Management of First-Time Dislocations of the Shoulder in Patients Older Than 40 Years

Abstract

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. Retrospective cohort study, evidence-based medicine level IV. Ninety-two patients older than 40 years (mean 66.6 years of age) with a first-time anterior dislocation of the shoulder. Closed reductions by the emergency medicine physicians under conscious sedation, in the emergency department. Prevalence of iatrogenic fracture on postreduction radiographs. 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. 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. 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.