1. Imaging Findings

Based on the chest X-ray and plain CT images, the following observations can be made:

• A circular, bone-density shadow (indicated by an arrow) is visible in the right upper thoracic cavity on the chest X-ray. Its abnormal position suggests that the shoulder joint structure (the humeral head) has entered the thoracic cavity.
• Cross-sectional CT images further confirm that this bony structure is located in the same-side thoracic cavity, with noticeable surrounding soft tissue disturbance. There are signs of rib fractures and a possible lung contusion or hemopneumothorax (needs clinical verification).
• A preliminary assessment indicates a disruption of the connection between the humeral head and the humeral shaft or proximal region (possibly near the surgical neck), with the humeral head having penetrated inward through the chest wall or the intercostal space into the thoracic cavity.

2. Potential Diagnoses

Based on the imaging findings and clinical information (high-energy trauma, concurrent head and chest injuries, patient unconscious), the following conditions are considered:

1. Proximal humeral fracture with joint dislocation (humeral head displaced into the thoracic cavity): This best aligns with the current imaging findings and clinical history, commonly seen with violent trauma leading to inferior or posterior dislocation of the shoulder joint, combined with a fracture near the surgical neck.
2. Complex shoulder fracture-dislocation: A complex dislocation of the shoulder may cause the humeral head to shift into surrounding soft tissues or adjacent spaces, but it usually does not enter the thoracic cavity, as seen in anterior or posterior dislocations.
3. Severe comminuted fracture of the scapula or clavicle: Although such fractures may cause deformity or displacement of shoulder joint structures, pushing the humeral head directly into the thoracic cavity is relatively rare.

3. Final Diagnosis

Considering the patient’s history of high-energy trauma, imaging findings (clearly showing the humeral head in the thoracic cavity), and rare reports in the literature, the most likely final diagnosis is:

“Proximal humeral fracture-dislocation (a rare type of shoulder dislocation with the humeral head entering the ipsilateral thoracic cavity).”

This condition arises from a violent external force separating the humeral head from the humeral shaft, with the humeral head then entering the thoracic cavity through a tear in the shoulder joint capsule. It commonly involves rib fractures, hemopneumothorax, or pulmonary contusions, among other chest injuries.

4. Treatment Plan and Rehabilitation

In view of the patient’s current imaging and clinical condition—particularly with multiple injuries, serious chest and cranial injuries—the treatment plan should emphasize overall monitoring and a multidisciplinary approach. Major steps include:

1. Stabilization of Vital Signs and Intensive Care: Because the patient has concurrent cranial trauma, chest trauma, and possibly a hemopneumothorax, initial management should focus on intensive care unit monitoring, chest drainage when necessary, correction of shock, and respiratory support.
2. Surgical Reduction and Internal Fixation:
   • Once the patient’s vital signs are stable, early surgery to remove the humeral head from the thoracic cavity, reduce the shoulder joint, and internally fix the fracture should be considered.
   • Generally, an open thoracotomy or thoracoscopic approach may be required to address the humeral head within the thoracic cavity, along with fixation of the fracture fragments. The surgical plan depends on the fracture type, surrounding soft tissue condition, and the patient’s overall status.
3. Postoperative Rehabilitation and Exercise Prescription: Postoperative rehabilitation includes restoring shoulder joint stability and function. Given the patient’s multiple injuries, an individualized approach is needed:
   • Acute Phase (0-2 weeks post-surgery): Emphasis on immobilization and basic care, focusing on chest recovery and respiratory exercises. The shoulder joint may undergo gentle passive movement or arm-swing exercises, avoiding excessive traction.
   • Early Rehabilitation Phase (2-6 weeks): Once chest and cranial injuries are stable, gradually begin passive and mild active exercises for the shoulder to improve range of motion. Include breathing exercises and enhance transfer and sitting-up training.
   • Intermediate Rehabilitation Phase (6-12 weeks): Depending on fracture healing and imaging follow-up, further increase active range of motion in the shoulder joint and begin strength training of periarticular muscles (e.g., light resistance band exercises or aquatic therapy). Avoid excessive loading.
   • Late Rehabilitation and Functional Consolidation (12 weeks and beyond): Gradually transition to weight-bearing training and compound shoulder movements (such as lifting and functional daily activities), combined with endurance and cardiopulmonary fitness exercises. Closely monitor shoulder stability and pain response.

   Throughout rehabilitation, adhere to the FITT-VP principles:
   • Frequency: 3-5 times per week, adjusted as tolerated;
   • Intensity: Gradually increase according to pain and range of motion, using resistance bands or light loads progressively;
   • Time: Begin with 15-30 minutes per session, gradually increasing to 30-45 minutes;
   • Type: Initially focus on passive movements and mild active movements, then incorporate functional activities and resistance training;
   • Progression: Transition to normal activity loads as the fracture heals and pain is managed, with regular follow-up and evaluation.

Disclaimer

This report is a reference analysis based on current imaging and related information. It cannot replace an in-person consultation or a professional physician’s opinion. If you have further questions or experience changes in your condition, please seek timely medical attention and consult the relevant specialist.