Difficult access to medical care in times of COVID-19: late presentation of locked anterior shoulder dislocation: a case report

Glenohumeral instability most commonly affects patients in their late teenage years.19Mohtadi N. Chan D. Hollinshead R. Boorman R. Hiemstra L. Lo I. et al.A randomized clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability: two-year follow-up with disease-specific quality-of-life outcomes.J Bone Joint Surg Am. 2014; 96: 353-360https://doi.org/10.2106/JBJS.L.01656Crossref PubMed Scopus (100) Google Scholar Anterior shoulder dislocations account for 97% of all shoulder dislocations1Abrams R. Akbarnia H. Shoulder Dislocations Overview.2020Google Scholar and are usually caused by a forced abduction, external rotation, and hyperextension.16Kirkley A. Werstine R. Ratjek A. Griffin S. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long-term evaluation.Arthroscopy. 2005; 21: 55-63https://doi.org/10.1016/j.arthro.2004.09.018Abstract Full Text Full Text PDF PubMed Scopus (238) Google Scholar Seizures are a common cause of shoulder dislocation and persistent glenohumeral instability.11Goudie E.B. Murray I.R. Robinson C.M. Instability of the shoulder following seizures.J Bone Joint Surg Br. 2012; 94: 721-728https://doi.org/10.1302/0301-620X.94B6.28259Crossref PubMed Scopus (29) Google Scholar Although posterior shoulder dislocations are typically associated with seizures, anterior instability following an ictal episode is more common, and bilateral dislocations are possible.4Bühler M. Gerber C. Shoulder instability related to epileptic seizures.J Shoulder Elbow Surg. 2002; 11: 339-344https://doi.org/10.1067/mse.2002.124524Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar The patients presenting with an anterior dislocation usually present with acute pain, the arm held in abduction and external rotation, or an adducted arm at the side. There is often loss of the normal contour of the deltoid and prominence of the acromion posteriorly and laterally.8Cutts S. Prempeh M. Drew S. Anterior Shoulder Dislocation.Ann R Coll Surg Engl. 2009; 91: 2-7https://doi.org/10.1308/003588409X359123Crossref PubMed Scopus (99) Google Scholar The initial management of acute anterior shoulder dislocation in younger active patients remains controversial.14Kane P. Shawn M.B. Dodson C.C. Freedman K.B. 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Anterior shoulder dislocation: a review of reduction techniques.Am J Emerg Med. 1991; 9: 180-188Abstract Full Text PDF PubMed Scopus (95) Google Scholar,24Stayner L. Cummings J. Andersen J. Jobe C. Shoulder dislocations in patients older than 40 years of age.Orthop Clin North Am. 2000; 31: 231-239Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar A glenohumeral dislocation that persists for multiple months can lead to osteopenia of the subchondral bone13Jerosch J. Riemer R. Schoppe R. Asymptomatic chronic anterior posttraumatic dislocation in a young male patient.J Shoulder Elbow Surg. 1999; 8: 492-494Abstract Full Text PDF PubMed Scopus (11) Google Scholar and collapse of the humeral head at the time of reduction, leading to poor long-term outcomes.9Flatow E. Miller S. Neer C. Chronic anterior dislocation of the shoulder.J Shoulder Elbow Surg. 1993; 2: 2-10Abstract Full Text PDF PubMed Scopus (45) Google Scholar Due to the COVID-19 pandemic, many patients have failed to seek medical care in a timely manner. Fear of the virus and the fact that many health care providers were exclusively doing virtual consultations are reasons that lead to worse outcomes documented across multiple specialties during the COVID-19 pandemic.18Masroor S. Collateral damage of COVID-19 pandemic: Delayed medical care.J Card Surg. 2020; 35: 1345-1347https://doi.org/10.1111/jocs.14638Crossref PubMed Scopus (123) Google Scholar,20Moisan P. Barimani B. Antoniou J. Orthopedic Surgery and Telemedicine in Times of COVID-19 and Beyond: a Review.Curr Rev Musculoskelet Med. 2021; 14: 155-159https://doi.org/10.1007/s12178-021-09693-9Crossref PubMed Scopus (10) Google Scholar,23Shin D. Cho J. Kim S. Guallar E. Hwang S. Cho B. et al.Delay to curative surgery greater than 12 weeks is associated with increased mortality in patients with colorectal and breast cancer but not lung or thyroid cancer.Ann Surg Oncol. 2013; 20: 2468-2476https://doi.org/10.1245/s10434-013-2957-yCrossref PubMed Scopus (109) Google Scholar Orthopedic surgery is the surgical field that has seen the highest proportion of its activities canceled or postponed due to the pandemic.6Collaborative C. Nepogodiev D. Omar O.M. Glasbey J.C. Li E. Simoes J.F.F. et al.Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans.Br J Surg. 2022; 107: 1440-1449https://doi.org/10.1002/bjs.11746Crossref Scopus (724) Google Scholar This explains why waiting lists to see an orthopedic surgeon have significantly increased.21Phillips M. Chang Y. Zura R. Mehta S. Giannoudis P. Nolte P. et al.Impact of COVID-19 on orthopaedic care: a call for nonoperative management.Ther Adv Musculoskelet Dis. 2020; 12https://doi.org/10.1177/1759720X20934276Crossref PubMed Scopus (20) Google Scholar Virtual consultations allow the physician to gather an adequate history but prevent the ability to perform significant portions of the physical examination which can be essential in establishing the correct diagnosis. Shoulder dislocations are quite often easily diagnosed due to the clear symptoms, signs, and functional limitations associated with this pathology. A missed diagnosis of shoulder dislocation is rare, and the majority of these cases are associated with a clear traumatic event and are adequately managed.2Ahmad K. Bin Ayaz S. Bin Khalil H. Matee S. Bilateral spontaneous anterior shoulder dislocation: A missed orthopedic injury mistaken as proximal neuropathy.Chin J Traumatol. 