Shoulder: An acutely unstable shoulder dislocation

Shoulder dislocations are typically treated by the ER physicians. An orthopedic surgeon rarely sees an acute shoulder dislocation because our ER colleagues do such a good job with closed reduction.

Occasionally closed reduction is not successful.

Such a rare case is described here.

This was a grandma in her late 70's who fell after tripping on a carpet edge. The ER physician told me that he "could not reduce" the shoulder. The ER doc had felt the "clunk" of relocation, he thought the shoulder had been put back in place, but xrays afterward showed the shoulder to be still dislocated.

I dutifully went to the emergency room and I reduced the shoulder myself. I felt the "clunk" of relocation too. I was certain that the shoulder was back in place. I placed the arm in a sling and I ordered post reduction xrays.

The postoperative xrays are shown below. The shoulder appears reduced in the first xray only. The shoulder is redislocated in the two other xrays. The shoulder must have redislocated in the time between the first and second xray.

After a couple more successive relocation/dislocation cycles, it was clear that closed reduction was not going to be successful.

At this point I asked the patient to choose between surgery and nonoperative treatment. Nonoperative treatment would have resulted in a permanently dislocated, stiff shoulder. Elbow, hand, and finger motion would be expected to be normal. It might have been a tolerable situation.

The patient did not hesitate to elect surgery. Next day I performed an arthroscopic examination, repair of the torn structures.

Here are the first arthroscopic pictures. Note that there is acute hemorrhage inside the joint. The glenohumeral joint is still dislocated. The head of the humerus is anterior to an abnormal glenoid. An impression fracture, known as a Hill Sachs lesion can be seen on the humeral head.

In the picture below, the blood inside the joint has been rinsed a bit better.

It is clear that a large chunk of bone is missing from the glenoid. This is known as a bony Bankart lesion. This is a large enough fracture to cause immediate acute glenohumeral instability. The glenoid "socket" is small to begin with, and a defect of the anterior part of the glenoid makes it so much easier for the humeral head to "fall off."

Suture anchors were first placed in the main glenoid fragment, and then the sutures were passed through anterior capsule above and below the fracture. I could not resist the temptation to place a cannulated screw through the bony fragment. Afterwards the sutures were tensioned, tied, and cut. This resulted in stable reduction.

This is the final appearance of the glenoid.

At this point the shoulder was taken through a range of motion, was seen to be stable, and the operation was terminated. Arm was placed in a sling. Xrays were done immediately which showed maintained reduction.

Xrays were repeated a week later, a month later, 3 months later. The shoulder stayed reduced. Pain decreased and motion improved.