Proximal humeral fracture dislocations require prompt reduction of the glenohumeral joint dislocation.
Keep in mind that with fracture dislocations it may be necessary to convert to an open reduction procedure in order to reduce the joint. Therefore, arrange for operating room availability.
Since the reduction of the dislocation may be difficult, regional or general anesthesia, including muscle relaxation, is recommended.
Note: Definitive operative treatment is usually best for glenohumeral fracture dislocations. Nonoperative treatment should be considered only if surgery has a significant risk, or if shoulder reduction has resulted in acceptable reduction of the fracture components.
Principles of closed reduction (see illustration)
Axial traction on the arm is almost always helpful. Even with a fracture of the proximal humerus there is usually sufficient intact soft tissue so that the traction is transmitted to the humeral head.
Direct manipulation of the dislocated head segment can assist the reduction. Pressure should be applied over the prominent humeral head, and directed to push it back into the glenoid. Beware pressure on neurovascular structures.
Confirmation of glenohumeral reduction
Once the glenohumeral reduction is felt, it should be confirmed with true AP and axillary x-rays. Additional fractures or displacement should be looked for. When x-ray anatomy is not completely clear, a CT scan, often with reconstructed views, can be very helpful.
Check also the neurovascular status, especially distal pulses, motor function, and sensation. The axillary nerve is at particular risk and can be assessed by sensation over the lateral deltoid and the cooperative patient’s ability to contract the deltoid muscle.
Rule out rotator cuff tear
Particularly in older patients, glenohumeral dislocations may result in a torn rotator cuff. Early repair, before tendon retraction or significant atrophy, is the most effective treatment. If physical assessment does not confirm rotator cuff strength, additional studies (eg, ultrasound, MRI) should be performed promptly.