A 65-year-old woman comes to the emergency department due to severe pain in her left arm. The patient tripped and fell while working in her yard this morning. To save her head and face from hitting the concrete, she fell on her outstretched left hand. The patient reports no head injury or loss of consciousness. She has no back or neck pain. Vital signs are within normal limits. On examination, the left arm is externally rotated and abducted, and the patient is unable to move her arm without excruciating pain. Distal pulses and sensation are intact. X-ray shows anterior shoulder dislocation and a nondisplaced fracture of humeral neck. The patient is given appropriate analgesics for pain control. What is the best next step in management?

Question

A 65-year-old woman comes to the emergency department due to severe pain in her left arm.  The patient tripped and fell while working in her yard this morning.  To save her head and face from hitting the concrete, she fell on her outstretched left hand.  The patient reports no head injury or loss of consciousness.  She has no back or neck pain.  Vital signs are within normal limits.  On examination, the left arm is externally rotated and abducted, and the patient is unable to move her arm without excruciating pain.  Distal pulses and sensation are intact.  X-ray shows anterior shoulder dislocation and a nondisplaced fracture of humeral neck.  The patient is given appropriate analgesics for pain control.  What is the best next step in management?

Quizplus · Accepted Answer

Explanation: This elderly woman has an acute glenohumeral (shoulder) dislocation associated with a humeral neck fracture. Shoulder dislocations are associated with additional injuries, including axillary nerve injury, fracture, and rotator cuff tear, in up to 40% of cases. Risk factors for associated injuries include age >40, first-time dislocation, and traumatic mechanism (eg, fall on an outstretched hand, which is generally associated with posterior dislocation but can cause anterior dislocation). If any of these factors is present, x-ray is recommended to rule out fracture. fall on an outstretched hand For patients with no associated fracture and no other evidence of neurovascular (eg, radial artery, axillary nerve) injury, closed reduction under sedation can generally be attempted (eg, in the emergency department). Postreduction care typically includes immobilization of the shoulder for 2-3 weeks, followed by a progressive physical therapy program (Choice A). The most common fractures associated with shoulder dislocation are Hill-Sachs defect (ie, avulsion fracture of the posterolateral humeral head) and Bankart lesions (ie, glenoid labrum disruption); these injuries are often minor and generally (though not always) not a contraindication to closed reduction. Humeral neck fractures may disrupt blood flow to the humeral head (via the circumflex humeral arteries), leading to an increased risk for avascular necrosis. In addition, closed reduction may lead to further displacement of the fracture. Therefore, dislocations associated with humeral neck fractures, as in this patient, should not be reduced in the emergency department but require open surgical repair. (Choice B) Arterial injury is relatively uncommon in glenohumeral dislocation. CT angiography of the upper extremity is indicated for patients with signs of arterial injury (eg, large hematoma, diminished distal pulses) but is not needed for patients with an intact neurovascular examination. Posterior dislocation of the knee is commonly associated with injury to the popliteal artery and generally warrants vascular imaging. (Choice D) Venous duplex ultrasonography is indicated to assess for deep venous thrombosis, which typically presents with arm heaviness and swelling but is unlikely in the acute setting. Educational objective: Acute glenohumeral dislocation is often complicated by additional injuries, including axillary nerve injury, fracture, and rotator cuff tear. Humeral neck fractures are associated with an increased risk for avascular necrosis, and closed reduction may lead to further displacement of the fracture. Therefore, dislocation associated with humeral neck fracture requires open surgical repair.

A 65-Year-Old Woman Comes to the Emergency Department Due to Severe