From the Guidelines
A patient with a reduced shoulder dislocation and a mildly comminuted, mildly displaced fracture of the great tuberosity should be referred to orthopedics for follow-up care. After initial management in the emergency department, including reduction, pain control with medications, and immobilization with a sling, orthopedic consultation is necessary to determine the optimal treatment approach. According to the American College of Foot and Ankle Surgeons, simple immobilization is appropriate when fracture fragments are small, nonarticular, or minimally displaced 1. However, in the context of a greater tuberosity fracture, an orthopedic specialist needs to evaluate whether the specific fracture pattern, degree of displacement, and patient factors warrant surgical intervention. The orthopedist will also establish an appropriate rehabilitation protocol to prevent complications like adhesive capsulitis while allowing proper healing. Key considerations in the emergency department include:
- Pain control with medications like ibuprofen 600mg every 6 hours or acetaminophen 1000mg every 6 hours
- Immobilization with a sling to prevent further injury
- Patient education on the importance of follow-up care with an orthopedic specialist
- Instructions to maintain sling immobilization until seen by orthopedics, typically within 7-10 days, and to return sooner if experiencing increased pain, numbness, or color changes in the affected extremity.
From the Research
Management of Shoulder Dislocation with Fracture of the Great Tuberosity
- The patient's condition involves a mildly comminuted and mildly displaced fracture of the great tuberosity after a shoulder dislocation was reduced in the emergency department 2, 3, 4.
- Studies suggest that the management of greater tuberosity fractures lacks a standardized approach, but surgical intervention is warranted if displacement exceeds 0.5 cm 2.
- For comminuted fractures with large fragments, open reduction and internal fixation (ORIF) with plate osteosynthesis may be recommended 2.
- Arthroscopic treatment of greater tuberosity fractures has been described, allowing for the identification and addressing of coexisting injuries, such as rotator cuff tears or labrum lesions 5.
- A proposed treatment algorithm suggests that anterior dislocations with greater tuberosity fractures can be safely reduced under sedation in the emergency department, with a success rate of 94% and no fracture propagation 3.
- However, other studies suggest that closed reduction in the emergency department may not be safe for all patients, particularly older patients or those with larger fragments of the greater tuberosity, due to the risk of iatrogenic fractures 6.
Referral to Orthopedic Department
- Given the complexity of the patient's condition, with a mildly comminuted and mildly displaced fracture of the great tuberosity, referral to an orthopedic department may be necessary for further evaluation and management 2, 3, 4.
- The orthopedic department can assess the need for surgical intervention, such as ORIF or arthroscopic procedures, and develop a treatment plan to ensure optimal outcomes for the patient 2, 5.