A six months old neglected anterior shoulder dislocation managed by closed reduction and Latarjet procedure

A neglected shoulder dislocation is a rarer entity and only few cases are reported in the literature. An anterior dislocation of the shoulder is rarely missed as patients present with limb in abduction and external rotation, an attitude very familiar to orthopaedic surgeon. Occasionally such cases are missed when they present with fracture of proximal humerus or when they receive treatment from unqualified practitioners who commonly practise in rural areas. Owing to very few reports there is paucity of literature and no standard treatment protocol exists for neglected anterior dislocation of the shoulder, though most such chronic cases are managed by open reduction. This case report describes a six months old neglected anterior dislocation with a significant Hill Sachs lesion, which was managed by closed reduction and Latarjet procedure.     

Modified MacLaughlin procedure in the treatment of neglected posterior dislocation of the shoulder

Posterior dislocation of the shoulder is an unusual injury that most often occurs secondary to a highenergy trauma. Unfortunately the diagnosis is commonly missed, thus making its treatment a challenge. Neglected posterior dislocation is mainly characterised by an impression fracture on the anterior articular surface of the humeral head, which makes the dislocation often difficult to reduce. Diagnosis is based upon a careful history assessment, physical examination and radiological findings. Several treatment approaches have been described. The modified MacLaughlin procedure in our hands has been shown to be a reproducible technique allowing good results at medium- and long-term follow-up. According to our experience it is possible to adopt this technique also in patients with a locked posterior dislocation older than 6 months or in cases with a humeral head defect up to 50% when a shoulder prosthesis is not a good indication. Poorer results should be expected in patients with an associated fracture of the proximal humerus.     

闭合复位老年肩关节前脱位过程中发生医源性肱骨颈骨折的成因分析和对策

目的分析在闭合复位老年肩关节前脱位的过程中发生医源性肱骨颈骨折的原因并探索避免的方法。 方法对上海市第一人民医院2012年1月至2017年1月在肩关节前脱位复位过程中发生肱骨颈骨折患者的临床资料和影像学特点进行回顾性分析。 结果共5例患者在闭合复位过程中发生肱骨颈骨折,导致肱骨头、颈分离。这些患者的特征：（1）老年女性,低能量损伤,初次肩关节脱位;（2）复位前肩关节正位片：肩关节前脱位伴大结节骨折;（3）肱骨头内移至喙突下方或内侧;（4）均为无麻醉下采取Hippocrates足蹬法复位。 结论闭合复位肩关节前脱位过程中发生肱骨颈骨折的原因与复位前遗漏盂肱关节脱位时伴随的肱骨颈骨折有关。老年肩关节前脱位有其特点,在治疗上应与年轻患者加以区别。对老年初次肩关节前脱位伴大结节骨折的患者应加以特别重视,复位前规范的影像学检查以除外肱骨颈骨折是避免此类医源性并发症的关键。     

高龄肩关节前脱位合并肱骨解剖颈骨折的治疗

目的探讨肩关节前脱位合并肱骨解剖颈骨折的治疗方法和疗效。方法 20例肩关节前脱位合并肱骨解剖颈骨折患者中,手法复位成功外展架固定3例,切开复位内固定15例,人工肱骨头置换术2例。结果20例均获随访,时间7～22个月。手法复位成功外展架固定3例均有不同程度的关节功能障碍;切开复位锁定解剖钢板固定、术后外展架固定15例中,12例肩关节功能恢复正常,3例肩关节功能轻度受限;2例肱骨头置换术者肩关节功能基本正常。结论肩关节前脱位合并肱骨解剖颈骨折,若无手术禁忌,宜采用切开复位锁定解剖钢板内固定、术后外展架固定,肩关节功能恢复良好。     

Unreduced chronic dislocation of the humeral head with ipsilateral humeral shaft fracture: a case report

