Chronic posterior dislocation of shoulder

Ravi Mittal; Siddharth Jain; Shivanand Gamanagatti

doi:10.1016/j.jcot.2022.101926

. 2022 Jun 21;31:101926. doi: 10.1016/j.jcot.2022.101926

Chronic posterior dislocation of shoulder

Ravi Mittal ^a,^∗, Siddharth Jain ^a, Shivanand Gamanagatti ^b

PMCID: PMC9253901 PMID: 35799881

Abstract

Purpose

Chronic posterior dislocation of shoulder (PDS) is an uncommon injury and there are very few publications describing its different injury patterns and their treatment. This study was carried out to study the associated injuries in chronic PDS, which can help to classify and guide the treatment.

Methods

We retrospectively studied 16 chronic posterior dislocation of shoulder. CT scan was used to classify the injury based on the amount of bone loss in humeral head, malunion of greater tuberosity and malunion of proximal humerus metaphysis. Visual analogue score (VAS) for pain, university of California Los Angles (UCLA) shoulder score and American shoulder and elbow surgeon (ASES) shoulder score were recorded pre operatively and at an average of 27 months post operatively.

Results

– Type A1 injury was PDS with <50% humeral head bone loss with intact greater tuberosity (GT). It was managed by modified McLaughlin procedure (MMP). Type A2 injury was PDS with >50% bone loss with intact GT. It was managed by hemi-replacement (HRA). Type B1 injury was PDS with <50% bone loss with severe GT malunion. It was managed by MMP and corrective osteotomy of GT. Type B2 injury was PDS with >50% bone loss and severe GT malunion. It was managed by reverse shoulder arthroplasty (RSA). Type C1 injury was PDS with <50% bone loss and metaphyseal malunion. It was managed by MMP and osteotomy of proximal humeral metaphysis. Type C2 injury was PDS with >50% bone loss and metaphyseal malunion. It was managed by HRA. The VAS, UCLA score and ASES score improved significantly after the surgery in all cases. There was no recurrence of the instability

Conclusions

We concluded that chronic PDS could have fractures of tuberosities and/or proximal metaphysis in addition to bone loss in humeral head. The treatment is guided by all three factors-amount of bone loss in humeral head, malunion of GT and proximal humeral metaphysis. The proposed classification can help in choosing the optimum treatment out of joint salvage procedure, anatomic shoulder replacement and reverse shoulder arthroplasty

Keywords: Chronic, Posterior shoulder dislocation, Reverse hill-sachs lesion, Fracture dislocation proximal humerus

1. Introduction

Glenohumeral joint is the commonest joint to dislocate in the body. Most of the shoulder dislocations are anterior and <3% are posterior dislocations.¹ Posterior shoulder dislocation (PDS) constitutes 2–5% of all shoulder dislocations.² The common reasons for PDS are epileptic seizures, electric shock, electro-convulsive therapy without muscle relaxation, major trauma or injuries.²

High-energy trauma can cause PDS when there is axial loading of arm in position of adduction, internal rotation and forward flexion.¹ A significant number of these dislocations are missed in the initial examination and rate of missed injuries varies up to 79%.² A PDS is considered acute when the duration of injury is less than 3–6 weeks and it is considered chronic after this period.² It may be neglected in old people with low functional demands, but needs to be treated in younger population.² Any PDS, when present for more than 6 weeks, is difficult to reduce in a closed manner and requires operative intervention.² The various operative procedures vary according to the presence of associated injuries and they can be broadly classified as joint arthroplasty or joint salvage procedures. Although there is extensive literature on acute shoulder dislocation, there have been few studies on the chronic posterior dislocation of shoulder. Currently, there is no consensus for treating this injury. One of the reasons could be varying severity of chronic PDS in different scenario. The other reason could be limited of this injury seen by a single surgeon. This article aims to present our experience in the management of chronic PDS and possibly a treatment algorithm.

2. Methods

This is a retrospective study of 16 chronic PDS, which were managed between March 2012 and June 2018. There were 2 females and 12 males. The age of patients ranged from 27 to 64 years with average of 34.6 years. After clinical examination, all the patients underwent examination with X-rays and CT scan. The CT scan images were analyzed to look for the amount of bone loss in humeral head (RHSL), status of greater tuberosity (GT) and proximal metaphysis. The amount of bone loss in humeral head (<50% or >50%) was evaluated on axial section of humeral head. Based on the above-mentioned criteria, we could group the patients as in Table 1. All patients were followed for 2–3 years and evaluated for range of motion, VAS for pain, ASES and UCLA score before the surgery and at an average of 27 months after surgery. One patient who was 64 years old female was managed by “supervised neglect” as she could manage her daily activities with minimal pain. The rest of the patients were younger and had significant loss of shoulder function. They did not accept their shoulder function and demanded treatment.

