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Abstract:
Background:
Unreduced anterior shoulder dislocation is a fairly
uncommon condition with different treatment options and varying
outcome. The aim of this study was to determine if open
reduction of unreduced shoulder dislocation is beneficial to
patients.
Method:
Medical records of five patients with unreduced anterior
shoulder dislocation treated by open reduction in the
Orthopaedic unit of the University of Calabar Teaching Hospital
(UCTH) from 1st April 2006 to 31st March 2009 were reviewed.
Data extracted from the case notes include patient’s
socio-demographic information, shoulder affected, handedness of
patient, cause of injury, interval between injury and
presentation in UCTH, type of surgery performed, post operative
treatment, post operative complications, patients’ satisfaction
with the outcome of surgery. Data obtained were analysed.
Results:
The five (5) patients in this study were all males with
age ranging from 20 to 65years, with mean age of 37years. The
right shoulder was affected in 3 patients (60%) and the left in
2 (40%). All the patients were right-handed. The interval
between injury and presentation in UCTH ranged from 4 months to
1year 8months, with mean interval of presentation of 7.2 months.
The cause of the dislocation was road traffic injury in 4
patients (80%) and seizure disorder in 1 patient (20%).All the patients followed up gained up to 650 of
abduction of the affected shoulder at three months post
operatively. All patients were able to perform activities of
daily living.
Conclusion:
Open reduction of unreduced shoulder dislocation is
beneficial to patients.
J.Orthopaedics 2010;7(2)e11
Keywords:
Shoulder; Unreduced Dislocation; Open Reduction; Calabar.
Introduction:
Anterior shoulder dislocation is the most common dislocation
affecting man due to the peculiar anatomy of the shoulder joint
and its tremendous wide range of movement 1. The
condition usually affects the young and active ones males. The
treatment of the acute condition is usually easy with excellent
results if patients present on time. However, in our environment
it is not uncommon to find patients with anterior shoulder
dislocation presenting to the doctor weeks and even months after
injury. This condition at this stage is referred to as unreduced
anterior shoulder dislocation. Even though there is a wide
variation in the definition of the time at which acute anterior
shoulder dislocation becomes unreduced (a case presenting after
24 years has been reported! 2), three weeks post
dislocation is generally acceptable as the cut off time 3.
The methods that have been described for the treatment of
unreduced anterior shoulder dislocation include among others
closed reduction under anaesthesia, open reduction and leaving
the old dislocation alone! 3,4 The treatment of this
condition is usually more difficult with highly unpredictable
outcome 5,6 and variable impact on the patient’s
occupation and activities of daily living 3.
In view of this, the authors considered it necessary to
determine whether the treatment of this neglected unreduced
anterior shoulder dislocation by open reduction is really worth
the trouble and beneficial to the patient especially considering
the huge resources involved and high complication rate. This
consideration necessitated the review of five cases of neglected
unreduced anterior shoulder dislocation treated by open
reduction in the orthopaedic unit of the University of Calabar
Teaching Hospital (UCTH) over a three-year period.
Materials
and Methods:
All cases of neglected unreduced anterior shoulder dislocation
treated by surgery in the orthopaedic unit of the University of
Calabar Teaching Hospital over a-three-year period (1st April
2006 – 31st March 2009) were reviewed. Patients’ hospital
numbers were obtained from operating theatre records and then
their case notes were retrieved from the medical records unit of
the hospital. Data extracted from the case notes include
socio-demographic information, shoulder affected, handedness of
patient, cause of injury, interval between injury and
presentation in UCTH, type of surgery performed, post operative
treatment, post operative complications, patients’ satisfaction
with the outcome of surgery.
The data so obtained were analysed in relation to the
abovementioned parameters.
Results :
The five (5) patients in this study were all males with age
ranging from 20 to 65years, with mean age of 37years. Most of
our patients were students (40%) while farmer, policeman and
trader constituted 20% each. All the patients were educated with
80% attaining secondary education and 20% primary education. The
right shoulder was affected in 3 patients (60%) and the left in
2 (40%). All the patients were right-handed. The interval
between injury and presentation in UCTH ranged from 4 months to
1year 8months, with mean interval of presentation of 7.2 months.
