Anterior Shoulder Fracture Dislocation

Dr Caoimhe Sheppard (F2 Emergency Medicine), Dr Kevin Martin (SHO Emergency Medicine), Dr H Ghazzawi (Emergency Medicine Consultant), Dr A McKelvey (Emergency Medicine Consultant)

The above named are the sole authors of this case. Consent was obtained from the patient to produce this report.

Shoulder dislocations are a common presentation in ED and account for approximately 50% of all dislocations seen in the department. Of these 80-90% are anterior dislocations, mainly as a result of trauma [1]. As a general rule reduction of these dislocations are straight forward and result in minimal complications. Haemarthrosis, recurrence and neurapraxia are the most recognised complications and it is unusual to identify a new fracture on post reduction films. [2]

An 87 year old lady presented to ED after a fall while out shopping with a comminuted fracture dislocation of her right shoulder.

She lived independently in a fold and had a good baseline mobility. Her pmhx included ME and mild cognitive impairment.

On examination she had an obvious deformity of her right shoulder in keeping with an anterior dislocation. Severe bruising was noted over the axilla and radial pulse and distal sensation were intact.  There was also a dental laceration to lower lip requiring sutures. No other injury was noted.

An X- Ray of her right shoulder was performed and showed an anterior dislocation of the humeral head with a comminuted displaced fracture of the glenoid (see Figure 1). On the basis of this X-ray the decision was taken to attempt simple reduction. The patient was sedated using fentanyl and midazolam and the joint appeared to reduce with relative ease.

A further X-ray was completed to confirm position (see Figure 2). This demonstrated that although the reduction attempt had been partially successful the articulating surface remained displaced in the axilla. She remained neurovascularly intact.

Given the nature of this complication the patient was discussed with the fracture/orthopaedic team and transferred under their care in a tertiary centre. A CT was performed at this time and showed a comminuated fracture of the proximal humerus with multiple displaced fractures plus displacement of the humeral head into the subacromial fossa. On the basis of this, the decision was taken to perform hemiarthroplasty of the right shoulder.

The patient recovered well from this procedure and was discharged home a short time later.

 

Learning points

This case highlights the importance of always imaging clinically dislocated joints prior to attempting reduction to check for the presence of associated fractures. As the presence of a fracture will help to tailor the specific management plan for that dislocation.

 xray pre reduction

   Figure 1: X-ray Right shoulder (pre reduction)

xray post reduction

 Figure 2: X-ray Right shoulder (post reduction)

References

[1] Marinelli M, de Palma L. The external rotation method for reduction of acute anterior shoulder dislocations. Journal of Orthopaedics and Traumatology: official journal of the Italian society of Orthopaedics and traumatology. 2009

[2] Mallia K et al. Reduction of Shoulder dislocation. Medscape. 2017

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