Shoulder and Elbow Cases to Consider.

Last updated Friday, February 11, 2005

Figure 1

Figure 2

Chronic anterior shoulder dislocation

Clinical presentation

This is the radiograph of a 45 year old man who presented to our clinic with a painful left shoulder of 5 months duration (see figure 1). His chronic anterior dislocation apparently resulted from a fall after an epileptic seizure. An unsuccessful attempt had been made 1 month earlier to reduce the dislocation in the emergency room. His current complaint was disabling pain and limited range of motion.

On examination the patient held his right shoulder in fixed internal rotation. Obvious asymmetry was present around the shoulder girdle when compared to the contralateral side. His humeral head could be palpated anteriorly and inferiorly and any form of shoulder movement caused severe pain. His axillary nerve was functioning and his remaining neurovascular examination was normal. The patient had a history of alcoholism and epilepsy poorly controlled by medication.

Our concerns include :

1. The patients' general health and well-being.
2. The possibility of maintaining a reduction following an open procedure.
3. The condition and viability of his humeral head.
4. If a hemiarthroplasty was necessary, what soft tissues would maintain stability in this patient.
5. Would there be a need for a bony procedure around the glenoid to establish stability?

Management

Despite the patient's history of alcoholism and poorly controlled epilepsy we thought it appropriate to try to treat the patient and his shoulder due to his chronic disabling pain.

No attempt was made to perform a closed reduction due to the chronicity of the dislocation.

A routine deltopectoral incision was made exposing the subscapularis and dislocated humeral head. Care was then taken to identify and protect the axillary nerve. It was impossible to openly reduce the humeral head due to a large Hill Sachs lesion involving at least 50% of the articular surface and severe contracture of the posterior structures.

Due to the humeral head destruction yet an intact glenoid, a decision was made to perform a hemiarthroplasty rather than a TSA. An extensive release of the posterior capsule and cuff was performed before inserting the humeral component. This was then reduced with difficulty and showed signs of anterior subluxation when the arm was rotated away from neutral. The component was therefore placed in some 45 degrees of retroversion and a more extensive posterior release was performed around the glenoid. We did not feel the necessity to place an anterior bone block on the glenoid although this would be a possibility if instability persisted.

Due to concerns of patient compliance and the potential for instability post-operatively he was placed in a shoulder immobilizer for 6 weeks.

The current radiographs are shown demonstrating a located humeral head and a small amount of heterotopic ossification which commonly occurs following a chronic dislocation (see figure 2). No further episodes of instability have occurred at 6 months follow-up and the patient is currently satisfied with the result.

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