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Four cases of posterior dislocation of the shoulder at birth in association with obstetric brachial plexus palsy are presented. Review of the literature suggests that this association is not generally recognised. All cases were diagnosed late; two were treated by open reduction, one by humeral osteotomy and one managed conservatively.
Posterior dislocation of the shoulder may be associated with an anteromedial impaction fracture rendering the shoulder unstable in internal rotation. The modified McLaughlin procedure as described by Neer involves transplanting the lesser tuberosity with the attached subscapularis tendon into the anteromedial defect. We have used this procedure acutely (from the day of injury to 10 days postinjury) in seven shoulders. All patients were unstable in internal rotation and had an anteromedial impaction fracture occupying 25-40% of the articular surface. This technique provides good stability, enables immediate active range of motion, and allows the patient to rapidly return to activities of daily living.
There are different opinions on the duration of post-operative shoulder immobilisation following arthroscopic repair of labrum tears. Between 1993 and 1994 at our department arthroscopic repairs of the glenoid labrum as described by Habermeyer (15, 16) have been performed in 38 patients. In 20 of these patients postoperative treatment included immobilisation of the operated shoulder in a Gilchrist-bandage for 3 weeks, while in the remaining 18 patients this postoperative immobilisation period was decreased to only 1 or 2 weeks. Physiotherapy started the day after the operation, using a device for passive-motion exercises. The mean follow-up time of our examinations was 15.4 month. The mean score by Rowe rose significantly from 20.0 preoperatively to 82.6 at the follow-up examination. Results were excellent or good in 89.4% of all cases, new shoulder dislocations did not occur in any case. Patients having their shoulders immobilised for 3 weeks reached significantly higher Rowe-scores at our follow-up than those patients, whose shoulders were immobilised for only 1 or 2 weeks. Therefore, postoperative management following arthroscopic repair of labrum tears should include immobilisation of the operate shoulder for 3 weeks and an early start of passive-motion exercises.
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The classical anterior-inferior dislocation of the shoulder is diagnosed easily by clinical examination and x-ray. The additional lesions like impression fracture at the humerus, avulsion of the anterior rim of the glenoid, lesions of the rotator cuff or neurologic deficits are more difficult to realise. In young patients the redislocation rate is rather high. Indication for surgery is still on debate. Modern diagnostic tools will help to determine additional lesions. More problems are incountered in presence of a posterior dislocation. Those are often overlooked.
Early traumatic anterior dislocation of the shoulder may be reduced very easily using a method combining gentle traction along the axis of the arm, slow external rotation and outwards pressure on the humeral head with the patient seated. This gentle method does not require sedation or analgesia.
Transfer of the subscapularis tendon using a slightly modified Magnuson-Stack procedure was done in 154 shoulders with recurrent anterior dislocation. A follow-up to two to twenty-two years (average, 7.6 years) revealed only three recurrences of the dislocation and no serious complications.
Dislocation of the shoulder with ipsilateral shaft fracture is an uncommon, but serious injury. I present one case report and the guidelines used for treatment. The method employed was Hackethal's pins through open reduction. The dislocation was reduced during surgery. The fracture and dislocation healed without any problems, and there was no damage to the radial nerve. After a recent follow-up, the patient was allowed to return to work without restrictions, and he has regained normal mobility.
It is known that thinning and lengthening of the subscapularis tendon occur in shoulders with recurrent anterior dislocation. However, no studies have been performed to quantify the morphologic changes of the subscapularis tendon under such conditions. We retrospectively measured the thickness and cross-sectional area of the subscapularis tendon by use of magnetic resonance imaging in 22 shoulders in 11 patients with unilateral recurrent anterior dislocation of the shoulder. The contralateral shoulder in each patient served as a control. The thickness and cross-sectional area of the subscapularis on the affected side were smaller than those on the normal side (6.5 +/- 1.7 mm vs 8.0 +/- 1.9 mm, P = .001, and 388.6 +/- 120.0 mm 2 vs 547.9 +/- 128.5 mm 2 , P = .0001, respectively). We conclude that the subscapularis tendon undergoes an 18.7% decrease in thickness and a 29.1% decrease in cross-sectional area in shoulders with recurrent anterior dislocation.
Boytchev's operation for recurrent dislocation of the shoulder, in which three muscles attached to the coracoid process are re-routed deep to the subscapularis muscle and immediately adjacent to the gleno-capsular rent, is described. Seventeen patients have been reviewed after an average post-operative interval of six years. No recurrence of the dislocation had occurred and all patients were graded as excellent or good on objective examination although on subjective assessment one patient was considered only fair and the remainder good or excellent.
The authors describe the clinical and radiographic findings of posterior dislocation of the shoulder by examining 19 cases observed at the Rizzoli Orthopaedic Institute between 1981 and 1990; of the total number of cases, 16 were acute and 3 inveterate, equal to 1.7%. After analyzing the pathogenesis of the lesion, which was due to direct trauma, indirect trauma, or which occurred during an episode of convulsions, the authors call attention to the rareness of the lesion, and consequently the little amount of knowledge of the clinical and radiographic elements characterizing it. Three varieties are distinguished: subacromial (or retroglenoid), subglenoid, and subspinous. Finally, the results obtained with non-surgical treatment, which always allows for recovery of the joint relationships and complete functional recovery, are reported.
Humeral head retroversion and shoulder rotation in both the frontal and scapular plane were studied in 34 patients with anterior glenohumeral instability. Twenty-two patients had traumatic anterior shoulder dislocations and another 12 patients had nontraumatic dislocations with generalized joint laxity. Patients with traumatic recurrent dislocations had a smaller than normal retroversion angle in the unstable shoulder. The angles were 26 degrees on the dominant side and 23 degrees on the nondominant side compared with 33 degrees and 29 degrees, respectively, in normal shoulders. The stable contralateral shoulder joint was clinically and roentgenographically similar to the normal shoulder. The patients with nontraumatic dislocations had increased rotation and smaller retroversion angles, irrespective of stability in the shoulder joint. The retroversion angles were 18 degrees for unstable shoulders on the dominant side and 15 degrees on the nondominant side. The retroversion angle of the stable contralateral joint in these patients was less in five of eight shoulders.
Acute posterior dislocations of the shoulder are uncommon. Recommended surgical treatments for recurrent posterior dislocation include soft-tissue advancement, posterior glenoid osteotomy, rotational osteotomy of the humerus, and posterior bone block. The posterior bone-block procedure successfully prevented recurrent dislocation in our series of five patients. The patients ranged in age from seventeen to forty-four years, and have been followed for two and one-half to eight years. All returned to unrestricted activity and recreational sports. The complications included a later anterior dislocation of the shoulder in one patient and an unsightly scar requiring revision in two patients. There were no complaints of pain. Radiographs showed decreased density of the bone block in two patients, but graft resorption did not occur.