Three-Part Fracture Dislocation and Four-Part Fracture Dislocation of the Proximal Humerus: How Different are the Glenoid Labrum and Capsular Injuries Between Them?

Background

Anterior fracture dislocation of the shoulder may have associated injury to the glenoid labrum and/or capsule. There is a need to look at the possible patterns of capsulo-labral injuries intra-operatively and correlate them with pre-operative radiographs and CT scans. It can enable surgeons to predict the patterns of soft-tissue injuries in a specific fracture type.

Methods

Patients operated for ORIF of 3- and 4-part anterior fracture dislocation between January 2017 and December 2022 were included in the study. The following data were collected: demographic details, fracture morphology and classification on radiograph and CT scan, neurovascular injury, the subtype of anterior dislocation, and intra-operative identifiable injury to glenoid labrum and/or capsule.

Results

A total of 24 cases (mean age 40 ± 10 years) of anterior fracture dislocation of the shoulder were included in the study and were grouped based on Neer's classification. 12 patients had 3-part anterior fracture dislocation (3-part Group) with a mean age of 34 ± 9 years, while 12 patients had 4-part anterior fracture dislocation (4-part Group) with a mean age of 46 ± 7 years (p = 0.001). 10 out of 12 patients in the 3-part Group had the subcoracoid position of the dislocated head, whereas the head was present in 9 out of 12 patients of the 4-part Group at the preglenoid position (p = 0.003). The head position was at a mean distance of 1.85 cm from the anterior glenoid rim in the 4-part Group, whereas the head was engaged at the anterior rim of the glenoid in the 3-part Group. The medial metaphyseal beak was present in 11 out of 12 patients in the 3-part Group, whereas it was absent in all the cases of the 4-part Group (p = 0.001). 92% of the included patients in our study had capsulo-labral injury. 11 out of 12 patients in the 3-part Group had labral injury compared to 10 out of 12 patients in the 4-part Group with severe capsular stripping (p = 0.001).

Conclusion

The 3-part fracture dislocation with radiological findings such as the long medial metaphyseal beak and subcoracoid position of the dislocated head had a strong association with a glenoid labral injury, whereas the 4-part fracture dislocation type had a widely displaced preglenoid position of the dislocated head with an absent metaphyseal beak and had a strong association with a capsular type of soft-tissue injury.

Level of Evidence

III.

Performance of the Fresno-Quebec Rule in identifying patients with concomitant fractures not requiring a radiograph before shoulder dislocation reduction: a multicenter retrospective cohort study

BACKGROUND AND IMPORTANCE

Although shoulder dislocation diagnosis is often solely based on clinical examination, physicians may order a radiograph to rule out a concomitant shoulder fracture before performing reduction. The Fresno-Québec decision rule aims to identify patients requiring a radiograph before reduction to avoid unnecessary systematic imaging. However, this novel approach needs further validation.

OBJECTIVE

To evaluate the performance of the Fresno-Québec rule in identifying patients who do not require a prereduction radiograph and assess the variables associated with a clinically significant fracture.

DESIGN, SETTINGS, AND PARTICIPANTS

A multicenter, retrospective cohort study from 2015 to 2021. Data were extracted from three ED university-affiliated tertiary-care centers. Patients aged ≥18 years with a final diagnosis of anterior glenohumeral dislocation were included.

OUTCOMES MEASURE AND ANALYSIS

Accuracy metrics [sensitivity (Se), specificity (Sp), positive (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR)] of the Fresno-Québec rule were measured. Multivariable logistic regression model was used to identify variables associated with the presence of a concomitant clinically significant fracture.

