a combination of fracture shaft of humerus with ipsilateral shoulder fracture dislocation is rare injury .
only few cases are reported in the english literature till date having anterior dislocation of shoulder and ipsilateral closed humeral shaft fracture [ 110 ] .
there are cases of two - part fracture dislocation associated with humeral shaft fracture [ 2 , 58 , 10 ] and cases of three - part fracture dislocation associated with humeral shaft fracture .
we report an even rarer combination of injury where there was a two - part fracture dislocation of shoulder and ipsilateral compound fracture of humerus shaft .
we have discussed the probable mechanism of injury , and share our difficulties while managing this case and have reviewed the literature .
a 30-year - old female came to the emergency department at midnight following a road traffic accident with severe pain and swelling over the left shoulder and arm .
her arm was trapped when the vehicle in which she was travelling skidded off the road . on examination
she had degloving injury over posteromedial aspect of the arm extending to axilla with acute bend over arm and loss of shoulder contour ( fig . 
1b ) showed anterior dislocation with displaced greater tuberosity fracture and transverse fracture of humerus in its middle third .
an external fixator was applied on humerus and then shoulder was reduced without difficulty . after reduction ,
greater tuberosity fracture was found displaced so it was fixed with a cannulated cancellous screw through a deltoid splitting approach ( fig . 
skin grafting over the raw area was done on 10th day after the wound bed was ready .
there was poor take over axillary region so another grafting was done after 1 week .
after 3 weeks , wound healed completely and then , passive movement at shoulder joint was started .
after two and half months , the external fixator was removed and functional brace was applied . after 4 months , the fracture had united completely ( fig . 
she had a useful range of motion at the time of brace removal , with abduction and flexion of around 90. external rotation was 20 while internal rotation was normal . at the last follow - up of 11 months
, she had a good range of motion with abduction and flexion of 160flexion and full rotation . 

( b ) preoperative x - ray of left shoulder with arm anteroposterior view showing dislocation of shoulder , greater tuberosity fracture and humerus mid - shaft fracture .
( c ) postoperative x - ray showing shoulder reduction , greater tuberosity fracture fixation with a cannnulated screw and humerus fracture fixed with external fixation .
( d ) four months postoperative x - ray showing fracture union . ( a ) clinical picture at the time of presentation to emergency . ( b )
preoperative x - ray of left shoulder with arm anteroposterior view showing dislocation of shoulder , greater tuberosity fracture and humerus mid - shaft fracture . ( c )
postoperative x - ray showing shoulder reduction , greater tuberosity fracture fixation with a cannnulated screw and humerus fracture fixed with external fixation .
fracture shaft of humerus associated with ipsilateral dislocation is rare injury , whereas isolated shoulder dislocation or humerus fracture is very common .
anterior dislocation is relatively more common than posterior , in association with humerus shaft fracture . of the reported cases , almost all
so , this case , where we have the fracture dislocation with ipsilateral compound fracture of humerus shaft , is probably one of the few reported cases and is important due to three aspects .
sankaran - kutty and sadat - ali   suggested that force exerted along the axis of the humerus simultaneously fractured the humerus and dislocated the shoulder , whereas kontakis et al .  
proposed that the shoulder dislocated first and subsequent , bending or torsion forces fractured the shaft of humerus .
we believe that the mechanism of injury in our patient was as described in the second case by kontakis et al . , and this is supported by the fracture pattern that is transverse , acute bending of arm during emergency presentation and degloving of skin flap over arm with compounding of fracture .
closed reduction is sometimes assisted by steinman pin as reported by barquet et al .   and winderman .
sankaran - kutty and sadat - ali   used limb lengthening apparatus to assist in closed reduction of shoulder .
open reduction was required in cases reported by kontakis et al .   and baker .
only in few cases , the authors have reduced the shoulder prior to fracture fixation , otherwise all have fixed fracture before reduction of the shoulder .
splint , casting [ 1 , 3 , 4 , 9 , 10 ] , plates and screw [ 4 , 5 , 8 ] , external fixator   and even intra - medullary nail [ 2 , 3 ] all have been used with consistent result in fracture union . in our case too , we fixed the fracture prior to reduction .
we were bound to use external fixator in our case due to compound nature of injury .
we fixed the greater tuberosity fragment through a deltoid splitting approach after thorough debridement of wound and did skin grafting on the raw wound later .
we believe that external fixator is not ideal for humerus fracture with shoulder dislocation as it is cumbersome , it affects mobilization and hence the outcome of shoulder movement but it has consistent results on fracture union .
the presence of wound required skin grafting later and this also affected early mobilization of the shoulder .
almost all reported cases have reported satisfactory outcome ( some degree of restriction of abduction and flexion ) despite different modalities of management .
we also had a good outcome in our patient despite having more severe injury , open fracture and associated fracture of greater tuberosity and the fact that she was managed with external fixator initially .
we believe that following the basic principles of trauma care was the key for good outcome in this case .
 humerus fracture is very rarely associated with ipsilateral shoulder dislocation . here , 
 we have reported probably the first case of compound fracture of humerus associated with a two - part fracture dislocation of ipsilateral shoulder . a 30-year - old female presented to the emergency department after a road traffic accident . the vehicle in which she was travelling skidded off the road and she got trapped . 
 she had degloving injury over her left arm with a fracture of left humerus and anterior dislocation of ipsilateral shoulder and greater tuberosity fracture . 
 she was managed initially with wound debridement , external fixation over humerus , closed reduction of shoulder dislocation , and open reduction and internal fixation of greater tuberosity fracture . 
 skin grafting was done over the wound later on . 
 fracture united at 4 months with a good range of movement at shoulder at the final follow - up . 