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).
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.
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].
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].
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.
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 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].
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.
- 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
- 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
- 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
- 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
- Court-Brown CM, McQueen MM. Two-part fractures and fracture dislocations. Hand Clin. 2007 Nov;23(4):397-414. PMID: 18054667
- 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
- 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
- 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
- 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
- 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
- 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.
- 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
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