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Mechanism of injury and management in traumatic anterior shoulder dislocation with concomitant humeral shaft and ipsilateral scapula fracture: a case report and review of the literature
© Farooque et al.; licensee BioMed Central. 2014
Received: 19 May 2014
Accepted: 15 October 2014
Published: 16 December 2014
Traumatic anterior dislocation of the shoulder is an emergency and warrants urgent attention. However, it becomes difficult to manage in cases of associated fractures of humerus and other bones surrounding the shoulder joint. There have been reports of traumatic anterior dislocation of the shoulder associated with humeral fractures in the literature but the trilogy of anterior dislocation of the shoulder; humeral shaft fracture; and scapular fracture have never been described.
We present the case of a 27-year-old south Asian man presenting with the above-mentioned injury. He was managed with open reduction and internal fixation of the fracture and subsequent reduction at the shoulder joint. The fracture of the scapula was managed conservatively. Radiological union was achieved at 14 weeks with a good range of movements at the shoulder.
Shoulder dislocation associated with fractures of humerus and scapula occurs in rare circumstances due the peculiar mechanism of injury. There is risk of neurovascular damage while attempting joint reduction without fracture fixation so, in these cases, the fracture should be addressed first and dislocation later.
Traumatic anterior dislocation of the shoulder with concomitant humeral shaft and ipsilateral scapula fracture is a serious but rare injury. There have been reports of anterior dislocation with humeral fracture in the literature, but its association with fracture of the scapula has not been reported. We report a case of traumatic anterior dislocation of the shoulder, associated with ipsilateral fracture of shaft humerus along with fracture of the scapula due to an unusual mechanism of injury and its proposed management.
Dislocation of the shoulder with ipsilateral humeral shaft fracture is a rare injury with very few reported cases in the literature. The very first case of the same was reported by Winderman et al..
Various mechanisms of injury have been proposed by previous authors. Whether the dislocation or the fracture occurs first is debatable. Some authors have postulated that direct transmission of force leads to simultaneous dislocation and fracture  while others propose, indirect force leading to the dislocation and direct force leads to the fracture. Kontakis et al. proposed dislocation at the shoulder was the preceding event and subsequently the bending or torsional force fractured the shaft of the humerus while Sankaran-Kutty et al. postulated that force along the axis of the humerus resulted in dislocation and fracture of the humeral shaft. In our case, our patient was hit from behind by a speeding truck while he was a pedestrian. The force was transmitted from back to front, which resulted in the fracture of his scapula and the anterior dislocation of his shoulder. The same force vector may have fractured the humeral shaft or the shaft could have been fractured secondary to the fall with the left arm entrapped under the body, as a result of direct impact with the ground.
The treatment modalities include closed reduction and plaster of paris slab application , nailing , and plating  of the humeral shaft along with reduction of the shoulder dislocation. Good clinical results have been reported with almost all the modalities. However, there is no consensus in the literature for treating this type of injury.
In our case, the fracture of the humeral shaft was treated by open reduction and internally fixed with a proximal humerus locking plate as the transverse fracture was located in the proximal fourth of the humeral shaft. A dynamic compression plate would not have been able to engage a minimum eight cortices in the proximal fragment as per AO recommendation. Subsequently, the anterior dislocation of the shoulder was reduced, with gentle manipulation intraoperatively, under direct vision. Zlowodzki et al. in their systematic review of scapular fractures had reported excellent/good results in 82% of the cases treated conservatively. Cole et al. had suggested operative intervention in scapular fractures with a glenopolar angle greater than 30 degrees, medial displacement of the lateral border by more than 25mm, angular deformity more than 45 degrees, and concomitant intraarticular step greater than 3mm or double-displaced disruption of the superior shoulder suspensory complex. In our case, the scapular body fracture did not meet any of the criteria suggested by Cole et al. for operative intervention. Therefore the scapular body fracture was managed conservatively. The fracture united with good functional outcome at both the glenohumeral and scapulothoracic joint.
Dislocation of the shoulder is rarely associated with diaphyseal fracture of the humerus and fracture of the ipsilateral scapula. The anteriorly direct force and subsequent fall creating a second force vector could have led to the fracture dislocation. Prompt treatment with open reduction and internal fixation of the humeral fracture helps in reducing the shoulder dislocation thereby improving the functional outcome at the shoulder joint. The joint reduction should not be attempted prior to fracture fixation due the high risk of neurovascular damage. The scapular fracture needs to be treated on its own merit, depending on the fracture configuration.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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