The purpose of reporting this case is to illustrate a treatment plan for a chronically anteriorly dislocated shoulder associated with an ipsilateral humerus fracture, a condition heretofore not addressed in the literature to our knowledge. An 18-year-old female, left hand dominant, injured her left upper extremity and liver in a motor vehicle accident. X-rays at time of injury revealed a diaphyseal facture of her left humerus. No x-rays of the shoulder were taken at time of injury. Treatment consisted of a plaster cast application and discharge at 1 week. The patient was seen again 4 weeks postinjury, at which time only humerus films were taken and the immobilization was continued. At 45 days postinjury, the patient complained of left shoulder pain, and shoulder x-rays at that time revealed an anterior subcoracoid dislocation of the left humeral head. At surgery 52 days postinjury, the humeral shaft fracture was found to be unstable and external fixation of both the fracture (2 pins above and below the fracture) and the reduced but still unstable humeral head was performed (a pin through the humeral head into the glenoid). The external fixator was removed at 3 weeks, and at a 3-year follow-up, the patient had acquired nearly full range of motion of her shoulder without pain and no significant limitations of her arm movements or activities. In conclusion, given a patient with a chronic anteriorly dislocated shoulder and a healing ipsilateral shaft fracture, an external fixation stabilization of both the fracture and the relocated repaired dislocation is a viable treatment option.     

Dislocation of the shoulder joint with ipsilateral humeral shaft fracture: two case reports

Introduction: A combination of the shaft fracture of the humerus with shoulder dislocation is a rarely documented injury. Moreover, few reports describe a long-term outcome after a follow-up period over 10 years. The present article is the first report of long-term clinical results obtained with this combined injury. Materials and methods: We present two cases of the dislocation of the shoulder joint with ipsilateral humeral shaft fracture. One is an anterior dislocation and the other is posterior. The anterior dislocation was closely reduced on the date of injury, but the posterior dislocation required open reduction 6 weeks after the injury because it was missed at the initial diagnosis and identified 4 weeks after the injury. In the latter case, shoulder pain and limitation of the motion persisting after the first surgery had to be treated by anterior acromioplasty and arthrolysis of the shoulder. In both cases, the humeral fracture was fixed by retrograde intramedullary nailing using a Küntscher nail and successful bone union was achieved. Results: At over 10-year follow-up examination, both patients had no limitation in activities of daily living and no restrictions to their normal occupation. The radiographs of the shoulder joint demonstrated good clinical results, with no degenerative change or osteonecrosis. Conclusion: We have experienced two cases of dislocation of the shoulder joint with ipsilateral humeral shaft fracture and reported long-term results over 10 years. Good clinical results were demonstrated in both cases.     

A modified Bristow-Helfet-May procedure for recurrent dislocation and subluxation of the shoulder. Report of two hundred and twelve cases

A modified Bristow-Helfet-May procedure was performed for recurrent dislocation or subluxation of the glenohumeral joint in 207 patients (212 shoulders), whose average age at the time of surgery was 20.3 years (range, fourteen to forty-seven years). The procedure was modified by directing the coracoid segment and conjoined tendon over the superior border rather than through the substance of the subscapularis tendon and muscle. The indications were either documented recurrent anterior dislocation of the glenohumeral joint or subluxation with instability as demonstrated on examination with the patient under anesthesia. The procedure was evaluated on the basis of the rate of recurrence of dislocation and subluxation, postoperative complications, the patients' subjective evaluation, and the effect of the procedure on the motion of the glenohumeral joint and the strength of the muscles of the shoulder as related to overhead throwing. Eight (3.8 per cent) of the shoulders redislocated and ten (4.7 per cent) had one or more subjective episodes of subluxation after the procedure. Complications included postoperative infection in two patients and problems with the screw that required its removal in ten. One hundred and thirty-one (62 per cent) of the patients responded to a questionnaire regarding their subjective evaluation of the results of surgery. Eleven (8 per cent) were unable to perform daily activities that involved overhead work, and forty-five (34 per cent) stated that they still had some degree of discomfort or pain in the shoulder. One hundred and twenty-six patients (96.2 per cent) stated that they were happy with the results of the surgery and would have the procedure again. Thirty patients had Cybex testing of the muscles of the shoulder. Only three (16 per cent) of the nineteen athletes whose dominant arm had been operated on returned to their pre-injury level of throwing. Data obtained with regard to changes in the range of motion and strength of the glenohumeral joint indicate that this loss of throwing ability was not due solely to a loss of glenohumeral motion. It appeared to be also related to a concomitant loss of strength at the extreme of external rotation of the humerus and the initiation of internal rotation of the humerus.     

