Case Reports
Iatrogenic Propagation of Anterior Fracture-Dislocations of the Proximal Humerus: Case Series and Literature Review With Suggested Guidelines for Treatment and Prevention
Am J Orthop. 2007 September;36(9):E133-E137
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Anil S. Ranawat, MD, Gregory S. DiFelice, MD, Michael Suk, MD, JD, MPH, Dean G. Lorich, MD, and David L. Helfet, MD
Dr. Ranawat is Orthopaedic Trauma Resident, PGY-5, Hospital for Special Surgery, New York, New York.
Dr. DiFelice is Director, Orthopaedic Sports Medicine and Joint Reconstruction, Jacobi Medical Center, Bronx, New York.
Dr. Suk is Director, Orthopaedic Trauma Service, University of Florida–Shands Jacksonville, Jacksonville, Florida, and Assistant Professor, Orthopaedic Surgery, University of Florida, Jacksonville, Florida.
Dr. Lorich is Assistant Director, Orthopaedic Trauma Service, New York Presbyterian Hospital, New York, New York, and Assistant Professor, Orthopaedic Surgery, Weill Cornell University Medical College, New York, New York.
Dr. Helfet is Director, Orthopaedic Trauma Service, Hospital for Special Surgery and New York Presbyterian Hospital, New York, New York, and Professor, Orthopaedic Surgery, Weill Cornell University Medical College, New York, New York.
Abstract not available. Introduction provided instead.
Fracture-dislocations of the proximal humerus, though rare, are difficult to manage. An unfortunate and challenging subset of these injuries includes fractures that are iatrogenically created, or worsened, during reduction maneuvers for an anterior shoulder dislocation. Iatrogenic fracture-dislocations have 2 basic mechanisms. In the first, a shoulder dislocation with or without a concomitant tuberosity fracture or Hill-Sachs lesion is converted to a more complicated fracture dislocation with the creation of a new fracture line during a reduction maneuver; in the second, a shoulder dislocation with an unrecognized neck fracture is converted to a more complicated fracture-dislocation with displacement or propagation of the neck fracture during a reduction maneuver. In both cases, the patient is left with a more complicated, higher-grade fracture-dislocation of the proximal humerus—an injury most likely significantly displaced and in need of surgical intervention. In this article, we report on a series of 6 cases of iatrogenic fracture-dislocations. All 6 cases originally were anterior dislocations. Four of the 6 had concomitant greater tuberosity fractures; the other 2 had large Hill-Sachs lesions. Five of the 6 were converted to severely displaced fracture-dislocations of the proximal humerus after unsuccessful reduction attempts; 4 of the 5 required a shoulder hemiarthroplasty, and the fifth required open reduction and internal fixation (ORIF). In the sixth and final case, we applied a new technique to prevent the complication of iatrogenic displacement: We used prophylactic percutaneous fixation to prevent fracture propagation so that we could safely perform closed reduction of the dislocation. In retrospect, at least 2 and perhaps 3 cases had unrecognized anatomical or surgical neck fractures.