2017; 20: 370-372https://doi.org/10.1016/j.cjtee.2017.06.003Crossref PubMed Scopus (3) Google Scholar,5Chaudhary D. Joshi D. Jain V. Mohindra M. Mehta N. A six months old neglected anterior shoulder dislocation managed by closed reduction and Latarjet procedure.Chin J Traumatol. 2016; 19: 295-297https://doi.org/10.1016/j.cjtee.2016.06.005Crossref PubMed Scopus (5) Google Scholar,7Cuffolo G. Coomber R. Burtt S. Gray J. Case Report: Posterior shoulder dislocation while lifting weights: a missed diagnosis.2014https://doi.org/10.1136/bcr-2013-202156Crossref Scopus (6) Google Scholar On the other hand, recurrent atraumatic dislocations are seen infrequently and have not been described adequately in the literature, for which there is no consensus on the best management method. We present a case of late presentation of locked anterior shoulder dislocation with an atraumatic cause during the time of COVID-19 and describe our primary and revision surgical strategies. A previously healthy 25-year-old man with no orthopedic history presented to the emergency room of our hospital with a four-month history of worsening left shoulder pain. The patient is known for cocaine and benzodiazepine use, takes no prescribed medication, and has no relevant past medical or surgical history. Four months prior to presenting to our emergency room, the patient woke up with acute pain in both shoulders and the sensation of severely limited movement in both of his shoulders. He was able to relocate the right shoulder by himself but not the left shoulder. He contacted his family doctor and was only able to get a telephone appointment due to the COVID-19 pandemic. After questioning, the physician concluded that the pain was likely muscular and recommended rotator cuff strengthening exercises. The patient proceeded to do some strengthening exercises he found on the internet. During the next 4 months, he was able to mobilize his right shoulder but complained of worsening left shoulder pain at rest and some range of motion limitation. He presented to our hospital four months after the initial onset of symptoms. An X-ray of the shoulder was performed in the emergency room (Fig. 1), which showed a locked anterior dislocation of the left shoulder with a massive Hill-Sachs lesion of the humerus and a coracoid process fracture. On examination, the patient had 90 degrees of forward flexion, 80 degrees of abduction, and no external rotation. The good range of motion was likely due to scapulothoracic compensation and an enlarging Hill-Sach’s lesion. He had decreased strength and an intact neurovascular examination including full axillary nerve function. The right shoulder showed apprehension sign and was found to be positive on relocating test, suggesting an unstable shoulder that had previously dislocated. Due to the delay in presentation, closed reduction of the left shoulder was not deemed an option, and thus, we proceeded with left shoulder open reduction, fixation, and stabilization. The shoulder was stabilized using a Bristow procedure, and the massive Hill-Sachs lesion was treated with a hemi cap resurfacing hemiarthroplasty. In addition, a biceps tenodesis was performed. The postoperative films show adequate reduction of the glenohumeral joint (Fig. 2). Intraoperative mobilization demonstrated satisfactory shoulder stability. After the procedure, the patient was discharged home with a shoulder sling and instructions on the importance of maintaining the sling. Two weeks following the surgery, the patient returned to the clinic for his follow-up appointment and described increasing left shoulder pain. He mentioned the possibility of receiving a small trauma to the shoulder in the last 2 weeks and admitted to not wearing the sling consistently. The physical examination showed a slightly restricted and painful range of motion and an intact distal neurovascular examination. The surgical wound showed good healing and no signs of infection. Plain films of the left shoulder showed a recurrent anterior shoulder dislocation with no signs of hardware failure or associated fractures (Fig. 3). Following this new finding, the patient was indicated for a revision shoulder open reduction and Bristow procedure and an external fixator application. During the procedure, the surgeon noted that the subscapularis muscle appeared significantly medialized and torn as if the shoulder was subjected to a forceful movement such as trauma or seizure. The subscapularis was irreparable, and thus, a pectoralis major transfer was performed. The shoulder external fixator was applied by placing two self-tapping 5-mm Steinmann pins in the midshaft of the humerus anterolaterally, the clavicle anteriorly, and the acromion anterolaterally, which were then connected with 8-mm carbon fiber rods. After an extensive revision