A 65-year-old woman with a history of osteoporosis presents to the orthopedic clinic 4 weeks after a fall on her outstretched hand. She reports severe shoulder pain and inability to abduct the arm. On examination, there is marked shoulder swelling, ecchymosis, and severe pain with any passive movement. Plain radiographs show an anterior shoulder dislocation with an associated large 4-cm fracture of the anteroinferior glenoid rim (Bankart lesion). The humeral head is reduced on the current films. What is the most appropriate next step in management?

Explanation

## Management of Anterior Shoulder Dislocation with Glenoid Fracture ### Classification and Significance of Glenoid Fractures **Key Point:** A Bankart lesion (anteroinferior glenoid fracture) >2.5 cm or involving >25% of the glenoid surface is a **critical injury** that fundamentally changes management from conservative to operative. ### Why This Case Requires Surgical Intervention **High-Yield:** Large glenoid fractures (>2.5 cm or >25% of articular surface) compromise the bony socket and create chronic instability even after reduction. Conservative management alone leads to: - Persistent instability and re-dislocation (>80% recurrence rate) - Chronic pain and functional disability - Accelerated osteoarthritis ### Diagnostic and Surgical Planning Algorithm ```mermaid flowchart TD A[Anterior shoulder dislocation with glenoid fracture]:::outcome A --> B{Fracture size?}:::decision B -->|< 2.5 cm and < 25% glenoid| C[Conservative: sling + PT]:::action B -->|> 2.5 cm or > 25% glenoid| D[CT imaging for surgical planning]:::action D --> E{Fracture pattern and bone quality?}:::decision E -->|Suitable for arthroscopy| F[Arthroscopic Bankart repair + capsular plication]:::action E -->|Large/comminuted/poor quality| G[Open reduction and internal fixation]:::action C --> H[Physiotherapy protocol]:::action F --> I[Post-operative rehabilitation]:::action G --> I ``` ### Why CT Imaging Is Essential CT provides: 1. **Exact fracture size and location** — determines surgical approach 2. **Bone quality assessment** — osteoporotic bone may require open fixation rather than arthroscopy 3. **Associated injuries** — Hill-Sachs lesion, rotator cuff tears, labral pathology 4. **Surgical planning** — screw trajectory, graft requirements, approach selection **Clinical Pearl:** In elderly patients with osteoporosis (as in this case), bone quality is often too poor for arthroscopic repair alone. Open reduction with plate fixation or bone grafting may be necessary. ### Comparison of Management Approaches | Feature | Conservative (Sling) | Arthroscopic Repair | Open ORIF | |---------|----------------------|-------------------|----------| | Indications | Fracture < 2.5 cm, < 25% glenoid | Bankart lesion 2.5–4 cm, good bone quality | Large/comminuted fractures, poor bone quality | | Re-dislocation rate | > 80% with large fractures | 5–10% | < 5% | | Operative time | N/A | 60–90 min | 90–120 min | | Recovery | 6–8 weeks | 3–4 months | 4–6 months | | Osteoporotic bone | Poor outcome | May fail | Better outcome | ### Why Other Options Are Suboptimal - **Sling alone (6 weeks):** A 4-cm Bankart fracture is too large for conservative management. This approach will result in chronic instability and re-dislocation in > 80% of cases. - **Immediate arthroscopic repair without imaging:** Premature operative intervention without understanding fracture pattern, bone quality, and associated injuries risks inadequate fixation. CT is mandatory for surgical planning. - **Traction and closed reduction:** The dislocation is already reduced on current films. Traction is not indicated and does not address the underlying glenoid fracture. [cite:Rockwood & Green's Fractures in Adults Ch 14; Orthopedic Surgery Essentials Ch 8]