MAIN RESULTS

A total of 2129 patients were included, among whom 9.7% had a concomitant fracture. The performance metrics of the Fresno-Québec rule were as follows: Se 0.96 95% confidence interval (0.92-0.98), Sp 0.36 (0.34-0.38), PPV 0.14 (0.12-0.16), NPV 0.99 (0.98-0.99), PLR 1.49 (1.42-1.55) and NLR 0.12 (0.06-0.23). A total of 678 radiographs could have been avoided, corresponding to a reduction of 35.2%. Age ≥40 years, first dislocation episode [odds ratio (OR) = 3.18 (1.95-5.38); P  < 0.001], the following mechanisms: road collision [OR = 6.26 (2.65-16.1)], low-level fall [OR = 3.49 (1.66-8.28)], high-level fall [OR = 3.95 (1.62-10.4)], and seizure/electric shock [OR = 10.6 (4.09-29.2)] were associated with the presence of a concomitant fracture.

CONCLUSION

In this study, the Fresno-Québec rule has excellent Se in identifying concomitant clinically significant fractures in patients with an anterior glenohumeral dislocation. The use of this clinical decision rule may be associated with a reduction of approximately a third of unnecessary prereduction radiographs.

Shoulder reduction on the scene: current practice and outcome of the Bavarian Mountain Rescue Service-a prospective observational study

Out-of-hospital reduction of shoulder dislocations using the Campell method is recommended by the International Commission for Alpine Rescue and applied in the Bavarian Mountain Rescue Service (Bergwacht Bayern, BWB) protocols. This prospective observational study includes patients out-of-hospital with suspected shoulder dislocation and treated and evacuated by the BWB. Data were systematically collected using three questionnaires: one completed on-site by the rescuer, the second in hospital by the physician and the third within 28 (8-143) days after the accident by the patient. The suspected diagnosis of shoulder dislocation was confirmed in hospital in 37 (84%) of 44 cases. Concomitant injuries in other body regions were found in eight (16%) of 49 cases and were associated with incorrect diagnosis (p = 0.002). Younger age (p = 0.043) and first shoulder dislocation event (p = 0.038) were associated with a higher success rate for reduction attempts. Out-of-hospital reduction of shoulder dislocations leads to significant pain relief and no poorer long-term outcome. Signs that are associated with successful out-of-hospital reduction (younger age and first event), but also those that are associated with incorrect diagnosis (concomitant injuries) should be considered before trying to reduce shoulder dislocation on site. The considerable rate of incorrect first diagnosis on site should give rise to an intensive discussion around teaching and training for this intervention.Trial registration: This study is registered with the German Registry for Clinical Trials (DRKS00023377).

Evaluation of the relationship between scapula morphology and anterior shoulder dislocation accompanying greater tuberosity fracture

INTRODUCTıON: It is estimated that 5-30% of traumatic anterior shoulder dislocations are accompanied by greater tuberosity fracture (GTF), and the pathomechanism of these fractures is not yet clear. Our hypothesis is to examine the relationship between the scapula morphology and anterior shoulder dislocation (ASD) accompanying GTF. MATERıALS AND METHODS: The patients were divided into two groups according to the accompanying GTF. 40 patients with isolated traumatic ASD and 31 patients with accompanying GTF were included in the study. Critical shoulder angle (CSA), glenoid inclination (GI), acromial index (AI) and greater tuberosity angle (GTA) values were measured in two sessions by two independent observers in the standard antero-posterior radiographs of the patients in both groups. RESULTS: The mean CSA was 40.82°±3.19° and 35.49°±2.19° in accompanying GTF group and the isolated ASD group, respectively. The mean CSA was significantly higher in accompanying GTF group than isolated ASD group(P<0.001). The GI was significantly higher in the isolated ASD than in accompanying GTF group (P = 0.001). The mean GI was 18.7°±6.85° and 10.45°±4.87° in accompanying GTF group and the isolated ASD, respectively. Cut-off value of CSA and GI was 38° (88.2% sensitivity,88.9% specificity) and 14.5° (70.6% sensitivity and 72.2% specificity), respectively. There was no significant difference regarding the mean GTA and AI values between GTF group and the isolated ASD group (P = 0.98, P = 0.63). CONCLUSıONS: Increased CSA and GI values are associated with traumatic anterior shoulder dislocation accompanied by greater tuberosity fracture.

Early reduction of acute anterior shoulder dislocations in a ski field setting

OBJECTIVE

The present study describes the management of suspected shoulder dislocations in ski field clinics.