Table 1.

Types of chronic posterior dislocation shoulder based on CT scan.

Type of injury	Treatment	Number of cases
Type A – only RHSL
A1 - <50% bone loss in RHSLwith intact GT	Modified McLaughlin's procedure	5
A2 - >50% bone loss in RHSL with intact GT	HRA	4
	Supervised neglect	1
Type B – RHSL + severe malunion of GT
B1 - <50% bone loss in RHSL + severe malunion of GT	Modified McLaughlin's procedure + GT osteotomy	1
B2 - >50% bone loss in RHSL + severe malunion of GT	RSA	3
Type C – RHSL + metaphyseal extra-capsular fracture with GT in continuity with distal fragment
C1 - <50% bone loss in RHSL + metaphyseal malunion	Modified McLaughlin's procedure + metaphyseal osteotomy	1
C2 - >50% bone loss in RHSL + metaphyseal malunion	HRA	1

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RHSL – reverse Hill-Sachs lesion.

GT – greater tuberosity.

HRA – hemi-replacement arthroplasty.

RSA – reverse shoulder arthroplasty.

Type A injury – this type of injury only had reverse Hill-Sachs lesion (RHSL) with intact GT. These were further classified into two types.

Type A1 injury – this type of injury had <50% head bone loss in RHSL with intact GT. We had 5 injuries in this group and we performed modified McLaughlin procedure in all these patients. The delto-pectoral approach was used for this procedure. After identifying the long head of biceps and lesser tuberosity, an osteotomy of the lesser tuberosity was performed, keeping the insertion of subscapularis intact. The direction of osteotomy was planned with the help of axial images on CT scan. The osteotomy of lesser tuberosity allowed the entry into the gleno-humeral joint. The fibrous tissue in the joint was removed and tenotomy of the long head of biceps was performed. The posteriorly dislocated humeral head was carefully levered out and reduced. After reduction, the detached lesser tuberosity fragment, with the attached subscapularis, was placed in the bony defect of RHSL and fixed with two screws.

Type A2 injury – this type of injury had >50% head bone loss in RHSL with intact GT. We had 5 such injuries. One patient was managed by supervised neglect and 4 patients underwent hemi-replacement arthroplasty (HRA).

Type B injury-this type of injury had RHSL along with severe malunion of GT. These were further classified into two types.

Type B1 injury – this type of injury had <50% head bone loss in RHSL along with severe GT malunion. We had one case of type B1 where in addition to the RHSL; there was a malunited ‘shield fragment’. In this case we approached the joint through delto-pectoral approach and performed an osteotomy of lesser tuberosity with the attached subscapularis. This provided an access to the joint and allowed open reduction of the joint. Then an osteotomy of the GT with the attached rotator cuff was performed. GT was re-positioned to its anatomical site and provisionally fixed with k-wire. The reduction of the joint and position of the GT was checked under image intensifier. The GT was fixed using tension band wiring and the lesser tuberosity, with the attached subscapularis, was fixed in the bony defect of RHS using two screws. (Fig. 1A.Fig. 1B, Fig. 1C, Fig. 1D).

Fig. 1A — type B1 injury-preoperative Xray AP view.

Fig. 1B — pre-operative axial CT section showing posterior shoulder dislocation with malunited “shield fragment”.

Fig. 1C — postoperative X-ray Ap view showing reduced shoulder joint with modified Mclaughlin's procedure and corrective osteotomy of greater tuberosity.

Fig. 1D — post operative axial CT section showing reduced shoulder joint with union of greater tuberosity and lesser tuberosity.

Type B2 injury – this type of injury had >50% head bone loss in RHSL along with severe GT malunion. We had 3 patients in this group and we performed reverse shoulder arthroplasty (RSA) in all these patients.

Type C injury – this type of injury had RHSL along with metaphyseal extra capsular fracture with GT in continuity with distal fragment. These were further classified into two types.

Type C1 injury – this type of injury had <50% head bone loss in RHSL along with metaphyseal malunion. We had 1 patient in this group. In this case we performed an osteotomy of lesser tuberosity with the attached subscapularis. This provided an access to the joint and allowed open reduction of the joint. Another osteotomy was done along the original fracture and metaphyseal fragment was pulled distally to bring the GT in correct orientation in relation to the head fragment. Osteotomy was fixed with a locking plate and then modified McLaughlin procedure was performed to stabilize the joint (Fig. 2A)Fig. 2B, Fig. 2C, Fig. 2D.

