Open management of neglected inferior dislocation of the shoulder with proximal humeral fracture in an adolescent

Strategies in Trauma and Limb Reconstruction, Mar 2013

Neglected dislocation of the shoulder is a rare condition with some cases of anterior and posterior dislocation being reported. We report a case with a fracture dislocation of the proximal humerus with the dislocated head lying inferior to the glenoid. We also report on the surgical management of a case with this extremely rare condition which required shortening of the distal fragment to reduce tissue tension.

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Open management of neglected inferior dislocation of the shoulder with proximal humeral fracture in an adolescent

Strat Traum Limb Recon Open management of neglected inferior dislocation of the shoulder with proximal humeral fracture in an adolescent Shabir Ahmed Dhar 0 1 2 Sharief Ahmed Wani 0 1 2 Tahir Ahmed Dar 0 1 2 Shahid Hussain 0 1 2 Reyaz Ahmed Dar 0 1 2 Abdul Rouf Malik 0 1 2 0 S. Hussain Department of Orthopaedics, Skims MC , Bemina, Srinagar, Kashmir , India 1 S. A. Wani T. A. Dar R. A. Dar A. R. Malik The Government Hospital of Bone and Joint Surgery , Srinagar , India 2 S. A. Dhar (&) The Skims MC , Bemina, Srinagar , India Neglected dislocation of the shoulder is a rare condition with some cases of anterior and posterior dislocation being reported. We report a case with a fracture dislocation of the proximal humerus with the dislocated head lying inferior to the glenoid. We also report on the surgical management of a case with this extremely rare condition which required shortening of the distal fragment to reduce tissue tension. Fracture; Inferior dislocation shortening Introduction Neglected shoulder dislocation is a rare condition [ 1 ]. Neglected dislocation of the shoulder when reported in literature is usually of the anterior type with very few posterior types reported [ 2, 3 ]. A pertinent fact that usually causes neglect is the fact that the patient is usually injured in high velocity accidents and presents with more obvious accompanying injuries [ 4, 5 ]. Literature points to the fact that these injuries are difficult to manage. The exact method of management is a matter of debate and discussion. An 18-year-old male reported to our emergency department with a history of pain in the right shoulder and inability to move it without significant discomfort. He reported that he had been assaulted 4 weeks before the presentation and had sustained head injuries. He had been admitted elsewhere for the management of those injuries and had been managed on an indoor basis for 16 days. His shoulder discomfort had not been thought to be serious during his stay in that hospital. Orthopaedic consultation had been recommended at the time of discharge. Examination revealed a reasonably maintained contour of the shoulder with total restriction of abduction. The patient was able to internally rotate the shoulder up to 20 and external rotation was not possible (Figs. 1, 2, 3). Radiographs of the shoulder showed that the proximal humerus was fractured, and the proximal end of the distal fragment had migrated proximally to lie under the deltoid giving it a near normal contour. The head was dislocated inferiorly. This was confirmed by the axillary view. A significant callus had formed around the head and the shaft at their new position of contact. It was obvious that the proximal pull on the distal fragment had made it migrate proximally. According to these findings, open reduction and reconstruction of the proximal humerus were considered necessary. Under general anaesthesia, the patient was placed in a supine position and the glenohumeral joint was assessed via a deltopectoral approach. The axillary nerve was palpated to ascertain its position. The long head of the biceps was still intact. The glenoid cavity and the proximal humerus were exposed, and granulation tissue and the callus were cleared from it. After meticulous removal of the scar tissue, the glenoid articular cartilage looked to be in good condition and the humeral head was reduced. As expected, it was not possible to reduce the distal fragment to its normal position beneath the head of the humerus. The end was stripped of soft tissue and shortened by 2 cm. This made the reduction possible beneath the head. The supraspinatus was reattached to the tuberosity area. The other muscles were reefed along with the capsule of the shoulder joint. The wound was covered in layers, and the shoulder immobilised in 45 of internal rotation. After 4 weeks, pendular exercises were started with gradual institution of range of motion exercises. The final range of motion was recorded after 1 year when the patient had a more than normal internal rotation with an external rotation of 15 . However, abduction was only 25 at the joint. The flexion was 70 and the extension 20 . The patient was pain free and was able to perform his routine duties. The X-ray, however, showed a gradual superior subluxation of the shoulder joint which was suggestive of undue tissue tension and rotator cuff insufficiency. Discussion Shoulder dislocation is an injury which is at risk of being neglected in a patient with more severe injuries. The potential of missed diagnosis is always there [ 5 ]. Looking at literature, the neglect of this dislocation is thankfully rarely reported. There is, however, significant variability of this injury. Shoulder hemiarthroplasty has been used with these injuries [ 6 ]. However, it is recommended that the head should be preserved in young patients [ 5 ]. Sometimes neglect of these injuries is recommended with acceptance of subnormal functio (...truncated)


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Shabir Ahmed Dhar, Sharief Ahmed Wani, Tahir Ahmed Dar, Shahid Hussain, Reyaz Ahmed Dar, Abdul Rouf Malik. Open management of neglected inferior dislocation of the shoulder with proximal humeral fracture in an adolescent, Strategies in Trauma and Limb Reconstruction, 2013, pp. 53-55, Volume 8, Issue 1, DOI: 10.1007/s11751-012-0151-6