Irreducible Anterior Shoulder Dislocation with Interposition of the Long Head of the Biceps and Greater Tuberosity Fracture: A Case Report and Review of the Literature

Abstract

Background:Failure of closed manipulative reduction of an acute anterior shoulder dislocation is seldom reported in the literature and is usually due to structural blocks such as soft tissue entrapment (biceps, subscapularis, labrum), bony fragments (glenoid, greater tuberosity) and severe head impaction (Hill-Sachs lesion).Case report:We present a case of an irreducible anterior shoulder dislocation in a 57-year-old male patient after a road-traffic accident. He had severe impaction of the head underneath glenoid rim and associated fracture of the greater tuberosity. Closed reduction performed in the emergency room under sedation and later at the theatre under general anaesthesia was unsuccessful. Open reduction using the dectopectoral approach revealed that the reason for obstruction was the posterolateral entrapment of the biceps tendon between the humeral head and the tuberosity fragment. Reduction was achieved after subscapularis tenotomy and opening of the joint; the tuberosity fragment was fixed with transosseous sutures and the long head of the biceps tendon was tenodesized. The patient had an uneventful postoperative recovery and at his last follow up, 12 months postoperatively, he had a stable joint, full range of motion and a Constant score of 90.Conclusion:A comprehensive literature review revealed 22 similar reports affecting a total of 30 patients. Interposition of the LHBT alone or in combination with greater tuberosity fracture was the most common obstacle to reduction, followed by subscapularis tendon interposition and other less common reasons. Early surgical intervention with open reduction and confrontation of associated injuries is mandatory for a successful outcome.

Acil Serviste Omuz Çıkıklarının Değerlendirilmesi: Sedoanaljezi ve İzlem

“…The remaining 4 patients had their shoulders reduced under the conditions of an operating room as a result of a deeper anesthesia and muscle relaxation. In the literature, while an exact failure rate was not provided, 5-10% failure rate for the cases with anterior dislocations or a minimal failure rate for the closed reductions was reported (16)(17)(18). In our study, in the patients whose shoulders were reduced without a consultation with the Department of Orthopedics, no complication was seen following the reduction.…”

Irreducible anterior shoulder dislocation with interposition of the lesser tuberosity and subscapularis

“…Shoulder dislocation is a commonly seen presentation, with an incidence of 8 per 100,000 people/year [ 8 ]. The vast majority of anterior shoulder fracture dislocations are easily reducible, therefore irreducible shoulder dislocation case reports are not numerous [ 5 , 6 ]. Usually a rotator cuff tear results in patients older than 40, and in younger patients damage to the glenohumeral ligaments, labrum or glenoid occur with subsequent shoulder instability [ 8 ].…”

“…The current literature states the identified causes of the failed closed reduction and these include impaction of the Hill-Sachs lesion into the glenoid, interposition of soft tissues such as a torn subscapularis, labrum (soft tissue Bankart), LHBT, musculocutaneous nerve [ [5] , [6] , [7] ]. Bowstringing of the subscapularis, the LHBT, or interposition of bony structures such as the greater tuberosity or a bony Bankart lesion have been described as reasons to impede closed reduction [ 1 , 5 , 6 , 9 ]. In rare cases, posterior shoulder fracture dislocations with both greater and lesser tuberosities fractures may lead to infraspinatous interposition impeding closed reduction trials [ 10 ].…”

“…Irreducible shoulder dislocations, even though rare, are reported in the literature. In the described cases, causes of irreducibility include impaction of the humeral head on the glenoid rim, bony interposition in cases of greater tuberosity fractures and Bankart lesions, with the most common causes being due to the soft tissue interposition of interposed labrum, posteriorly dislocated long head of the biceps tendon, or rotator cuff, such as the subscapularis tendon being interposed within the glenohumeral joint [ 5 , 6 ]. There has also been a reported case of an interposed musculocutaneous nerve as the cause of irreducibility [ 7 ].…”

A Rare Case of Rotator Cuff Interposition Causing Humeral Head Subluxation Following Anterior Shoulder Dislocation

“…This was reduced under sedation; however, the patient had an ongoing feeling that his shoulder “was not right.” Subsequent investigations demonstrated persistent anterior subluxation of the humeral head with rotator cuff interposition in the glenohumeral joint. This case appears to be the first of its kind to be reported in which the supraspinatus, subscapularis, and long head of the biceps were collectively interposed [ 1 ]. This was treated operatively with open reduction and rotator cuff repair, although the procedure was technically difficult due to tissue fibrosis and the formation of adhesions.…”