The cause of the dislocation was road traffic injury in 4
patients (80%) and seizure disorder in 1 patient (20%). One
patient had associated fracture of the greater tubercle of the
humerus. The main complaints of the patients on presentation
were limitation of movement, deformity and pain in the affected
shoulder. All the patients first sought treatment at the
traditional bone setters’ (TBS) before presenting at UCTH when
their condition did not improve.
All the patients had open reduction of the dislocation using the
deltopectoral approach under general anaesthesia. The joint
capsule was incised to view the glenoid from which fibrous and
adipose tissues were removed before reduction. The joint capsule
was then repaired. The humeral head was fixed to the glenoid
using percutaneous pin/kirschner wire. In the patient with
fracture of the greater tubercle of the humerus, the fracture
was reduced and fixed with a cancellous screw. Broad arm sling
was applied post operatively. Percutaneous pins were removed
three weeks post operatively, however pin fell out at two weeks
in two patients. The patients were then started on a regime of
passive and active range of movement exercises of the affected
shoulder joint.
Post operative complications recorded include wound infection in
4 patients (80%), radial nerve injury with wrist drop in 1
patient (20%), resorption of the head of humerus in 1 patient
(20%) and re-dislocation in 1 patient (20%). The post operative
wound infections were treated successfully with appropriate
antibiotics and wound care, the radial nerve injury with wrist
drop recovered fully by the fourth week post operatively but the
patient with re-dislocation of the operated absconded.
All the patients followed up gained up to 650 of
abduction of the affected shoulder at three months post
operatively. All patients were able to perform activities of
daily living. Using the Rowe and Zarin rating system, the
outcome of treatment was assessed as fair in three patients and
good in one. In spite of this however, all the patients followed
up indicated reasonable level of satisfaction with the outcome
of treatment received.
Figure
I:
Pre Operative X-Ray Of One Of The Patients (right shoulder
affected)
Figiure II: Post Operative X-Ray Of One Of The Patients
Discussion :
Late presentation of trauma patients to the appropriate health
facility is not uncommon in our environment due to far-reaching
patronage and confidence in the treatment offered by traditional
bone setters in spite of their usual poor results 7,8,9.
Thus the fact that all the patients in this study first
patronised the traditional bone setter is not surprising. This
was the reason for the non-reduction of the dislocation as
against the finding in other studies where acute dislocations
were missed by the initial attending physicians 2.
Late presentation usually turns a condition (acute anterior
shoulder dislocation) requiring an otherwise simple and
effective treatment 10 to one (unreduced anterior
shoulder dislocation) with a wide range of treatment options but
with unfortunately very unpredictable results! 4,5
Closed manipulation under anaesthesia was not offered to our
patients because of the long interval between dislocation and
presentation in UCTH (the earliest patient in our series
presented at 4months post dislocation!) and the attendant high
complication rates associated with such procedures 5.
In our patients, the other options of treatment such as hemi or
total shoulder arthroplasty 2 were not considered due
to the non-availability of requisite facilities in our centre
and high cost implications to the patient should the patient be
referred to another centre. The patients were therefore treated
by open reduction of the dislocated shoulders with pin
insertion. However, other authors have reported good results
with open reduction without pin/screw fixation 2.
Even though the assessment of the outcome of treatment in our
series was fair in 3 and good in 1 patient, all of them were
able to carry out activities of daily living. In fact, all of
them expressed reasonable satisfaction with the outcome of
treatment obtained in spite of the clinical rating. It would
appear therefore that clinical rating alone is not adequate in
assessing the outcome of treatment of this condition by open
reduction. The satisfaction or otherwise of the patient is
critical in determining if indeed the treatment of the condition
by open reduction is worth the trouble and beneficial. From our
finding, it can be asserted that patients would express
reasonable satisfaction with results of open reduction of
unreduced anterior shoulder dislocation if they are able to
carry out their activities of daily living post operatively
especially when adequate pre-operative counselling was done.
In conclusion therefore, it is pertinent to emphasize that
unreduced anterior shoulder dislocation is a real problem in our
environment especially with the unregulated activities of
traditional bone setters. The treatment of this condition by
open reduction, though with variable clinical outcome, is
beneficial to patients as they are able to cope with activities
of daily living postoperatively.
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