A 17-year-old male was brought to the emergency department by ambulance after a road traffic accident (RTA). He was sitting in the front seat, wearing a seatbelt. The car did not roll over, and he was not ejected out of the vehicle. He did not remember his exact position inside the car at the time of the accident. In the primary assessment, the patient was conscious, oriented, alert, and hemodynamically stable, and his Glasgow Coma Scale (GCS) was 15/15; however, he was in severe pain. There were multiple minor injuries and bruises on the face, chest, and abdomen, and obvious deformity in the right arm. The patient complained of right arm pain with tenderness and inability to move the right arm. On examination, the patient looked unwell and distressed. There was swelling in the right arm and pain with minimal passive movement. The neurovascular examination was normal.
The initial plain X-ray and CT showed anterior dislocation of the right shoulder with an ipsilateral mid-shaft fracture of the humerus (Figures 1, 2).
Urgent closed reduction under surgical sedation was done by direct manipulation of the humeral head but the reduction failed. Due to the failure of closed reduction, the patient was shifted to the operating room (OR) the same night, as an open reduction was indicated. Intraoperatively, we reached the shoulder through a deltopectoral approach. Initially, shoulder dislocation was reduced easily. We then tried to insert the anterograde guide wire, but it could not pass the fracture site. Then, we tried to do open reduction and exploration of the fracture site but there was a blockage of the medullary cavity by blood clots, which explains the failure of the insertion of the guide wire. The blood clots were evacuated and the medullary cavity was washed. The guide wire was then inserted into the medullary cavity successfully. Immobilization of the limb was done by a U-shaped cast (Figures 3, 4).
There were no problems postoperatively; the patient was looking well, not in distress, and passing urine and stool. There was no nerve injury, especially at the level of the radial nerve. The patient was discharged after three days with follow-up in the outpatient department (OPD). Figure 5 shows the fracture four weeks following discharge.
After six weeks, the cast was removed with minimal progressive mobilization of the affected limb (Figure 6).