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Description
Acute anteroinferior shoulder dislocations respond well to closed reduction.1 However, if closed reduction fails, it may indicate a structural obstruction within the joint or interposed soft tissue.2 Here, we present a case of anterior shoulder dislocation with an unusual X-ray finding on the transthoracic lateral view, suggesting irreducibility by closed methods. The dislocation was accompanied by a significant rotator cuff tear, torn conjoint tendon and an interposed subscapularis muscle, making it irreducible with standard closed techniques.
Clinical details
‘An elderly patient presented at a peripheral healthcare facility with a history of left shoulder trauma, suggesting a dislocated joint. Shoulder X-rays confirmed the diagnosis of the preglenoid type of anterior dislocation. Attempts at closed reduction under analgesia and sedation were made but proved unsuccessful. Subsequently, the patient was referred to our trauma centre. Repeat X-rays of the shoulder were performed, and the transthoracic lateral view revealed an increased gap (6.69 mm; calculated on Radiant Dicom Viewer) between the posterior border of the humeral head and the anterior border of the glenoid (figure 1). This raised concerns about the difficulty of reducing this dislocated joint using closed methods (table 1). Therefore, the decision for open reduction was taken after obtaining informed consent from the patient. A CT angiogram was performed to delineate the altered anatomy and rule out any major vessel proximity (axillary neurovascular bundle)’.
Depicting features of types of dislocation for non-operative versus operative management
A transthoracic lateral radiograph of shoulder showing an increased distance (6.69 mm) between posterior border of head of humerus and lateral scapular border.
Surgical details
Under general anaesthesia, closed reduction was attempted, which was unsuccessful. Subsequently, in the beach chair position, the shoulder joint was exposed with the deltopectoral approach.3 The conjoint tendon was found to be crushed and the head of the humerus was found lying posteromedial to conjoint tendon over the subscapularis muscle, just lateral to the axillary neurovascular bundle (figure 2A). The anterosuperior part of humeral head was completely devoid of any tendinous or capsular attachment, which confirmed the tear of subscapularis and supraspinatus (figure 2B). Subscapularis was tagged with ethibond No 5 suture to pull it aside while attempting to relocate the head of the humerus into glenoid cavity. Both the subscapularis and supraspinatus tears were repaired using suture anchors (figure 3).
(A) Intraoperative image before reduction of joint showing interposed and crushed conjoint tendon with torn subscapularis and (B) postreduction.
Diagram illustrating the mechanism of dislocation (this figure is created by a senior artist Dharamjit Singh from our institute).
Conclusion
It is imperative to diagnose irreducible shoulder dislocation promptly and accurately to prevent unnecessary discomfort and complications resulting from unsuccessful closed reduction attempts. A thorough examination of plain radiographs is vital for preoperative evaluation, ensuring effective management and minimising the risk of potential neurovascular harm during treatment.
Learning points
Subtle findings on plain radiographs can dictate the management of shoulder dislocation.
Increased distance between humeral head and scapular border on transthoracic lateral radiograph of shoulder can indicate irreducibility by closed manoeuvres.
Ethics statements
Patient consent for publication
Footnotes
Contributors AD collected the patient data, explained and took patient consent and drafted the manuscript. He was also the first assistant in the surgical procedure. DKC performed the surgical procedure, revised the manuscript and edited all the clinical images as per the required format.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.