Treatment Plan for Shoulder Dislocation with Fracture and Decreased Deltoid Sensation

Initial Assessment and Management

• Initial evaluation should include a standard set of shoulder radiographs including anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view to properly assess the dislocation and associated fracture, as recommended by the American College of Radiology 1
• Radiographs should be performed upright as malalignment can be underrepresented on supine imaging, according to the American College of Radiology 1
• CT scan is indicated to better characterize the fracture pattern, displacement, and angulation, as suggested by the American College of Radiology 1, 2
• MRI should be obtained to evaluate the neurological component (decreased deltoid sensation) and assess for soft tissue injuries including rotator cuff, labral, and glenohumeral ligament injuries, as recommended by the American College of Radiology 3

Surgical Management

• Surgical intervention is indicated due to the presence of neurological deficit (decreased deltoid sensation) suggesting axillary nerve involvement, as indicated by the American College of Radiology 3
• Surgical approach should include exploration of the axillary nerve, as suggested by the American College of Radiology 3

Post-Reduction/Post-Surgical Care

• Close monitoring of neurological status, particularly deltoid function and sensation, is necessary, as recommended by the American College of Radiology 3
• Consider removable splint rather than traditional cast to allow for easier assessment of neurovascular status, as suggested by the American Academy of Orthopaedic Surgeons 4
• Limit post-operative imaging to only what will change management to minimize radiation exposure, as recommended by the American Academy of Orthopaedic Surgeons 4
• Early physical therapy focusing on neuromuscular re-education of the deltoid if nerve injury is present, is necessary, as indicated by the American College of Radiology 3

Complications to Monitor

• Axillary nerve injury may lead to permanent deltoid weakness if not addressed promptly, as warned by the American College of Radiology 3
• Delayed surgical intervention makes stabilization more technically demanding due to progressive labro-ligamentous injury, as noted by the American College of Radiology 3

Common Pitfalls to Avoid

• Inadequate imaging leading to missed fracture components or underestimation of injury severity, can be avoided by following the American College of Radiology guidelines 1, 2