title: When is it safe to reduce fracture dislocation of shoulder under sedation? Proposed treatment algorithm.
abstract: BACKGROUND
  Shoulder dislocations are common. It is known that incongruent shoulder should be promptly reduced. However, when associated with fracture of the proximal humerus, there is a clinical dilemma if reduction under sedation is a safe option. We wanted to establish when it is safe to attempt reduction of a shoulder fracture dislocation under sedation in emergency room.
  
  
  METHODS
  This is a retrospective cohort study assessing consecutive patients presenting with a dislocation of a gleno-humeral joint with an associated fracture of the humerus between 2007 and 2015. The radiographs and patients' records were examined. The number of fragments according to Neer's criteria and size of fragments were recorded.
  
  
  RESULTS
  We identified 102 patients who presented with 104 cases of fracture dislocation of shoulder joint. 10 of the dislocations were posterior, remainder were anterior. All posterior dislocations were reduced under general anaesthesia. Sixty-two anterior fracture dislocations had attempted reduction under sedation in emergency department. Eight of those were unsuccessful, and patient required general anaesthetic for further management. In five of those cases, significant displacement of humeral head in relation to the shaft after attempted reduction.
  
  
  CONCLUSIONS
  We propose pragmatic approach to the initial treatment of fracture dislocations of shoulder. In type I injury, where there is an anterior dislocation with greater tuberosity fracture, one should attempt a reduction under sedation; 94% of attempted reductions under sedation were successful and no fracture propagation occurred. In case of a type II injury, when the fracture is involving a surgical neck of the humerus with or without greater tuberosities fracture, our experience suggests that no attempt of reduction is undertaken under sedation and patient has general anaesthetic. Posterior dislocation with any fracture remains an unsolved problem, but in our series no attempt of reduction under sedation was made.
authors.affiliation: Department of Trauma and Orthopaedics, University Hospital of Wales, Cardiff, UK. konradwronka@doctors.org.uk.|ST6 Trauma and Orthopaedics, University Hospital of Wales, Cardiff, CF14 4XW, UK. konradwronka@doctors.org.uk.
authors.forename: Konrad Sebastian
authors.initials: KS
authors.lastname: Wronka
authors.affiliation: Department of Trauma and Orthopaedics, University Hospital of Wales, Cardiff, UK.|Trust SpR Trauma and Orthopaedics, University Hospital of Wales, Cardiff, UK.
authors.forename: Abhimanyu
authors.initials: A
authors.lastname: Ved
authors.affiliation: Department of Trauma and Orthopaedics, University Hospital of Wales, Cardiff, UK.|Consultant Trauma and Orthopaedic Surgeon, University Hospital of Wales, Cardiff, UK.
authors.forename: Khitish
authors.initials: K
authors.lastname: Mohanty
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000768:Anesthesia, General; D000070628:Closed Fracture Reduction / Q000379:methods*; D054810:Deep Sedation; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D012783:Shoulder Dislocation / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D012784:Shoulder Fractures / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D017211:Treatment Failure; D055815:Young Adult
keywords: Classification; Fracture dislocation gleno-humeral joint; Fracture dislocation shoulder