What immobilization is recommended for a patient with a reduced anterior shoulder dislocation and a greater tubercle fracture, and should they be considered for surgical intervention?

Management of Anterior Shoulder Dislocation with Greater Tubercle Fracture

For a patient with a reduced anterior shoulder dislocation and a greater tubercle fracture, immobilization should be achieved with a sling, and surgical intervention should be considered if the greater tubercle fragment is significantly displaced (>5mm).

Immobilization Approach

• Immobilization in a standard sling is the recommended approach for anterior shoulder dislocations with minimally displaced greater tubercle fractures 1
• The duration of immobilization should be approximately 3-4 weeks, though there is no conclusive evidence showing benefit of longer immobilization periods 2
• While some studies have explored external rotation bracing, the evidence does not conclusively demonstrate superior outcomes compared to traditional sling immobilization in internal rotation 3, 2
• Patient compliance with immobilization is critical for optimal outcomes, with studies reporting excellent compliance rates (approximately 80%) with both sling and external rotation devices 3

Surgical Considerations

• Surgical intervention should be considered if the greater tubercle fragment is significantly displaced (>5mm) 1
• The presence of a greater tubercle fracture actually reduces the risk of recurrent dislocation compared to dislocations without associated fractures 4
• Radiographic follow-up is essential to monitor fracture healing and to detect any late displacement of the greater tubercle fragment 5
• MRI or CT arthrography may be warranted if there is concern for associated labral tears or other soft tissue injuries 5

Follow-up Protocol

• Initial follow-up should occur within 1-2 weeks to assess:
  • Neurovascular status
  • Fracture alignment
  • Integrity of the immobilization 1
• Subsequent follow-up at 3-4 weeks to:
  • Evaluate fracture healing
  • Assess for any displacement of the greater tubercle fragment
  • Consider transitioning to rehabilitation if healing is progressing appropriately 2
• Final follow-up at 6-8 weeks to:
  • Confirm complete fracture healing
  • Evaluate shoulder stability
  • Assess range of motion 1

Rehabilitation Considerations

• After the immobilization period (typically 3-4 weeks), a progressive rehabilitation program should be initiated 6
• Initial rehabilitation should focus on:
  • Gentle passive range of motion exercises
  • Isometric strengthening
  • Scapular stabilization 1
• Advanced rehabilitation (after 6 weeks) should include:
  • Progressive strengthening of rotator cuff muscles
  • Proprioceptive training
  • Gradual return to functional activities 6

Pitfalls and Caveats

• Failure to recognize significant displacement of the greater tubercle can lead to rotator cuff dysfunction and impingement 5
• Young patients (under 30 years) have significantly higher recurrence rates after anterior shoulder dislocations, requiring closer monitoring 4
• Immobilization alone may be insufficient for patients with significant instability or those with high functional demands 1
• The presence of a Hill-Sachs lesion (posterior-lateral humeral head compression fracture) may indicate a need for more aggressive management, especially in older patients (23-40 years) 4
• Inadequate pain control during the immobilization period can lead to poor compliance and suboptimal outcomes 3