Frequency of Fractures Identified on Post-Reduction Radiographs after Shoulder Dislocation

Abstract

IntroductionMost emergency physicians routinely obtain shoulder radiographs before and after shoulder dislocations. However, currently there is limited literature demonstrating how frequently new fractures are identified on post-reduction radiographs. The primary objective of this study was to determine the frequency of new, clinically significant fractures identified on post-reduction radiographs with a secondary outcome assessing total new fractures identified.MethodsWe conducted a retrospective chart review using appropriate International Classification of Diseases, 9th Revision (ICD-9) codes to identify all potential shoulder dislocations that were reduced in a single, urban, academic emergency department (ED) over a five-year period. We excluded cases that required operative reduction, had associated proximal humeral head or shaft fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted separately by two study investigators with disagreements settled by consensus among three investigators. Images from indeterminate cases were reviewed by a radiology attending physician with musculoskeletal expertise. The primary outcome was the percentage of new, clinically significant fractures defined as those altering acute ED management. Secondary outcomes included percentage of new fractures of any type.ResultsWe identified 185 total patients meeting our study criteria. There were no new, clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI [3.3%–10.7%]) total new fractures identified, all of which were without clinical significance for acute ED management.ConclusionPost-reduction radiographs do not appear to identify any new, clinically significant fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED setting for shoulder dislocations.

Ultrasound for the diagnosis of shoulder dislocation and reduction: A systematic review and meta‐analysis

“…Additionally, POCUS was highly accurate for diagnosing associated fractures. While most fractures identified on imaging are of minimal clinical significance in the ED setting, 31,32 POCUS can be helpful for identifying more significant injuries which may complicate the reduction (e.g., humeral neck fracture) or increase the risk of re‐dislocation (e.g., large Bankart fracture).…”

A pictorial presentation and the clinical use of the modified trauma axial (MTA) shoulder x‐ray view

“…8 These new fractures mostly consisted of Hill-Sachs and Bankart lesions. 8 Another study has identified traumatic pathologies in 40% of shoulder radiographs with acute trauma, most of which were Hill-Sachs lesions. 5 Despite there being a statistically significant relationship between Hill-Sachs lesions and recurrent dislocations, 1,3 Gottlieb et al argued that Hill-Sachs and Bankart lesions do not require immediate attention by the orthopaedic team.…”

“…Most radiology departments routinely perform pre-and post-reduction shoulder radiographs for patients with shoulder dislocations consisting of AP and lateral scapula shoulder projections. 8 At the study site where the presented case studies were performed, the protocol was either a standard AP or glenoid AP along with the lateral scapula shoulder and MTA projection. The importance of post-reduction shoulder radiographs in ED has been under debate, along with which fractures are clinically important.…”

“…The importance of post-reduction shoulder radiographs in ED has been under debate, along with which fractures are clinically important. [8][9][10] none of the fractures identified are clinically important and change ED management. 8 These new fractures mostly consisted of Hill-Sachs and Bankart lesions.…”

“…1,3 The size of the Hill-Sachs lesion and the presence of glenoid rim fractures are important considerations for surgical intervention. 1,7 There remains a debate over whether radiographs are required for shoulder reductions, 8,9 but the following four case studies support the need for performing MTA views as part of the post-reduction shoulder series. The perspectives and interpretations of an emergency department (ED) doctor, radiologist, and orthopaedic doctor for each case study were also included.…”