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Neglected shoulder dislocation management
A 60-year-old woman with a left anterior shoulder dislocation following a fall presented with pain and limited movement. Examination and imaging reveal potential rotator cuff tears and other complications, leading to various treatment options such as closed reduction, open reduction, or arthroplasty depending on her condition and the age of the dislocation. Post-operative management includes rehabilitation strategies tailored to her specific needs and recovery progress.
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Neglected shoulder dislocation management
- 1. PREOP PLANNING DISCUSSION Oldunreduced anterior shoulder dislocation Dr ARJUN K Resident dept of orthopaedics Unit C LHMC
- 2. 60 yr oldlady with right hand dominant ,house maker by occupation resident of delhi came to Ortho opd with c/o pain left shoulder and decrease in left shoulder movement X 25 DAYS
- 3. A/H/o fall fromstairs at her residence and sustained injury to left shoulder 25 days prior to the presentation. • c/o pain left shoulder + since then • Acute onset • Initially progressively increased in intensity then gradually reduced but still persisting in mild severity • Non radiating • Aggrevated by shoulder movements • Relieved partially by rest and analgesics
- 4. • Limitation ofmovement of left arm and swelling in the axilla and front of the shoulder. • Not able to lift the weight • Not able to lift the hand above the head level No ho numbness / weakness in the upperlimb No ho any breathlessness or cough No ho LOC,vomitting, seizure , ENT bleed No ho any other joint pain or trauma to any other part of the body
- 5. Past history • Noprevious episodes of shoulder dislocation or # around the shoulder • No ho DM ,HTN, TB, ASTMA or any chronic drug use
- 6. Examination • Gc fair •Afebrile • Vitals stable • No signs of generalised ligamentous laxity • Beighton score joint hypermobility
- 8. • Swelling : bulge+ anterior and lateral edge of acromion • Tenderness #GT (33%) Rotator cuff tear( 40% in less than 60 yrs 80% in more than 60 yrs of age) Prox humerus # • Crepitus
- 9. • Neurovascular deficits(13-65%) Axillary N more then Musculocutaneous N • Deformity RESTRICTED • ABD+ IR : ANTERIOR DISLOCATION • ADD+ ER: POSTERIOR DISLOCATION • Dugas test • Hamilton ruler test
- 11. Posterior dislocation (< 5%all shoulder dislocations) • Comcomittant fracture/ multiple injury • Unresponsive • Intubated/ sedated/ alcohol • Shock/ seizure
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- 13. INVESTIGATIONS • XRAY • CTSCAN • MRI
- 14. X ray views •Ap • True ap ,Grashey view( 35- 40 oblique to sagital) • Valpeau axillary • Trauma axillary • West point view( for glenoid rim #- in prone positon) • Stryker notch view(for Hill sachs lesion) • Apical oblique view
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- 22. Stryker notch view(forHill sachs lesion)
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- 24. CT SCAN (ideal for bony lesion) • 3D reconstruction • Size of gelnoid # segment • # proximal humerous • Hill sach lesion GLENOID BONE LOSS GOLD STANDARD TEST CT 3D RECONSTRUCTION
- 25. % BONE LOSS = RADIUSOF BEST FIT CIRCLE - DISTANCE FROM CEMNTER TO ANTERIOR DEFECT DIAMETER OF THE BEST FIT CIRCLE
- 27. MRI • Rotator cufftear • Humeral avulsions of gleno humeral ligament. • MRI ARTHROGRAM ( IOC)
- 28. TREATMENT OPTIONS • NOTREATMENT • CLOSED REDUCTION(+/- ARTHROSCOPY ASSISTED) • ORIF • HEMIARTHROPLASTY • SHOULDER TOTAL ARTHROPLASTY
- 29. No treatment • Dementia •Very old age( too sick for surgery) • Low demand • Good shoulder function and no pain
- 30. CLOSED REDUCTION ASESS • AGE •OSTEOPOROSIS (disuse osteopenia) • VASCULAR STATUS ( axillary artery) • DURATION OF TRAUMA (3- 4 weeks) Closed reduction should be considered carefully after 4 weeks because • Fibrous tissue in the glenoid cavity • Retracted rotator cuff muscle • Soft tissue contractures
- 31. Not indicated in •Impression defect involving more than 20% of articular surface • dislocated for more than 4 weeks • If at all done do under GA Chance of axillary artery repture+ • Immobilise for 3-4 weeks
- 32. OPEN REDUCTION Indicated when •More than 4 weeks old dislocation • Failed closed reduction under GA • Intraop instability • Axillary nerve / arterial injury
- 33. OPEN REDUCTION DifficultyEncountered due to • Replacing humeral head because of fibrosis • Shortening of muscles • Contracture • Bowstringing of capsule across the glenoid • Defect in humeral head Difficulty in maintaing the reduction because of instability
- 34. • Subscapularis tenotomy •Extensive posterior capsular release • Excision of intra articular portion of long head of biceps and tenodese with P . MAJOR Bony / soft tissue recontruction procedure may be needed for managing intra op instability • Bankart procedure • Latarjet procedure • Iliac crest BG • Allograft BG
- 35. How to treatthe humeral head defect in old unreduced dislocations 1 . Filling the defect using sub scapularis tendon 2. Elevation + bone grafting( cab be used in defects upto 40%) 3. Hill sachs defect more than 45% -complete humeral head replacement
- 36. SOFT TISSUE PROCEDURE Bankartcapsulo labral repair ( open/ arthroscopic) • Open preferred in neglected cases ,when anatomy is altered, dfoemity+,HAGL, revision surgery BONY PROCEDURES LATARJET PROCEDURE Indication • Glenoid defect more than 25% • Hill sach more than 25% of the humeral head coracoid osteotomy (along with conjoined tendon and coracoacromial ligament)
- 37. Internal fixation SWISS SCREWK WIRES ACROMIAN TO HUMERAL HEAD (WILSON AND McKEEVER)
- 38. Post op managementafter ORIF PROTECTED ORTHOSIS X 6 WEEKS • ROM STARTS AT 6 WEEKS SHOULDER STRENGTHENING AT 3 MONTHS ONWARDS
- 39. Hemiarthroplasty • Less than50 yrs with good glenoid cartilage • If the duration is more than 6 months • Large defect more than 45%
- 40. TOTAL SHOULDER ARTHROPLASTY •Old patients with significant glenoid changes • bone graft may be necessary if extensive erosion of the posterior margin of the glenoid fossa REVERSE SHOULDER ARTHROPLASTY ELDERLY PATIENTS IF A) rotator cuff defieciency B) persistent instability
- 41. • Rouhani andNawali • Anterior capsular repair for chr. Ant. D/L (mean 1 yr follow up – 8 patients) 1 fair, 3 good, 4 excellent avg Rowe & Zarin score :86
- 42. J Shoulder ElbowSurg 2003;12:446-50.) No recurrent dislocations 2 fair 5 good 3 excellent results