Fig. 2A — type C1 injury – preoperative X-ray AP view.

Fig. 2B — preoperative axial CT section.

Fig. 2C — preoperative 3D CT showing posterior dislocation shoulder with metaphyseal fracture. Greater tuberosity is in continuity with the distal fragment.

Fig. 2D — postoperative X-ray AP view showing reduced shoulder joint with metaphyseal osteotomy stabilised with a locking plate and modified McLaughlin's procedure.

Type C2 injury – this type of injury had >50% head bone loss along with metaphyseal malunion. We had 1 patient in this group and we performed HRA for this patient.

No osteotomy was performed for HRA or RSA. A single surgeon performed all the surgeries.

3. Results

Fourteen shoulders dislocated due to trauma and 2 shoulders dislocated after electrocution. There were 2 patients with bilateral PDS and one of these had electrocution. The time since injury ranged from 2 months to 7 months. Three patients presented late to the hospital because they lived in remote areas and had difficulty in accessing medical care. In 11 patients, the injury was missed during the initial examination and not diagnosed. There was no infection or recurrence of instability in any of these patients. Patients who underwent modified McLaughlin procedure were immobilized in shoulder spica in external rotation of 45° for 4 weeks (Fig. 3). After removal of shoulder spica, active exercises were started and good range of motion were regained in next 4–6 weeks. Patients who underwent shoulder arthroplasty were immobilized in a sling for 2 weeks and then graded exercises of shoulder were started. Pre-operatively, the average UCLA score was 7.93(range 6–11), ASES was 33.2 (range 30–36) and VAS for pain was 2.6. In the modified McLaughlin procedure group, the average VAS for pain was 1, ASES was 82.85 (range 78–86) and UCLA score was 26.8/35 (range 24–30). In the HRA group VAS for pain was 2, ASES was 63.2 (range 59–65) and UCLA score was 18.8 (range 17–20). In the RSA group, VAS for pain was 1; ASES was 58 (range 56–60) and UCLA score was 17/35 (range 16–18). The improvement in VAS for pain, UCLA score and ASES score was statistically significant (p < 0.05) in all the patients (Table 2). All the patients were satisfied as their nocturnal pain and pain during their daily activities were relieved even though their range of motion was not complete (Table 3).

Fig. 3 — Shoulder spica applied after the surgery.

Table 2.

Patient evaluation scores.

Patient	UCLA score		VAS for pain		ASES score		Procedure
Patient	Pre-op	Post-op	Pre-op	Post-op	Pre-op	Post-op
1	6	17	3	1	30	56	RSA
2	7	24	2	1	34	82	Modified McLaughlin procedure + GT osteotomy
3	6	19	3	2	32	64	HRA
4	11	28	2	1	36	86	Modified McLaughlin procedure
5	8	20	3	2	34	59	HRA
6	6	30	3	1	32	84	Modified McLaughlin procedure
7	7	18	3	1	34	60	RSA
8	9	28	2	1	32	78	Modified McLaughlin + metaphyseal osteotomy
9	10	24	3	1	36	84	Modified McLaughlin procedure
10	6	16	2	1	32	58	RSA
11	8	24	2	1	34	84	Modified McLaughlin procedure
12	9	20	3	2	36	64	HRA
13	8	17	2	2	30	65	HRA
14	8	18	3	2	32	64	HRA
15	10	30	3	1	34	82	Modified McLaughlin procedure

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HRA – hemi-replacement arthroplasty.

RSA – reverse shoulder arthroplasty.

Table 3.

Pre-op and Post-op range of motion.

Patient	Shoulder abduction		Shoulder forward flexion		Internal rotation Arm by the side		External rotation
	Pre-op	Post-op	Pre-op	Post-op	Pre-op	Post-op	Pre-op	Pos-top
1	Not possible	100	Not possible	100	10	50	Not possible	40
2	10	100	20	120	10	60	Not possible	50
3	20	110	10	110	10	50	Not possible	40
4	Not possible	130	Not possible	120	2020	50	10	50
5	Not possible	120	Not possible	120	10	50	10	50
6	10	120	20	130	10	70	Not possible	50
7	20	100	30	120	20	50		40
8	10	110	20	120	20	50	Not possible	50
9	20	100	20	10	10	40	10	30
10	30	130	20	130	30	50	0	40
11	10	120	20	120	10	60	5	40
12	20	120	30	130	10	60	10	40
13	30	110	30	110	20	50	5	50
14	30	120	20	130	20	60	Not possible	50
15	20	120	20	130	20	60	Not possible	50

