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SplintER Series: More Than Just a Shoulder Dislocation?

Posted by Kenneth Chang, DO on

An 80-year-old female presents to the Emergency Department with right shoulder pain, deformity, and decreased range of motion after falling down half a flight of stairs. AP and Y-views of the right shoulder were obtained (Images courtesy of Kenneth Chang, DO).

What is the diagnosis?

Anterior inferior dislocation of the right glenohumeral joint with a comminuted and displaced fracture of the greater tuberosity of the humerus. This is a two-part fracture per the Neer classification.

  • Pearl: Proximal humerus fractures are classified based on the AO/OTA or Neer Classifications. The AO/OTA classification places emphasis on the blood supply to the articular surface [1]. If the greater/lesser tuberosity is still attached to the articular surface, there is a decreased risk for avascular necrosis.
  • Pearl: The Neer classification system is based on the number of fragment parts and displacement of those parts. The parts considered are 4 anatomical segments: greater tuberosity, lesser tuberosity, articular surface, and shaft [2].

Figure 2. Illustration demonstrating the 4 parts of the Neer Classification.

What are the risk factors and mechanism of injury?

Proximal humerus fracture-dislocations occur mostly due to low-energy mechanisms like ground-level falls, often onto an outstretched hand [4]. Approximately 85% occur in patients > 50 years old and are more common with osteoporotic bone [5]. Younger individuals with a proximal humerus fracture will sustain high-energy trauma and often have concomitant injuries [4].

What physical exam findings are expected?

Soft tissue swelling, ecchymosis, decreased convex contour of the shoulder, and anterior or posterior bulging suggesting a dislocation. Perform a neurovascular exam to assess the axillary nerve and artery. Test sensation over the lateral deltoid, function of external rotation, and abduction of the shoulder.

  • Pearl: Axillary artery injuries are rare, but must be evaluated carefully with capillary refill and distal pulses. Look for ecchymosis, swelling, and expanding hematomas in the axilla [6].

What imaging modalities can be used?

Plain radiographs – AP, scapular Y, and axillary views. The Grashey (true AP) view can evaluate the glenohumeral joint articulation [7]. The modified Velpeau view (similar to axillary) is useful when the patient cannot abduct their arm.

CT scans can help with operative planning in the case of proximal humerus fracture-dislocations. It will assess the integrity of the articulation, displacement of lesser or greater tuberosity fragments, and subtle coracoid fractures [7].

Figure 3: CT images of the right shoulder that demonstrate a comminuted and displaced fracture of the proximal humerus with a reduced glenohumeral joint. Author’s own images.

What is the management in the ED?

In this case, urgent reduction under procedural sedation. For a two-part fracture-dislocation with an isolated greater tuberosity fragment, ED sedation, and reduction with a modified Hippocratic method was found to be 94% successful with no further propagation of the fracture [8]. Appropriate sedation and pain control is fundamental in reducing iatrogenic injury.

Figure 4. Post-reduction images that demonstrate interval reduction of the glenohumeral joint and displaced fracture of the greater tuberosity again seen. Author’s own images.

When do you consult orthopedics?

When there is:

  • A complicated reduction or irreducible dislocation
  • Multiple fracture fragments
  • Neurovascular compromise
  • Open fractures

Anterior dislocation with a surgical neck fracture and posterior dislocations with any fracture type is better managed under general anesthesia in the OR [8].

  • Pearl: Involvement of the humeral shaft, glenoid rim, or very large greater tuberosity fragments are associated with a higher risk of iatrogenic injury during reduction [9]. Three or four-part fracture dislocations should be managed with orthopedics because these are rare, complex, and associated with devascularization of the humeral head [10,11].

What is the definitive management of this injury?

Non-operative injuries should be immobilized in a sling and be closely followed with outpatient sports medicine/orthopedics. These patients should undergo physical therapy as soon as possible for quicker recovery.

Operative injuries are less common. Two-part fractures with greater tuberosity displacement > 5mm are operative because of increased risk of functional impairment without any surgical intervention [12]. Numerous factors including age, fracture type, bone quality, comorbidities, and concurrent injuries are used to determine the optimal type of surgical intervention, including ORIF and arthroplasty [10,11].

Resources & References:

Check out ALiEM’s EMRAD post to brush up on other can’t miss adult shoulder injuries.

  1. Marongiu, G., Leinardi, L., Congia, S. et al. Reliability and reproducibility of the new AO/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems. J Orthop Traumatol 2020;21, 4. PMID: 32166457
  2. Carofino BC, Leopold SS. Classifications in brief: the Neer classification for proximal humerus fractures. Clin Orthop Relat Res. 2013;471(1):39-43. PMID: 22752734
  3. Mora Guix JM, Pedrós JS, Serrano AC. Updated classification system for proximal humeral fractures. Clin Med Res. 2009;7(1-2):32-44. PMID: 19574487
  4. Flint JH, Carlyle LM, Christiansen CC, Nepola J V. Case report and literature review anterior shoulder dislocation with three-part proximal humerus fracture and humeral shaft fracture. Iowa Orthop J. 2009;29:105-113. PMID: 19742096
  5. Court-Brown CM, McQueen MM. Two-part fractures and fracture dislocations. Hand Clin. 2007 Nov;23(4):397-414. PMID: 18054667
  6. Venkatesh Palanisamy J, Vaithilingam A, Das S, Trikha V. Proximal humerus fracture dislocation leading to axillary artery injury in an young adult: Case report of an unusual presentation. J Clin Orthop Trauma. 2017 Aug;8(Suppl 1):S62-S66. PMID: 28878544
  7. Plachel F, Schanda JE, Ortmaier R, Auffarth A, Resch H, Bogner R. The “triple dislocation fracture”: anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process-a series of six cases. J Shoulder Elbow Surg. 2017 Sep;26(9):e278-e285. PMID: 28372969
  8. 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;27(3):335-340. PMID: 28050700
  9. Guo J, Liu Y, Jin L, Yin Y, Hou Z, Zhang Y. Size of greater tuberosity fragment: a risk of iatrogenic injury during shoulder dislocation reduction. Int Orthop. 2019;43(5):1215-1222. PMID: 29948014
  10. Robinson CM, Khan LA, Akhtar MA. Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Br. 2006 Apr;88(4):502-8. PMID: 16567786
  11. Schirren M, Siebenbürger G, Fleischhacker E, et al. Anterior fracture dislocation of the proximal humerus: Management and treatment results. Obere Extrem. 2019;14(2):103-109.
  12. Dussing F, Plachel F, Grossauer T, et al. Anterior shoulder dislocation and concomitant fracture of the greater tuberosity: Clinical and radiological results. Obere Extrem. 2018;13(3):211-217. PMID: 30220922

Author information

Kenneth Chang, DO

Emergency Medicine Resident
Department of Emergency Medicine
New York-Presbyterian Queens

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