What is the treatment plan for a shoulder dislocation with a fracture and decreased deltoid sensation?

Treatment Plan for Shoulder Dislocation with Fracture and Decreased Deltoid Sensation

Immediate surgical consultation is required for a shoulder dislocation with fracture and decreased deltoid sensation, as this neurological deficit indicates potential axillary nerve injury requiring prompt surgical intervention to prevent permanent functional impairment.

Initial Assessment and Management

Imaging

• Initial evaluation should include a standard set of shoulder radiographs including anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view to properly assess the dislocation and associated fracture 1
• Radiographs should be performed upright as malalignment can be underrepresented on supine imaging 1
• CT scan is indicated to better characterize the fracture pattern, displacement, and angulation 1
• MRI should be obtained to evaluate the neurological component (decreased deltoid sensation) and assess for soft tissue injuries including rotator cuff, labral, and glenohumeral ligament injuries 1

Reduction Considerations

• Do not attempt reduction under sedation for a fracture-dislocation with neurological deficit 2
• Reduction under general anesthesia is recommended for complex fracture-dislocations, particularly when there is neurological compromise 2
• Attempting reduction under sedation in cases with surgical neck fractures has been associated with fracture propagation and worsening displacement in 8% of cases 2

Surgical Management

• Surgical intervention is indicated due to:

  1. Presence of neurological deficit (decreased deltoid sensation) suggesting axillary nerve involvement
  2. Fracture-dislocation combination indicating potential instability
  3. Need for exploration and possible repair of neurological structures 1, 2

• Surgical approach should include:

  • Exploration of the axillary nerve
  • Fracture fixation
  • Stabilization of the glenohumeral joint 2, 3

Post-Reduction/Post-Surgical Care

• Close monitoring of neurological status, particularly deltoid function and sensation 1
• Consider removable splint rather than traditional cast to allow for easier assessment of neurovascular status 1
• Limit post-operative imaging to only what will change management to minimize radiation exposure 1
• Early physical therapy focusing on:
  1. Maintaining range of motion without compromising stability
  2. Neuromuscular re-education of the deltoid if nerve injury is present
  3. Progressive strengthening as healing permits 3

Complications to Monitor

• Axillary nerve injury may lead to permanent deltoid weakness if not addressed promptly 1
• Risk of recurrent instability is higher in younger patients (under 25 years) 3
• Patients with recurrent instability appear to be at higher risk of developing osteoarthritis 3
• Delayed surgical intervention makes stabilization more technically demanding due to:
  • Elongation of the capsule
  • Progressive labro-ligamentous injury
  • Increased prevalence and severity of glenoid bone loss 3

Common Pitfalls to Avoid

• Misdiagnosis of the type of dislocation (anterior vs posterior) can lead to iatrogenic fractures during reduction attempts 4
• Using inappropriate reduction techniques such as Kocher's method in complex cases can cause iatrogenic fractures 4
• Delaying treatment of neurological deficit can lead to permanent functional impairment 3
• Inadequate imaging leading to missed fracture components or underestimation of injury severity 1

Remember that the presence of decreased deltoid sensation significantly changes the management approach from what might be used for an uncomplicated shoulder dislocation, necessitating more urgent surgical intervention to address the potential nerve injury.