Citation: Prince G and Sherman S. Ortho Pearls - Shoulder Pain: A Case for Caution [Internet]. Cook County Emergency Medicine Residency;Available from: https://cookcountyem.com/blog/2023/9/1/gf0ctkpkhqd1ayegrje981qucq5yxb
The Case:
52-year-old woman presented to the emergency department (ED) with right shoulder pain. She was walking her dog and tripped and fell onto the right upper extremity. On exam, she had limited range of motion with the shoulder held in slight abduction with the elbow flexed. Neurovascular function was preserved. Radiographs of the shoulder demonstrated an anterior shoulder dislocation with what appeared to be a nondisplaced fracture of the proximal humeral shaft (Figure 1). The orthopedics service was consulted over the phone and they requested that an attempt at closed reduction be made. The patient was consented and sedated with ketamine. Reduction with external rotation and inline traction was attempted, but a loud crack was heard with deformity of the upper extremity. Repeat radiographs revealed displacement of the fracture with the shoulder remaining dislocated (Figure 2). The patient was admitted to the hospital by the orthopedic service where she underwent successful open reduction and internal fixation the next morning.
Figure 2. Radiograph appearance after reduction attempt shows displacement of the fracture with dislocation still present.
Discussion
Shoulder dislocation is associated with fracture in 20-25% of cases. The most common fracture is that of the greater tuberosity, which occurs in approximately 15% of cases (1). It has been shown that closed reduction of glenohumeral dislocations with associated tuberosity fractures is safe, with a low rate (1%) of iatrogenic humeral neck fracture (2). The same is true of glenoid rim (Bankart) and Hill-Sachs impaction fractures.
However, when shoulder dislocation is associated with a fracture of the surgical neck or proximal humeral shaft, a closed reduction attempt in the emergency department with procedural sedation may displace the fracture; further reducing the blood supply to the humeral head and necessitating open operative reduction, as in our case. The limited available evidence suggests that patients with associated nondisplaced fractures of the humeral shaft be taken to the operating room (3, 4). In one retrospective case review, 6 of 8 patients with nondisplaced surgical neck fracture who underwent an initial ED reduction attempt developed displacement, while only 1 of 4 such displacements occurred when initial reduction occurred in the operating room (4).
For the emergency physician, who reduces shoulder dislocations routinely without the consultation of an orthopedist, the lesson here is three-fold. Make it a routine to look closely at the radiograph for evidence of a nondisplaced surgical neck or proximal humeral shaft fracture whenever one comes across an anterior shoulder dislocation. When there is suspicion of a fracture, consider a CT scan to better answer the question before proceeding to reduction attempts. Secondly, when such an associated fracture is confirmed, obtain consultation with your orthopedist before attempting reduction. While the available evidence suggests they might want to take the patient to the operating room, it would be wise to have their input before performing closed reduction in the ED. And finally, if the decision is made to perform reduction in the ED, the method of reduction should be considered. We would postulate, based on our experience, that any attempts at external rotation would be better avoided and a method such as scapular manipulation might reduce the risk of fracture displacement.
References:
Sherman S. 2019. Simon’s Emergency Orthopedics. 8th Edition. McGraw-Hill. New York, New York.
Mackenzie SP, Hackney RJ, Crosbie G et al. Closed reduction of glenohumeral dislocations with associated tuberosity fracture in the emergency department is safe. Injury 2021. Mar;52(3):487-92.
Wronka KS, Ved A, Mohanty K. When is it safe to reduce fracture dislocation of shoulder under sedation? Proposed treatment algorithm. Eur J Orthop Surg Traumatol. 2017. Apr;27(3):335-40.
Green A, Choi P, Lubitz M, et al. Proximal humeral fracture-dislocations: which patterns can be reduced in the emergency department? J Shoulder Elbow Surg. 2022. Apr;31(4):792-8.