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4. Discussion

Duration since injury is used to classify PDS as acute or chronic. Chronic dislocations are also labeled as neglected, unreduced, locked and missed dislocation.³ The common reasons for this injury to have a chronic presentation are failure to suspect and diagnose this condition, late presentation to the physician and inadequate radiological examination of the shoulder. Due to the posterior dislocation, an impression fracture occurs on the anterior humeral head and is known as reverse Hill-Sachs lesion. If the dislocation remains unreduced, this indentation fracture increases in size due to rotational movements of the shoulder. If the force producing the dislocation is severe, the impression fracture propagates to cause fracture of anatomical neck and/or tuberosities, resulting in fracture dislocation.¹^,²

Robinson et al. have considered this injury as two distinct entities – simple dislocation with only reverse Hill- Sachs lesion (RHSL) and those with some other fractures in addition are labeled as complex posterior fracture dislocation of shoulder (CPFDS).¹^,⁴ But they have described same mechanism of injury in both entities.¹ Since the mechanism of injury is same, we think that all these injuries should be considered as one entity and discussed together. The authors further classified the CPFDS into 3 types. The CPFDS can be associated with a composite tuberosity “shield fragment” which is a bone fragment consisting of greater and lesser tuberosities.⁵ This classification was described for acute injuries and all these fracture-dislocations were managed by open reduction and internal fixation.⁴ However the situation is quite different in chronic stage. In addition to dislocation, there is malunion/non union and associated fibrosis, contractures of ligaments and tendons and cartilage erosions, which require different management. Cecchia et al. proposed a classification for acute and chronic PDS.⁶ They advised McLaughlin procedure or its modification when the humeral head lesion was 20–50% and duration <6 months. For humeral head lesions >50% and duration up to 12 months of injury, they advised hemi-replacement (HRA). For CPFDS of duration 12 months to 2 years, they advised total shoulder arthroplasty (TSA). For CPFDS of duration >2 years, they advised arthrodesis or resection arthroplasty. This was probably the first attempt at looking the whole spectrum of PDS as a single entity and giving some guidelines for the treatment in chronic stage. But till now there is no standard treatment for chronic PDS and CPFDS.³ Even the recent literature review considers locked PDS as those with only HSL and does not include PDS with fractures of tuberosities and/or proximal metaphysis.⁷ We think that the so-called simple and complex PDS are caused by the same mechanism and should not be considered separately in the literature. Even in chronic stage, the spectrum of pathology remains the same, though fibrosis, tendon and ligament contractures, cartilage softening and erosion and osteoporosis complicate it. Hence, we propose a classification for the chronic PDS, which encompasses the so-called simple and complex injuries (Table 1). The severity of injury increases from type A to type C. The amount of bone loss in humeral head, status of greater tuberosity and proximal metaphysis determine the type of injury and the possible surgical treatment.

The joint salvage procedures are possible when the humeral head bone loss is less than 50%, estimated on the axial section of humeral head. The different salvage procedures may be classified as anatomical or non-anatomical. The anatomical procedures include osteochondral allograft insertion in the RHSL as advocated by Gerber et al.⁸ The procedure gives satisfactory results but the complication rates and cost are high.³ Also, this procedure is limited by the availability of the allograft, as in our case. The non-anatomical procedures include McLaughlin procedure and its modifications, rotational osteotomy of humerus and posterior glenoid augmentation. The joint arthroplasty in such injuries could be anatomical (hemi-replacement (HRA) or total shoulder arthroplasty (TSA)) or non-anatomical reverse shoulder arthroplasty (RSA). The results of HRA and TSA are dependent on achieving optimum tension in rotator cuff. This can be difficult to achieve, at times, in a neglected PDS. The results of HRA and TSA are not good if an osteotomy of the greater tuberosity (GT) is performed.⁹^,¹⁰ The malunion of GT and proximal metaphysis can make the insertion of prosthesis quite challenging. Osteotomy of GT may be required either for insertion of prosthesis or bringing it back to its correct orientation in relation to the prosthesis. The results of HRA are not good in presence of non-union of surgical neck of humerus.⁹ Hence HRA and TSA are not recommended if there is non-union surgical neck humerus or severe malunion of GT. In such situations RSA is recommended.¹¹

