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Anterior glenohumeral fracture-dislocation with associated greater-tuberosity fracture — MSRA MCQ

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HardShoulder InjuriesAnterior glenohumeral fracture-dislocation with associated greater-tuberosity fractureMSRA

A 71-year-old woman presents to your GP surgery 2 hours after falling onto her outstretched right arm. At an urgent treatment centre, anteroposterior and axial radiographs showed an anterior glenohumeral dislocation with an isolated greater-tuberosity fracture. The main greater-tuberosity fragment is estimated to comprise approximately 45% of the humeral-head width and is displaced by 8 mm. No surgical-neck fracture is seen. She has severe pain and holds the arm supported against her body. The shoulder contour remains abnormal. Radial pulse, capillary refill, hand power, and distal sensation are normal. The urgent treatment centre has not attempted reduction and asks for advice because the patient is haemodynamically stable. What is the most appropriate immediate management?

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Correct answer: E — Transfer immediately to the emergency department and obtain orthopaedic input before any attempted reduction

Explanation lettering: B = shown as A · A = shown as B · E = shown as C · C = shown as D · D = shown as E

This is an unreduced anterior shoulder fracture-dislocation, not an isolated greater-tuberosity fracture suitable for outpatient immobilisation. Although her distal neurovascular examination is normal, the persistent deformity and inability to use the arm require immediate hospital management. A dislocated shoulder should be assessed and reduced urgently in hospital rather than managed in the community. The associated greater-tuberosity fracture materially changes the reduction decision. Closed reduction can propagate the fracture or produce an iatrogenic proximal-humeral fracture. In a review of 172 reported reductions of anterior dislocation with isolated greater-tuberosity fracture, 22 iatrogenic fractures occurred; increased age, female sex and larger tuberosity fragments were associated with risk. Emergency-department reduction appeared safer principally in younger patients with fragments involving less than 40% of humeral-head width. This patient is older, female, and has a fragment estimated at 45%; reduction therefore warrants orthopaedic discussion before manipulation. A and E dangerously delay reduction. B may assist operative planning after specialist assessment but must not delay transfer or the reduction decision. C is appropriate for many uncomplicated anterior dislocations, and may be reasonable for selected younger patients with a small tuberosity fragment, but it underestimates this patient’s higher-risk fracture-dislocation.

Reference: NHS: Dislocated shoulder (Reviewed 17 May 2023) — https://www.nhs.uk/conditions/dislocated-shoulder/?src=conditionswidget When can anterior dislocations of the shoulder with an isolated fracture of the greater tuberosity be safely reduced in the emergency department? (2022) — https://pubmed.ncbi.nlm.nih.gov/35506721/