What is the appropriate management for a fractured dislocated shoulder?

Management of Fractured Dislocated Shoulder

For fractured dislocated shoulders, reduction approach should be based on fracture pattern, with type I injuries (anterior dislocation with greater tuberosity fracture) safely reduced under sedation in the emergency department, while type II injuries (involving surgical neck fractures) and all posterior fracture-dislocations should undergo reduction under general anesthesia. 1

Initial Assessment and Classification

• Obtain plain radiographs as first-line imaging including AP, Grashey, axillary, and scapular Y projections 2
• Classify the fracture-dislocation pattern:
  • Type I: Anterior dislocation with greater tuberosity fracture
  • Type II: Fracture involving surgical neck of humerus (with or without greater tuberosity fracture)
  • Posterior fracture-dislocations (any pattern)

Reduction Protocol

Type I Injuries (Anterior dislocation with greater tuberosity fracture)

• Attempt reduction under procedural sedation in the emergency department
• 94% success rate for reduction under sedation with no fracture propagation 1
• Use standard reduction techniques (e.g., traction-countertraction, scapular manipulation)

Type II Injuries (Involving surgical neck fractures)

• Do not attempt reduction under sedation
• Schedule for reduction under general anesthesia 1
• Consider open reduction and internal fixation based on fracture pattern

Posterior Fracture-Dislocations

• All cases require reduction under general anesthesia 1
• Open reduction and internal fixation is typically necessary
• Consider bone grafting of humeral head defects if causing residual instability 3

Post-Reduction Management

Immobilization

• Immobilize the shoulder for appropriate duration based on patient age:
  • For patients under 30 years: 3 weeks immobilization is recommended to reduce recurrence risk 4
  • For patients over 30 years: 1 week immobilization is sufficient 4

Position of Immobilization

• Traditional immobilization has been in internal rotation with a sling
• Recent evidence shows no significant difference between external rotation bracing vs. internal rotation sling immobilization (37% vs. 40% recurrence rates) 5

Rehabilitation Protocol

• Begin range-of-motion exercises including shoulder, elbow, wrist, and hand motion within the first few days following surgical treatment 6
• A sling may be worn for comfort only and discarded as pain allows 6
• Restrict above chest level activities until fracture healing is evident 6
• Implement appropriate rehabilitation program including:
  • Early physical training and muscle strengthening
  • Long-term balance training and fall prevention 6
  • Rotator cuff strengthening exercises and scapular stabilization 2

Cautions and Pitfalls

• Overly aggressive physical therapy may increase risk of fixation failure in the postoperative period 6
• Avoid attempting reduction under sedation for type II injuries or posterior dislocations due to high risk of complications 1
• Younger patients (under 30 years) have significantly higher recurrence rates and require longer immobilization 4
• Manual laborers experience more numerous redislocations than office workers 4
• Patients should be educated about proper positioning and handling of the affected arm 2

Follow-up Schedule

• Initial follow-up at 1-2 weeks to assess response to treatment
• Clinical reassessment at 6 weeks with possible repeat radiographs
• Evaluation for progress of rehabilitation at 3 months
• Long-term follow-up at 6-12 months to evaluate for late complications 2