Irreducible Anterior Shoulder Dislocation in 72 YO Male

HPI

A 72-year-old male with no relevant past medical history presented to the emergency department after falling approximately 2 meters and sustaining blunt trauma to the left shoulder. He reported severe pain, visible deformity, and complete inability to move the arm. Initial radiographs confirmed an anterior glenohumeral dislocation with the humeral head displaced in proximity to the axilla and chest wall. Three closed reduction attempts were performed with escalating analgesia and sedation: the first under systemic analgesia, the second with additional intra-articular infiltration, and the third under procedural sedation by the emergency medicine team. Approximately eight total reduction maneuvers were performed by trained orthopaedic personnel, including a senior PGY-5 resident and two orthopaedic emergency surgeons. All attempts were unsuccessful. Following the failed attempts, a CT scan was obtained to evaluate for occult fractures that could be contributing to the mechanical block. CT confirmed the anterior glenohumeral dislocation with no associated fractures. A Hill-Sachs lesion was identified but without glenoid engagement. No greater tuberosity, lesser tuberosity, or glenoid rim fractures were present. The absence of a bony cause of irreducibility raised suspicion for soft tissue interposition as the mechanism of obstruction. After the reduction attempts, ecchymosis over the anterior shoulder and periaxillary region became notably more prominent. No hard signs of vascular injury were present, but the progressive ecchymosis and proximity of the humeral head to the axillary neurovascular bundle raised concern for possible occult vascular injury. Clinical examination was consistent with axillary and musculocutaneous nerve involvement. Given the CT findings excluding occult fractures, the irreducibility after multiple skilled attempts under adequate sedation, the progressive ecchymosis, and the clinical nerve involvement, the decision was made to proceed directly to urgent open reduction via a deltopectoral approach without an additional closed reduction attempt under general anesthesia. Immediate operating room availability supported this decision.

PMH

No known medical conditions. No prior shoulder surgery, instability, or dislocation.

PE

Visible anterior shoulder deformity with loss of normal contour. Marked pain and complete inability to actively move the shoulder secondary to pain and mechanical block. Ecchymosis over the anterior shoulder and periaxillary region, progressive after multiple closed reduction attempts. Sensory examination demonstrated hypoesthesia over the lateral aspect of the shoulder consistent with axillary nerve involvement; clinical findings also consistent with musculocutaneous nerve injury. Distal pulses palpable and symmetric bilaterally. No hard signs of vascular injury. Capillary refill less than 2 seconds distally.