71.14 Dislocation of the shoulder with fracture of the neck of the humerus

This is a serious injury, usually of older people. The neck of the patient’s humerus breaks, either at the time of the accident, or while a simple dislocation is being reduced with excessive force. The head of his humerus lies in front of his glenoid, or it may be displaced into his axilla. His axillary vessels and his brachial plexus are sometimes injured at the same time.

FRACTURE DISLOCATION OF THE HEAD OE THE HUMERUS

If possible refer the patient, particularly if he is a child, because the results of operating are better in children.

If this is not possible, give the patient a general anaesthetic and proceed as follows. Good relaxation is essential.

REDUCTION Try the following methods in turn, until you find one which works.

(1) Try the arm swinging method for a dislocated shoulder (71.8). Combine this with gently trying to push the head back into place with your thumbs.

(2) Try the Hippocratic method with a foot in the patient’s axilla (71.8).

(3) Ask an assistant to pull the patient’s arm into abduction, as in Fig. 71-13. As he does so, use both your thumbs to press the head of his humerus towards its socket.

If possible, X–ray his shoulder to check reduction while he is still anaesthetized.

If you can reduce the head , treat him as if he had an uncomplicated fracture of the neck of his humerus (71.12).

If you cannot reduce the head the first time, try only once more. If you fail again, and cannot refer him, accept the position and start ’pendulum’ exercises immediately (Fig. 69-11). Later, attempt wall ’crawling exercises’ (Fig. 71-7). Function will not be perfect, and he will not be able to raise his arm above his head, but he will be able to use it at waist level without pain.