Our preferred procedure for type A1 injury was Neer's modification of McLaughlin procedure. We found it simple to perform and had consistent good results with minimal complications as elaborated by other authors.¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷ For the type A2, our preferred treatment was HRA. Good results of HRA (also TSA) have been reported for this type of injury in various reports.⁶^,⁹^,¹¹ During the reduction of the dislocated humeral head, we had to remove the fibrous tissue overlying the glenoid and perform capsular release at the glenoid. During this, it was impossible to prevent the peeling of superficial layer of cartilage. It was invariably discolored at places but there was no complete loss of cartilage at any place in the glenoid. Hence we chose HRA over TSA in this group of our patients. There was 1 case in type B1which we managed by modified McLaughlin procedure and corrective osteotomy of GT. We could not find such a case and its management in the literature. We performed RSA for type B2 injuries. These are unsalvageable injuries because >50% of head is injured. It corresponds to type 4 injuries in the classification for sequelae of fracture of proximal humerus, proposed by Boileau et al.⁹ HRA and TSA do not give good results in such injuries because of severe malunion of GT requiring an osteotomy.⁹^,¹⁰ Instead RSA has been advocated for such type 4 sequelae.¹¹^,¹⁸ There was 1 case in type C1, which we managed by modified McLaughlin procedure and corrective osteotomy of the metaphysis. We could not find such a case and its management in the literature. Type C2 injuries can be managed like type A2 injuries by HRA. The malunion in metaphysis can make the insertion of prosthesis, a little tricky. Many modifications have been advised to put the prosthesis in presence of proximal humerus malunion. A small prosthesis with a small sized head, varus position, altering the entry point, increasing or decreasing the height of prosthesis and even bending of the humeral stem are some of the tricks that have been advised in the literature.⁹^,¹⁹

When we compared our results with the published literature, we did not find many reports to compare with. Many reports had heterogeneous patient groups. Some reports did not use any objective outcome score and others used parameters other than ASES and UCLA. Similar issues were faced by Boileau et al.⁹ For modified McLaughlin procedure, our average ASES was 83 and UCLA score was 27. The published literature shows average ASES score as 78 and UCLA score as 30.²⁰^,²¹^,²² For the HRA our average ASES was 63 and UCLA score was 19. The published literature shows the average ASES to be 55.6.²³ But the authors used TSA in this study. We could not find any study to compare our results of RSA in the literature. Joint salvage procedures gave better outcome than joint arthroplasty; though they were done in cases with <50% humeral head bone loss.

The limitations of this study are that it is a retrospective study with no control group, has small numbers of patients with some groups having only one patient and does not have a very long follow-up of patients. The strong points of this study are that a single surgeon operated all the patients and no patient was lost during follow-up.

5. Conclusion

We conclude that chronic PDS can have malunion of tuberosities and/or proximal metaphysis in addition to RHSL. The treatment is guided by all three factors-amount of bone loss in humeral head, malunion of greater tuberosity and malunion of proximal humeral metaphysis.

Declaration

The authors declare that.

1.
They have no relevant financial or non-financial interests to disclose.
2.
No funds, grants, or other support was received.

CRediT authorship contribution statement

Ravi Mittal: Conceptualization, Methodology, reviewing and editing of manuscript. Siddharth Jain: Data curation, original draft writing. Shivanand Gamanagatti: Investigation, Supervision.

References

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[bib1] 1.Robinson C.M., Aderinto J. Posterior shoulder dislocations and fracture-dislocations. J Bone Joint Surg Am. 2005;87(3):639–650. doi: 10.2106/jbjs.d.02371. [DOI] [PubMed] [Google Scholar]

[bib2] 2.Kokkalis Z.T., Iliopoulos I.D., Antoniou G., Antoniadou T., Mavrogenis A.F., Panagiotopoulos E. Posterior shoulder fracture-dislocation: an update with treatment algorithm. Eur J Orthop Surg Traumatol. 2017;27(3):285–294. doi: 10.1007/s00590-016-1840-5. [DOI] [PubMed] [Google Scholar]

[bib3] 3.Basal O., Dincer R., Turk B. Locked posterior dislocation of the shoulder: a systematic review. Efort Open Rev. 2018;3(1):15–23. doi: 10.1302/2058-5241.3.160089. [DOI] [PMC free article] [PubMed] [Google Scholar]

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PERMALINK

Chronic posterior dislocation of shoulder

Ravi Mittal

Siddharth Jain

Shivanand Gamanagatti