The question here is to do open reduction and internal fixation or shoulder repleacement. The fact that this fracture dislocation is 2 days old means that there is high risk of avascular necrosis of humeral head. On the other side the young age of the patient is not in favour of shoulder repleacement.

I would discuss with patient and family and would go ahead and fix it first and wait and see if it develops later avascular necrosis then I would do prosthesis in a second stage.The decision is not easy.

Initially one must preserve the humeral head and attempt a closed reduction +/- open reduction of the fracture. It would be unlikely to reduce after 2 days, the status of the axillary nerve should be assessed and documented pre-operatively.

I would get further X-rays including a lateral and axillary view, if any suggestion of a head split or large hill sachs, would consider a ct prior for operative planning. From this image looks like a 2 part fracture, should be able to reduce adequately with a locking plate construct. Need to assess the rotator cuff at the time of surgery and make sure no glenoid fracture. Patient needs to be counselled about risk of AVN and this can be dealt with appropriately at a later date. AVN can be accepted if patient has minimal symptoms, no head collapse and reasonable function of their shoulder. If not, arthroplasty could be considered, but not as a first line.

I agree with the above answers. A hemiarthroplasty in a young patient is not a good option. The fracture seems relatively simple to fix with a locking plate construct. Nevertheless, a pre-op CT is important to evaluate the humeral fracture itself and the glenoid.

There is a risk of AVN, but it is often well tolerated. Furthermore if it does occur, a prosthesis is always an option later on if necessary.

Remember to proceed with a complete neurovascular evaluation of the limb pre-op, if the humeral head has been dislocated for 2 days.

Agree with both of you

Thanks all for educative inputs...