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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.
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 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.
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.
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
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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