chronic shoulder dislocation

A Case of Chronic Shoulder Dislocation

Case Introduction

A 25 year old male presents to the Emergency Department stating “my shoulder has been dislocated for 6 months”. The patient has a history of a seizure disorder. He endorses recurrent dislocations and had a “procedure” previously, although he doesnt know what the procedure was. He was told he needed surgery back where he used to live. He is not currently taking any medications and he denies any neurological symptoms. However he endorses pain, loss of range of motion and inability to work due to pain.
Classic appearance of a shoulder dislocation (right). Note the squared off shoulder, loss of deltopectoral groove.
On physical exam, he looked similar to the above photo (scar not pictured). His range of motion was very limited and not fully tested. He was intact in his median, ulnar, radial, musculocutaneous and axillary nerves. His radial pulse was 2+ and sensation to light touch was intact.
Watch the video presentation of the case!
Chronic shoulder dislocation is an uncommonly encountered clinical entity. The incidence is not known and literature is limited to case reports and case series. Even though shoulder dislocations are common, the vast majority are reduced emergently, thus making this a rare clinical case. The definition is controversial, however the most commonly accepted definition of a chronic shoulder dislocation is greater than 3 weeks[1] Unreduced chronic dislocation of the humeral head with ipsilateral humeral shaft fracture: a case report. Micic ID, Mitkovic MB, Mladenovic DS. J Orthop Trauma. 2005;19:578–581. Management is complex and there is no consensus about the best surgical approach. Patients tend to have poor outcomes in terms of restoration of function.
Chronic shoulder dislocations are most commonly encountered in elderly patients where senescence and sarcopenia can predispose them to this condition. It is much less common in younger patients. When seen, younger patients tend to have a history of seizure disorder, alcohol use disorder and/or trauma.
PA radiograph of a chronic shoulder dislocation. Yellow are identifies the glenoid and bankart lesions, the red arrow the large hill-sachs lesion. Please note the significant bone remodeling.
Associated conditions include Bankart lesions, Hill-Sachs deformity, Glenoid bone loss, Glenoid fracture, Rotator Cuff Tears, Acromion Fracture, Proximal Humerus Fractures, Axillary Artery Injury, Axillary Nerve Injury
The clinical presentation of a chronic shoulder location is fairly typical. Patients almost universally will know they are dislocated chronically. They will have chronic shoulder pain worse with movement. Range of motion is quite limited. They effectively have the inability to use the shoulder for any purpose with reduced activities of daily living and inability to work.
Axial cut of the CT scan of the chronic shoulder dislocation. Red arrow designates the glenoid. White measurements quantify the Hill-sachs lesion. Note all the bone remodeling.
On physical exam, the shoulder will look abnormal compared to the healthy shoulder. There may be squaring off of the acromion and loss of the deltopectoral groove (see above image). The patient will have severely limited range of motion at the shoulder. Range of motion should be preserved at the elbow, wrist and hand. A complete neurovascular exam should be performed and documented.
Workup should begin with standard view radiographs of the shoulder. These are sufficient to make the diagnosis. Findings include chronic dislocation, bankart and Hill-sachs lesions and often bone spurring and bone remodeling. CT scan can be used to better characterize the bony lesions and to help with surgical planning. The role of MRI is less clear but can be used to evaluate for associated muscle and tendon injuries as well as evaluating the brachial plexus if needed.
Management is primarily surgical. Nonoperative management can be considered in patients who are poor surgical candidates, can’t adequately participate in rehabilitation or are unlikely to benefit from surgical intervention. The decision to forego surgery should be made in consultation with an orthopedic surgeon.
Surgical decision making and management is complex for both the physician and the patient. There is no consensus among orthopedic surgeons about optimal management. Surgical technique includes Closed reduction, Open reduction and fixation with Kirschner wires, Bankart repair, Bristow-Laterjet procedure, Coracoid transfer, Bone grafting, Hemiarthroplasty, and Reverse shoulder arthroplasty
Patient’s will need extensive rehabilitation following surgery in order to return to work or any level of function. Prognosis is typically poor and functional demands, outcome expectations and rehabilitation potential must be taken into account. The ability to restore stability and activity is variable with a high failure rate[2]Matsoukis J, Tabib W, Guiffault P, et al. Primary unconstrained shoulder arthroplasty in patients with a fixed anterior glenohumeral dislocation. J Bone Joint Surg Am, 2006, 88: 547–552.. Comlications include loss of function, chronic pain, and chronic neurovscular injuries affecting the rest of the extremity.

Case Conclusion

Our patient was seen by orthopedic surgery in the ED who ordered the CT scan to better characterize the lesions. They were in agreement with outpatient follow up for surgical planning. Unfortunately, the patient was lost to follow up in our healthcare system.

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