The management of anterior dislocation of the shoulder with proximal humerus fracture,bony Bankart lesion,and associated glenoid labrum avulsion: a report of 2 cases

Proximal humerus fractures are common in the older population. These fractures can be associated with dislocation of the shoulder. Four-part fracture-dislocations and head-splitting 3-part fractures are generally indicated for shoulder hemiarthroplasty in the older population. When such surgery is warranted, inspection of the glenoid during the procedure is indicated, as loss of evaluation may lead to postoperative shoulder instability. There is value in alerting orthopedic surgeons to the possibility of anterior glenoid rim fracture in association with proximal shoulder fracture-dislocation. We focus on this issue and advise that the lesion can be visualized and confirmed at open reconstruction and does not need multiple radiographic views.     

旋转截骨矫形手术在分娩性臂丛损伤治疗中的应用

目的　评价肱骨及桡骨旋转截骨术治疗分娩性臂丛损伤(产瘫)肩肘后遗症的价值。方法　1999年8月至2000年12月,对8例产瘫肩肘后遗症患儿（肩关节外旋挛缩2例,内旋挛缩1例,前臂旋后挛缩并发桡骨小头脱位5例）施行肱骨内旋截骨、外旋截骨、及前臂旋前截骨等手术,并经术后3～16个月(平均8个月)的随访。术后肩关节功能采用Mallet评分、前臂功能采用旋前位置角度的改善作为评价标准。结果　2例行肱骨内旋截骨者,1例按Mallet评分,术前术后的改变为肩外展3→3,外旋4→4,手到颈后4→3,手到背2→4,手到嘴2→4;另1例因感染及螺钉断裂致骨不连行内固定手术后尚在康复中。1例行肱骨外旋截骨者,按Mallet评分,术前术后改变为肩外展2→3,外旋2→4,手到颈后2→3,手到背4→3,手到嘴2→3。5例行桡骨旋前截骨者,术后前臂均处于旋前30°位置,功能及外观均获得改善。结论　肱骨及桡骨旋转截骨矫形手术在产瘫肩肘挛缩后遗症的治疗中具有一定的应用价值。     

改良Mclaughlin手术联合肱骨近端锁定钢板治疗肩关节后脱位伴骨折

目的:探讨改良的Mclaughlin手术联合锁定钢板治疗肱骨头损伤面积40%的肩关节后脱位伴骨折患者的临床疗效。方法:自2012年7月至2017年6月收治肩关节后脱位伴骨折患者7例,其中男5例,女2例;年龄37～53岁;合并肱骨头劈裂骨折3例,肱骨外科颈骨折4例。手术方法采用改良的Mclaughlin手术联合锁定钢板固定。观察术后肩关节活动范围,采用加州大学肩关节功能评分(University of California-Los Angeles Shoulder Scale,UCLA)进行临床疗效评价。结果:7例患者获得随访,时间10～33个月。末次随访时肩关节前屈上举130°～170°,外旋45°～75°,外展105°～150°,内旋均在L_3椎体到臀水平之间; UCLA评分29～34分,其中优1例,良6例。结论:改良的Mclaughlin手术联合肱骨近端锁定钢板对肩关节后脱位伴骨折这一罕见损伤的治疗,可有效保证术后肩关节稳定性,但对术后肩关节内旋存在一定程度的影响。     

Bilateral anterior fracture-dislocation shoulder: a case report with a review of the literature

Although bilateral anterior dislocation of the shoulders are not that much uncommon, but incidences of bilateral anterior fracture-dislocation shoulder are relatively rare with about 16 reported cases in the world literature. We report a rare case of bilateral anterior dislocation of the shoulders with bilateral 3-part fracture of the proximal humerus after first time epileptic attack. The diagnosis of bilateral anterior fracture shoulder dislocation was done on the same day of the epileptic injury, and patient had been operated within 48 h of injury. Patient was treated with open reduction and internal fixation through the delto-pectoral approach for both the sides. For right side, fixation was done with proximal humerus locking plate, and for left side, fixation was done with multiple screws with washers. Primary rotator cuff repair was done on both the sides. We had got excellent result in our case report at 1-year follow-up. The literature on this injury is also reviewed.     

