fracture is not immediately reduced.Therefore, it is imperative that physicians be able topromptly identify the clinical presentation to preventunwanted sequelae. � 2013 Published by Elsevier Inc.

, Keywords—skin dimpling; proximal humerus fractures

INTRODUCTION

Proximal humerus fractures comprise 5% of all fracturesthat present to the Emergency Department (ED) and arethe most common type of humerus fracture (1). They usu-ally occur after low-energy trauma in older patients such

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as a fall onto an outstretched upper extremity, but alsoafflict younger patients after high-energy trauma suchas motor vehicle accidents. Patients clinically presentwith the involved upper extremity held closely to thechest by the contralateral hand along with pain, swelling,tenderness, and decreased range of motion. The majorityof proximal humerus fractures are either non-displaced orminimally displaced and can be conservatively managedwith non-operative treatment. Up to 20% of these frac-tures are comminuted or displaced and require eitherclosed reduction with splinting or surgical intervention(2). In the majority of cases, these fractures can bemanaged in the ED with pain control and referral to anorthopedic specialist.

Dimpling of the skin over the fracture site is a raresign, with devastating consequences, that can occurwith this type of fracture. To our knowledge, there areonly three previous reports of this complication in theliterature (3–5). We present our experience with skindimpling after a proximal humerus fracture and ourshort-term management of the patient.

CASE REPORT

A 46-year-old woman presented to the ED after assault byher ex-boyfriend. The patient reported being pusheddown, falling backwards, and landing on her left shoul-der. She had immediate pain and swelling, went to anoutside hospital and was diagnosed with a closed left

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Figure 1. Patient’s left shoulder demonstrating the skin dim-pling overlying the proximal humerus fracture site.

Figure 3. Anteroposterior X-ray study of the patient’s leftproximal humerus.

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proximal humerus fracture. She was transferred to ourhospital and the orthopedic service was consulted shortlyafter arrival, approximately 4 h after the trauma.

Physical examination findings demonstrated the pa-tient holding the involved extremity in an adducted, inter-nally rotated position, while supporting it with thecontralateral upper extremity. There was minimal swell-ing, with an apparent skin dimple overlying the fracturesite. The skin dimple measured approximately 1.2 cm �1.2 cm, with ecchymosis and skin wrinkling around theperiphery. Images of the skin dimple as well as anteropos-terior and lateral radiographs of the proximal humerus arepresented as Figures 1 through 4. The patient haddifficulty with range of motion but was neurovascularlyintact, with full sensation along axillary, radial, median,and ulnar nerve distribution. She was able to contracther deltoid as well as minimally flex and extend theelbow with significant pain.

After reviewing the physical examination and radio-graphs, it was determined that the incarcerated skin had

Figure 2. Patient’s left shoulder demonstrating the skin dim-pling overlying the proximal humerus fracture site.

to be released under conscious sedation. The patient un-derstood the plan, associated risks and benefits, and de-cided to proceed. The patient was placed on a monitorwith a pulse oximeter, and the standard hospital con-scious sedation protocol was followed. A nurse assistedin monitoring the patient during sedation while the Emer-gencyMedicine resident and staff oversaw the procedure.The senior author pulled axial traction and immediatelynoted release of the dimple with immediate improvementof skin discoloration. An image of the arm after releasingthe incarcerated skin is presented as Figures 5 and 6. Thefracture fragments were realigned in an acceptableposition under fluoroscopic imaging and the upperextremity was immobilized in a shoulder immobilizer.Post-reduction radiographs were taken and the patient ex-pressed a strong desire to return home. Although the pa-tient did not require hospitalization, she was advised toremain until post-reduction radiographs were reviewedin the event that further manipulation was required to

Figure 4. Axillary view X-ray study of the patient’s left proxi-mal humerus.

Figure 5. Patient’s left shoulder post reduction and releaseof skin dimple.

Figure 7. Anteroposterior X-ray study of the patient’s leftshoulder post reduction.

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achieve better alignment. The patient subsequently leftagainst medical advice while the radiographs were beingreviewed. Post-reduction X-ray studies are presented asFigures 7 and 8.

DISCUSSION

Dimpling of the skin after a displaced supracondylar hu-meral fracture in children has been well documented.Also known as the pucker sign, it occurs when the prox-imal humeral fragment penetrates the brachialis muscleand pierces the overlying dermis (6). Skin dimpling inproximal humerus fractures occur when a fracture frag-ment punctures through the deltoid muscle. If not treatedemergently with immediate reduction and alleviation ofentrapped skin, there is risk of skin necrosis with subse-quent conversion to an open fracture. In these cases,closed reduction might be difficult to accomplish due tosoft tissue interposition. If closed manipulation fails,then open reduction and internal fixation is needed.

Figure 6. Patient’s left shoulder post reduction and releaseof skin dimple.

Although open reduction and internal fixation was re-quired to release the soft tissue in the two previous casereports, we were able to achieve release of the incarcer-ated skin and reduction of the fracture using simple trac-tion only (3,4).

Despite its rare occurrence, skin dimpling overlyingany fracture site is very important to recognize in theED. A thorough history and physical examination shouldalways be performed on patients with suspected proximalhumerus fractures and should include careful inspectionof the skin overlying the fracture site. When skin dim-pling is present, we advise an urgent attempt to free theincarcerated tissue using axial traction to prevent skinbreakdown and development of an open fracture. After

Figure 8. Transthoracic lateral X-ray study of the patient’sleft shoulder post reduction.

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such, attention may be turned towards treatment of theunderlying fracture.

CONCLUSION

In conclusion, skin dimpling with proximal humerusfractures is an uncommon occurrence that, when recog-nized, can help with diagnosis and treatment planning.Due to the potential for devastating soft tissueinjury, prompt reduction and release of entrapped skinmust occur. This can be accomplished through closedmanipulation, as demonstrated in the presented casereport. Open reduction is required if closed manipula-tion fails.

REFERENCES

1. Court-Brown CM, Garg A, McQueen MM. The epidemiology ofproximal humeral fractures. Acta Orthop Scand 2001;72:365–71.

2. Bohsali KI, Wirth MA. Fractures of the proximal humerus. In:Rockwood CA, Matsen FA III, Wirth MA, Lippitt SB, eds. Theshoulder. 4th edn., Volume 1. Philadelphia: Saunders Elsevier;2009:295–300.

3. Davarinos N, Ellanti P, Khan Bhambro KS, Keogh P. Skin puckeringan uncommon sign of underlying humeral neck fracture: a case re-port. Ir J Med Sci 2011;180:731–3.

4. Alshryda SJ, Odak S, Patel AD. Skin puckering as a sign of humeralneck fracture. Ann R Coll Surg Engl 2008;90:692–3.

5. Robinson CM, Stone OD, Murray IR. Proximal humeral fracturesdue to blunt trauma producing skin compromise. J Bone Joint SurgBr 2011;93:1632–7.

6. Egol KA, Koval KJ, Zuckerman JD. Handbook of fractures. 4th edn.Philadelphia: Lippincott Williams and Wilkins; 2010.