Should closed reduction be attempted in the emergency department for an acute anterior shoulder fracture dislocation?

BACKGROUND: Whether an anterior shoulder fracture dislocation should be reduced under sedation in the emergency department is still a dilemma. This retrospective study aimed to determine when it is safe to perform a closed reduction based on the fracture pattern. METHODS: Surgically treated anterior shoulder fracture dislocations over eight years were classified into three groups. Group 1 involved an isolated greater tuberosity fracture. Group 2 and 3 involved surgical and or anatomical neck fractures. In group 2, the head and the shaft fragments were displaced together anteriorly and inferiorly; whereas in group 3, the head was displaced and locked under the glenoid, but the shaft migrated superiorly. The outcome and complications of closed reduction were reviewed. RESULTS: Twenty-nine patients with 30 surgically treated anterior shoulder fracture dislocations were reviewed. These included twelve patients (thirteen shoulders) in group 1, six patients in group 2, and eleven patients in group 3. Closed reduction was attempted in twelve shoulders in group 1, five shoulders in group 2, and six shoulders in group 3. Eleven group 1, four group 2, and none group 3 dislocations were successfully reduced. The patient who failed reduction in group 1 sustained an iatrogenic anatomical neck fracture. One patient failed reduction in group 2. His surgical neck fracture was displaced further after manipulation. No other complications occurred after closed manipulation. DISCUSSION AND CONCLUSION: Closed reduction under sedation is usually successful and safe for group 1 injuries with an iatrogenic complication rate of only 8.3% (1/12) in our series. It should also be considered for group 2 injuries as 80% (4/5) were successfully reduced. However, further displacement from the reduction maneuver may warrant an urgent open reduction. Closed reduction is futile for group 3 injuries. We recommend an acute management algorithm based on our results.