Locked posterior dislocation of the shoulder joint: Report of two cases

Posterior dislocation of the shoulder joint is very rare. Most cases are missed initially because it is difficult to diagnose using conventional radiographic images. Computed tomography (CT) is the best tool for diagnosis. We report two cases of posterior dislocation of the shoulder joint that were missed initially at another hospital. The patients presented with painful disability of the shoulder joint. Posterior dislocation of the shoulder joint was suspected after physical examination. Anteroposterior radiography was unable to confirm the diagnosis because an abnormal posterior relationship of humeral head to glenoid fossa could not be clearly identified. An axillary view was unobtainable because of severe pain and the limited joint motion available. CT showed posterior dislocation of the humeral head. The bony defect of the humeral head was incarcerated by the posterior rim of the glenoid process. Open reduction via an anterior approach was performed on both patients, who recovered with good shoulder function after rehabilitation (the Constant score of Case 1 was 85 and that of Case 2 was 75). We concluded that “Mouzopoulos sign” obtained via an anteroposterior view is helpful for the diagnosis of posterior dislocation of the shoulder joint and that CT is required for a definitive diagnosis. If the dislocation is locked and closed reduction fails, then open reduction should be carried out.     

A case of irreducible shoulder dislocation as an initial manifestation of osteosarcoma of the proximal humerus

We experienced a case of osteosarcoma of proximal humerus with an initial clinical manifestation of irreducible shoulder dislocation. An eleven-year-old girl was transferred due to shoulder dislocation after minor collision, which could not be reduced even under anesthesia. After failed closed reduction under anesthesia, open reduction through deltopectoral exposure was performed evacuating the organized fibrous tissue, even without the suspicion of primary bone malignancy. Histopathologic report was osteosarcoma. Retrospective review of the imaging studies revealed subperiosteal hemorrhage, organized hematoma underneath the deltoid musculature, and osseous parenchymal changes, which suggested bone tumor. Subsequently, lung metastases were detected, and the chemotherapy was accompanied by neutropenic fever and Stevens Johnson syndrome. She expired 1 month thereafter. High index of suspicion would have led to more early diagnosis and established more appropriate management plan. Osteosarcoma of proximal humerus should be included in the differential diagnosis of a shoulder dislocation that could not be readily reduced.     

Shoulder dislocation after infraclavicular coracoid block

OBJECTIVE: We report a case of shoulder dislocation after a brachial plexus block with a double-injection technique using the infraclavicular coracoid approach. CASE REPORT: An obese woman with no previous episodes of joint dislocation developed an anterior dislocation of the head of the humerus after an infraclavicular coracoid block performed for hand surgery. Dislocation was probably because of a combination of unrecognized glenohumeral instability, paralysis of some muscles of the shoulder, and positioning of her arm on a board below her torso. Shoulder dislocation was recognized after surgical positioning of her arm, and painless reduction was achieved. There were no sequelae after 10-day follow-up. CONCLUSIONS: When motor block of the muscles of the shoulder occurs after brachial plexus anesthesia, special care must be taken in patient positioning to avoid shoulder dislocation.     

Dynamic posterior stabilization of shoulder hemiarthroplasty in long-standing neglected posterior dislocation of the glenohumeral joint

Posterior dislocations of the shoulder are rare. They account for less than 3% of all shoulder dislocations. The treatment of neglected bilateral posterior dislocation of the shoulder is controversial. We present a novel operative technique to stabilize a shoulder hemiarthroplasty that we used in the treatment of a chronic posterior dislocation of a shoulder with an acute four-part fracture of the proximal humerus.     

定制型肱骨近端假体结合人工补片重建肩关节的疗效分析

目的 探讨肱骨近端骨肿瘤保肢术中使用人工补片重建盂肱关节囊的手术方法及其对稳定肩关节、预防术后肱骨头脱位的效果.方法 2006年2月至2009年1月,回顾性分析接受定制型肱骨近端假体结合聚丙烯非降解性人工补片重建肩关节的患者12例,男7例,女5例;年龄21～55岁,平均38岁.肿瘤类型:骨巨细胞瘤9例,骨肉瘤1例,软骨肉瘤2例.9例骨巨细胞瘤患者中3例为Campanacci Ⅱ期,6例为Campanacci Ⅲ期;1例骨肉瘤患者为Enneking ⅡB期;2例软骨肉瘤患者均为Enneking Ⅱ A期.采用国际骨与软组织肿瘤协会(MSTS)功能评估标准评价术后肩关节功能.结果 患者均获得随访,随访时间24～52个月,平均35个月.手术出血量150～500 ml,平均254 ml;手术时间150～200 min,平均172 min.术后患者肩关节前屈20°～60°,平均41°;外展20°～70°,平均42°.MSTS评分为53%～77%,平均66%.术后无一例患者出现臂丛损伤、切口感染及假体脱位;随访期间无一例患者出现局部复发、远处转移或死亡.结论 使用聚丙烯非降解性人工补片重建盂肱关节囊可显著减少肱骨近端骨肿瘤保肢术后肱骨头假体脱位的发生,便于周围软组织的附着和长入.