METHODS

Data were collected from two clinics in Queenstown, New Zealand. Suspected anterior shoulder dislocations, with no suspicion of significant fractures and without imaging, underwent attempted reduction.

RESULTS

Ninety percent (n = 49) of dislocations were successfully relocated. No short-term complications because of this procedure were observed.

CONCLUSION

This short report raises the possibility that early anterior shoulder reduction in a ski field clinic can be safe without imaging, in select cases. Prospective studies including patient centred data are recommended.

A systematic review of pre-hospital shoulder reduction techniques for anterior shoulder dislocation and the effect on patient return to function

PURPOSE

The majority of acute anterior shoulder dislocations are sustained during sports and wilderness activities. The management of acute dislocations in the pre-hospital setting is currently without guidelines based on the evidence. The study aims to assess the risk of acute complications in pre-hospital shoulder reduction and identify which pre-hospital reduction technique has the highest success rate in the published literature.

METHODS

The involved databases were Allied and Complementary Medicine, CENTRAL, CINAHL, Cochrane Database of Systematic Reviews, Embase, Europe PMC, Ovid MEDLINE®, Pedro, Proquest, Trip, and World Health Organization International Clinical Trials Registry platform. Only original research of high methodological quality was included, which was defined by the recently developed assessment tool-assessing the methodological quality of published papers (AMQPP) and investigated the management of acute anterior shoulder dislocations in the pre-hospital setting.

RESULTS

Two hundred and ninety-eight articles were identified and screened. A full text review was performed on 40 articles. Four articles published between 2015 and 2018 met the inclusion criteria. A total of 181 patients were included with the study duration ranging from 6 to 60 months. All studies reported zero immediate complication following pre-hospital reduction and there were no documented subsequent adverse events regardless of the technique used. Prompt resolution of neurological symptoms was observed following the early and successful pre-hospital reduction. First attempt success rate, when performed by skilled practitioners, ranged from 72.3% to 94.9%.

CONCLUSION

Pre-hospital shoulder reduction appears to be a safe and feasible option when carried out with the appropriate expertise. A novel reduction technique adapted from the mountain medicine diploma course at the University of Paris North was found to have the highest first attempt reduction success rate of 94.9%. Other techniques described in the literature included Hippocratic, Stimson's, Counter-traction and external rotation with the success rates ranging from 54% to 71.7%.

Management of primary anterior shoulder dislocations: a narrative review

Abstract

The recurrence rate following acute anterior shoulder dislocations is high, particularly in young, active individuals. The purpose of this paper is to provide a narrative overview of the best available evidence and results with regards to diagnostic considerations, comorbidities, position of immobilization, surgical versus conservative management, and time to return to play for the management of primary anterior shoulder dislocations. Three independent reviewers performed literature searches using PubMed, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials and systematic reviews meeting inclusion criteria from 1930 to April 2019 were appraised and discussed with the intent to consolidate the best available evidence with regards to lowering recurrence rates. A majority of studies support early surgical intervention for individuals between 21 and 30 years of age following primary shoulder dislocations, as this group is particularly susceptible to recurrence. Conservative treatment plans favor 1–3 weeks of immobilization in internal rotation, followed by rehabilitation. Surgical methods are associated with longer time to return to play, but lower recurrence rates. Return to play time is best determined on an individualized basis, when subjective and objective function of both shoulders is determined to be symmetric. This paper broadly summarizes the best available evidence for the management of primary anterior shoulder dislocations. There remains a need for randomized studies to determine ideal long-term treatment following conservative or surgical management, as general timelines for returning to play following injury remain vague.

Level of evidence

IV, Narrative Review

Current Approach to the Diagnosis and Management of Shoulder Dislocation in Children

Shoulder dislocations are a common presentation to the emergency department. Although many cases may be diagnosed by history and clinical examination alone, imaging may help diagnose more challenging cases. Three-view radiographs are important for identifying subtle posterior dislocations, and ultrasonography has been gaining evidence as an alternate diagnostic modality. Intra-articular lidocaine and nerve blocks may improve pain control and reduce the need for procedural sedation. Multiple, evidence-based reduction techniques are described including tips for improving success. Immobilization strategies and follow-up are also discussed.

