Management of bilateral posterior shoulder dislocation with grade III reverse Hill-Sachs lesion: a case report

Posterior shoulder dislocation is rare, with an annual incidence of approximately 1.1 cases per million population, and is most frequently associated with high-energy trauma or epileptic seizures.^[1] Among affected patients, reverse Hill-Sachs lesions (rHSLs) occur in up to 86% of first-time posterior dislocations,^[2] which pose management challenges due to instability, cartilage damage, and joint destruction.^[3] Based on the defect sizes, rHSLs are classified as grade I (<1.5 cm²), grade II (1.5-2.5 cm²), or grade III (>2.5 cm²).^[4] Grade III lesions are particularly challenging, often requiring surgical reconstruction.

Due to atypical presentation and limited clinical awareness, posterior shoulder dislocations are frequently overlooked, with misdiagnosis rates ranging from 50% to 80%.^[5] Once diagnosis is delayed beyond six weeks, the injury is considered chronic,^[6] which substantially increases treatment complexity and poorer functional outcomes.^[7] Bilateral posterior shoulder dislocations are even rarer, especially those secondary to epileptic seizures. Here, we report the successful treatment of a patient with chronic bilateral posterior shoulder dislocation accompanied by grade III rHSLs.

A 73-year-old woman presented with a two-month history of bilateral shoulder pain and restricted mobility following a generalized seizure that occurred while she was dancing. Immediately after the event, she experienced severe pain in both shoulders and was unable to lift either arm. Initially, she received medical care at a local hospital, where acupuncture, physiotherapy, and oral analgesics were provided without definitive imaging evaluation.

Upon admission, physical examination revealed stable vital signs with marked limitations in active range of motion (ROM) in all directions in both shoulders. Bilateral shoulder tenderness was present, and both Dugas and straight-edge tests were positive. Neurovascular examination demonstrated no deficits. Her medical history was significant for untreated epilepsy and well-controlled hypertension. Subsequent magnetic resonance imaging (MRI) confirmed bilateral posterior shoulder dislocations with rHSLs and a concomitant right-sided labral tear. Given that the duration of injury exceeded six weeks, the injury was deemed chronic.

After multidisciplinary evaluation and preoperative preparation, the patient underwent bilateral modified McLaughlin procedures with allogeneic femoral head grafting, followed by arthroscopic debridement on the 3rd hospital day under general anesthesia with regional nerve block.

Intraoperatively, humeral head defects were identified on both sides, measuring 2.5 cm × 3.5 cm × 1.5 cm on the right side and 1.5 cm × 3.5 cm × 1.5 cm on the left side. These defects were repaired using allograft bone secured with screw fixation. The subscapularis tendon tears and joint capsule were repaired, while the right irreparable labral tear was stabilized with a Kirschner wire (K-wire). Postoperative computed tomography (CT) confirmed satisfactory reduction.

Following surgeries, the patient received standard postoperative management, including analgesic therapy, anti-inflammatory treatment, and thromboprophylaxis. Both shoulders were immobilized using abduction braces. The K-wires were removed four weeks later. Recovery progressed uneventfully. By five months postoperatively, the patient had resumed moderate physical activities. At the one-year follow-up she achieved a Constant-Murley score of 80, indicating near-complete functional recovery.

Bilateral posterior shoulder dislocation accounts for only 2%-5% of all shoulder dislocations and is associated with a particularly high rate of missed diagnosis, largely because radiographic findings may be subtle on initial plain films.^[8-10] Given the complexity of this case, a multidisciplinary team (MDT) was established. The team included orthopedic surgeons, rehabilitation therapists, and nursing staff, ensuring coordinated and continuous care throughout the treatment course. Through regular communication and collaborative decision-making, this model facilitated individualized treatment planning and timely adjustment of rehabilitation strategies, ultimately contributing to this patient’s favorable clinical outcomes.

A major challenge during rehabilitation was the patient’s fear of movement. Kinesiophobia is commonly observed among orthopedic patients, with reported prevalence rates reaching 53%.^[11,12] Consistent with this observation, our patient demonstrated significant movement-related fear before surgery, as evidenced by a Tampa Scale for Kinesiophobia (TSK) score of 36. To address this issue, a multimodal analgesic strategy was implemented, including preemptive analgesia, intraoperative nerve blockade, postoperative patient-controlled analgesia, and cryotherapy. Adequate pain control created favorable conditions for the early initiation of rehabilitation exercises. Simultaneously, structured educational intervention targeting fear avoidance was introduced. Detailed explanations of the surgical procedures, expected recovery trajectory, and rehabilitation goals were provided using anatomical models and visual aids. Gradual exposure to movement began with simple hand and elbow exercises and progressed incrementally to more demanding activities. This stepwise approach enhanced the patient’s confidence and reduced fear-avoidance behaviors. As a result, the patient’s TSK score decreased from 36 to 13 by the time of discharge, accompanied by a substantial improvement in rehabilitation adherence.