Abstract：

Objective To investigate the surgical technique,postoperative function and dislocation incidence of proximal humerus reconstruction with metallic endoprostheses and polypropylene knitted nonabsorbable mesh after proximal humeral tumor resection.Methods Twenty patients with proximal humeral tumor were retrospectively reviewed.They were performed proximal humerus reconstruction with proximal humeral prosthesis and polypropylene knitted non-absorbable mesh from February 2006 to January 2009.There were 5 women and 7 men with a mean age of 38 years(range,21-55 years)at the time of surgery,and giant cell tumor in 9 patients(including Campanacci Ⅱ for 3,Campanacci Ⅲ for 6),osteosarcoma in 1(Enneking ⅡB).and chondrosarcoma in 2 (Enneking ⅡA).The operative time,blood loss,and shoulder movement postoperation were analysed.According to the assessment system by MSTS,the function of limb after surgery was assessed.Results Patients were followed clinically and radiographically for a minimum of 24 months (mean,35 months;range,24-52 months).The mean operative time was 172 min(range,150-200min).The mean blood loss was 254 ml (range,150-500 ml).There were no shoulder dislocations at final follow-up.The mean shoulder flexion was 41°(range,20°-60°)and mean shoulder abduction was 42°(range,20°-70°).The mean postoperative functional assessment score of the limb was 66%(range,53%-77%).None of the Datients had a wound infection,traction neuropraxia or died after the surgical procedure.Conclnsion The data suggests that the use of a polypropylene knitted non-absorbable mesh for proximal humerus reconstruction may reduce dislocations and facilitate soft tissue attachment after tumor resection.     

Anatomy and function of the glenohumeral ligaments in anterior shoulder instability

The anatomy of the glenohumeral ligaments has been shown to be complex and variable and their function is highly dependent on the position of the humerus with respect to the glenoid. The superior glenohumeral ligament with the coracohumeral ligament was shown to be an important stabilizer in the inferior direction, even though the coracohumeral ligament is much more robust than the superior glenohumeral ligament. The middle glenohumeral ligament provides anterior stability at 45 degrees and 60 degrees abduction whereas the inferior glenohumeral ligament complex is the most important stabilizer against anteroinferior shoulder dislocation. Therefore, this component of the capsule is the most frequently injured structure. An appropriate surgical procedure to repair the inferior glenohumeral ligament complex after shoulder dislocation must be considered. In addition, a detached labrum can lead to recurrent anterior instability and a compromised inferior glenohumeral ligament complex. However, additional capsular injury usually is necessary to allow anterior dislocation.     

A severely displaced metaphyseal fracture of the proximal humerus with dislocation of the shoulder in a child

Fracture of the proximal humerus meta- physis with coexistent dislocation of the shoulder in chil- dren is a rare injury. The injury often occurs as a conse- quence of high velocity trauma. Most fractures of the proxi- mal humerus commonly associated with the epiphysis in children can be treated with closed reduction. We presented a case of 5-year-old girl who sustained this type of fracture-dislocation of the shoulder. Open reduction and internal fixation with multiple smooth K-wires was performed. At two years follow-up, the patient was pain free and regained full range of motion.     

Recurrent shoulder dislocations secondary to coracoid process fracture: a case report

Coracoid process fracture is easily missed in recurrent anterior shoulder dislocation. We report one such case in a 48-year-old man. Radiology revealed the Bankart lesion and the Hill-Sachs lesion only; the coracoid process fracture was discovered intra-operatively. The anatomy of the shoulder was restored by fixing the fragment to its scapular remnant with a 4-mm cannulated cancellous screw. The tip and the proximal fragment were reamed before inserting the screw. This fragment was routed with attached short head of biceps and coracobrachialis through the lower one third of the subscapularis, before homing it and fixing it to the proximal coracoid fragment. This extraarticular repair resulted in less stiffness than any intra-articular procedure. At the 2-year follow-up, the patient had had no further shoulder dislocation.