International Commission for Mountain Emergency Medicine Consensus Guidelines for On-Site Management and Transport of Patients in Canyoning Incidents

Canyoning is a recreational activity that has increased in popularity in the last decade in Europe and North America, resulting in up to 40% of the total search and rescue costs in some geographic locations. The International Commission for Mountain Emergency Medicine convened an expert panel to develop recommendations for on-site management and transport of patients in canyoning incidents. The goal of the current review is to provide guidance to healthcare providers and canyoning rescue professionals about best practices for rescue and medical treatment through the evaluation of the existing best evidence, focusing on the unique combination of remoteness, water exposure, limited on-site patient management options, and technically challenging terrain. Recommendations are graded on the basis of quality of supporting evidence according to the classification scheme of the American College of Chest Physicians.

Management of first-time dislocations of the shoulder in patients older than 40 years: the prevalence of iatrogenic fracture

OBJECTIVE

To evaluate the prevalence of iatrogenic humeral neck fracture after attempted closed reduction in patients older than 40 years who present with a first-time anterior dislocation.

DESIGN

Retrospective cohort study, evidence-based medicine level IV.

PATIENTS

Ninety-two patients older than 40 years (mean 66.6 years of age) with a first-time anterior dislocation of the shoulder.

INTERVENTION

Closed reductions by the emergency medicine physicians under conscious sedation, in the emergency department.

MAIN OUTCOME MEASUREMENTS

Prevalence of iatrogenic fracture on postreduction radiographs.

RESULTS

Nineteen (20.7%) patients were diagnosed with a concomitant greater tuberosity fracture on initial radiograph. In the postreduction radiographs, 5 patients (5.4%) were identified with a postreduction humeral neck fracture, and all of them had a greater tuberosity fracture on initial radiographs. A highly significant association (P < 0.0001) was observed between the finding of a greater tuberosity fracture on the initial radiographs and the occurrence of iatrogenic humeral neck fracture after close reduction.

DISCUSSION

Previous case reports have described an iatrogenic humeral neck fracture with reduction attempt of shoulder dislocation. In our retrospective study, 21% of the cohort of patients older than 40 years had a concomitant greater tuberosity fracture; 26% of them had an iatrogenic humeral neck fracture after reduction attempt under sedation in the emergency room. These patients ended up with poor outcome.

CONCLUSIONS

Patients older than 40 years, presenting with a first-time anterior shoulder dislocation with an associated fracture of the greater tuberosity have a significant rate of iatrogenic humeral neck fracture during closed reduction under sedation.

Incidence of associated injury in posterior shoulder dislocation: systematic review of the literature

OBJECTIVE

Posterior shoulder dislocations are rare and often missed. Classically associated with seizures, very little is known about the incidence and type of associated injuries. Unfortunately, the majority of the literature consists of incidental reports or small case series. Our goal was to increase the strength of available data by performing a systematic review.

DATA SOURCES

We searched EMBASE and PubMed for the terms "posterior shoulder dislocation." Our inclusion criteria were articles in either English or French with the words "posterior" and "dislocation" in the abstract or title. All reports of chronic cases or instability as well as those without patient information were excluded. Data regarding demographics, etiology, investigations, associated injuries, treatments, and outcomes were extracted. All data were analyzed by using SPSS 18.0 (IBM, Chicago, IL).

RESULTS

A total of 766 articles were found of which 108 were retained for analysis. A total of 475 patients (543 shoulders) were compiled. Seizures were reported in 34% of cases. A majority of dislocations (65%) had associated injuries. Fracture was most common followed by reverse Hill-Sachs and cuff tears. In the absence of fracture or reverse Hill-Sachs injury, the risk of cuff tear increased nearly fivefold (odds ratio, 4.6; P = 0.016).

CONCLUSION

Our results suggest the amount of associated injuries related to posterior shoulder dislocation is far greater than thought. We propose an investigation algorithm for acute posterior shoulder dislocations.