Another important consideration was the elevated risk of redislocation arising from extensive bony defects, associated soft-tissue injuries, and the patient’s underlying epilepsy.^[12] To minimize this risk, multiple preventive measures were implemented, including stabilization using the modified McLaughlin technique, temporary K-wire fixation, strict postoperative immobilization in abduction braces, patient education regarding seizure control with medication adherence, and early controlled mobilization of distal joints. These interventions effectively prevented redislocation during follow-up.

Prolonged immobilization also increases the risk of accelerated bone loss, particularly in elderly patients. In the present case, preoperative imaging suggested significant osteopenia.^[13] Interventions included vitamin D supplementation, calcium regulation, and dietary counseling.

These interventions were associated with an increase in serum calcium levels from 1.8 mmol/L at admission to 2.4 mmol/L one month after discharge, and no fragility fractures occurred during recovery.

In addition, although upper extremity deep vein thrombosis (UEDVT) is less common than lower extremity thrombosis, it remains a serious postoperative complication. The thrombosis risk was assessed using the Caprini score. Individualized prophylactic measures were implemented, including adequate hydration, administration of low-molecular-weight heparin, regular limb circumference monitoring, patient education regarding warning signs, and periodic ultrasound screening. No thrombotic events were observed throughout the follow-up period.

To facilitate functional recovery, a structured and phased rehabilitation program was developed (Table 1). The protocol incorporated progressive strengthening exercises, balance training, aerobic conditioning, and respiratory exercises. Advancement through each phase was guided by pain intensity (visual analogue score [VAS] score <3), ROM recovery, and muscle strength gains. Continuous follow-up and remote support further promoted adherence to the rehabilitation program. At the one-year follow-up, the patient achieved substantial restoration of shoulder function and returned to her normal daily activities.

Table 1.

A structured and phased rehabilitation program

Stages	Duration	Core objectives
Phase I	0-4 weeks	Protection of surgical repair and maintenance of distal joint mobility
Phase II	5-8 weeks	Gradual restoration of shoulder active range of motion and improvement of muscular endurance
Phase III	9-14 weeks	Achievement of full shoulder active range of motion and initiation of low-intensity strengthening
Phase IV	15-20 weeks	Advanced strengthening and functional training
Phase V	>20 weeks	Return to daily and recreational activities

This case highlights several important clinical principles. First, multidisciplinary collaboration may improve care coordination and ensure comprehensive management of complex orthopedic conditions. Second, integrating psychological support with physical rehabilitation effectively addresses kinesiophobia, which is often an obstacle to functional recovery. Third, proactive prevention of complications including osteoporosis-related bone loss and thromboembolic events is important, particularly in elderly patients requiring prolonged immobilization. Finally, individualized and goal-oriented rehabilitation programs may improve long-term outcomes.

The favorable recovery observed in this patient may be attributed to the synergistic effects of multidisciplinary nursing care. The MDT integrated orthopedic management, rehabilitation therapy, and specialized nursing interventions into a coordinated treatment protocol. This collaborative approach facilitated early identification of potential complications, optimization of pain management, individualization of rehabilitation planning, and dynamic monitoring of functional progress. Such comprehensive care may enhance patient engagement, improve adherence to rehabilitation protocols, and ultimately promote functional recovery.

Pain control and reduction of kinesiophobia appeared to be closely interconnected in this case. Persistent postoperative pain is a well-recognized contributor to fear-avoidance behaviors, which may lead patients to restrict their movement, delay rehabilitation participation, and consequently experience poorer functional outcomes. Adequate analgesia provides the physiological basis for early mobilization, while the structured education on fear-avoidance intervention addresses psychological barriers to mobility engagement. Through gradual exposure to rehabilitation activities and continuous encouragement from the MDT, the patient gained confidence and decreased movement-related fear substantially. The marked reduction in the TSK score was accompanied by improved rehabilitation adherence and progressive restoration of shoulder function, suggesting that effective pain management and kinesiophobia reduction may jointly contribute to favorable functional outcomes.

Funding: The study was supported by grants from the Medical and Health Science Program of Zhejiang Province (2025HY0423); Zhejiang Provincial Science and Technology Plan of Traditional Chinese Medicine (2024ZL572).

Ethical approval: Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Conflicts of interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Contributors: GPX: conceptualization, data collection, data analysis, writing and manuscript editing; QFY: data analysis, writing and manuscript editing; LL: data collection, manuscript editing; GXS: clinical practice guidance; YTZ: rehabilitation protocol design, clinical intervention implementation, writing and revision.