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)