procedure, the patient was discharged with an external fixator for 6 weeks and a brace (Fig. 4). At the 6-week follow-up, the external fixator was removed and the shoulder had remained reduced. At one-year follow-up, the patient showed more than 100 degrees of active forward flexion and 90 degrees of abduction. After extensive physiotherapy, the patient had improved musculature of the deltoid and a painless and stable shoulder but persistent anterior deltoid atrophy. Plain films showed the shoulder remained reduced (Fig. 5), and the patient was happy with the result of the surgery and mentioned having no pain at rest. The patient has been advised to continue with physical therapy to try and improve his shoulder range of motion and strength. This case of late presentation of locked anterior shoulder dislocation with an atraumatic cause during the time of COVID-19 in a young adult offers multiple discussion points. We will address the late presentation and thus diagnosis of dislocation and the surgical strategy used for the revision procedure. This patient initially consulted with his primary care doctor during the COVID-19 pandemic and was therefore only assessed via telemedicine. This missed diagnosis highlights the shortcomings of teleconsultations, more specifically the inability to proceed to an adequate physical examination virtually and the additional challenges posed by the virtual assessment of acute orthopedic pathologies.20Moisan P. Barimani B. Antoniou J. Orthopedic Surgery and Telemedicine in Times of COVID-19 and Beyond: a Review.Curr Rev Musculoskelet Med. 2021; 14: 155-159https://doi.org/10.1007/s12178-021-09693-9Crossref PubMed Scopus (10) Google Scholar Chronic glenohumeral dislocations can present with minimal symptoms and be missed without adequate examination by a skilled clinician. This case presents delay in diagnosis and lack of treatment, which likely contributed to the increased risk of recurrence and worsening of the Hill-Sachs lesion. Prolonged delay to surgical fixation contributed to difficulty of the procedure due to the presence of scar tissue along with the absence of the subscapularis muscle which posed an additional challenge. Although rare, missed shoulder dislocations are associated with unsatisfactory long-term functional outcome. Due to the challenging nature of the procedure and the inherent glenohumeral instability,5Chaudhary D. Joshi D. Jain V. Mohindra M. Mehta N. A six months old neglected anterior shoulder dislocation managed by closed reduction and Latarjet procedure.Chin J Traumatol. 2016; 19: 295-297https://doi.org/10.1016/j.cjtee.2016.06.005Crossref PubMed Scopus (5) Google Scholar reduced long-term range of motion of the shoulder and a high incidence of postoperative pain are common complications.2Ahmad K. Bin Ayaz S. Bin Khalil H. Matee S. Bilateral spontaneous anterior shoulder dislocation: A missed orthopedic injury mistaken as proximal neuropathy.Chin J Traumatol. 2017; 20: 370-372https://doi.org/10.1016/j.cjtee.2017.06.003Crossref PubMed Scopus (3) Google Scholar,5Chaudhary D. Joshi D. Jain V. Mohindra M. Mehta N. A six months old neglected anterior shoulder dislocation managed by closed reduction and Latarjet procedure.Chin J Traumatol. 2016; 19: 295-297https://doi.org/10.1016/j.cjtee.2016.06.005Crossref PubMed Scopus (5) Google Scholar,7Cuffolo G. Coomber R. Burtt S. Gray J. Case Report: Posterior shoulder dislocation while lifting weights: a missed diagnosis.2014https://doi.org/10.1136/bcr-2013-202156Crossref Scopus (6) Google Scholar Some authors have recommended using the acromiohumeral transfixing pins for stability when using an open reduction technique for chronic dislocations.10Goga I. Chronic shoulder dislocations.J Shoulder Elbow Surg. 2003; 12: 446-450https://doi.org/10.1016/s1058-2746(03)00088-0Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,17Mansat P. Guity M. Mansat M. Bellumore Y. Rongières M. Bonnevialle P. [Chronic anterior shoulder dislocation treated by open reduction sparing the humeral head].Rev Chir Orthop Reparatrice Appar Mot. 2003; 89 ([Article in French]): 19-26PubMed Google Scholar The Bristow procedure has been shown to be safe and effective15Khawaja K. Mohib Y. Khan D.M. Juman N. Habib A. P H. Functional outcomes of modified Bristow procedure in recurrent shoulder dislocation.J Pak Med Assoc. 2021; 71: 2448-2450https://doi.org/10.47391/JPMA.05-608Crossref PubMed Scopus (0) Google Scholar and to have a rate of recurrent dislocation and revision surgery of 2.9%.12Griesser M. Harris J. McCoy B. Hussain W. Jones M. Bishop J. et al.Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review.J Shoulder Elbow Surg. 2013; 22: 286-292https://doi.org/10.1016/j.jse.2012.09.009Abstract Full Text Full Text PDF PubMed Scopus (354) Google Scholar The most common reason for failure of the Bristow procedure is graft nonunion.27Willemot L. De Boey S. Van Tongel A. Declercq G. De Wilde L. Verborgt O. Analysis of failures after the Bristow-Latarjet procedure for recurrent shoulder instability.Int Orthop. 2019; 43https://doi.org/10.1007/s00264-018-4105-6Crossref PubMed Scopus (32) Google Scholar External fixators of the shoulder are used in cases of complex proximal humeral fractures, allowing shoulder stability with a minimally invasive technique3Blonna D. Assom M. Bellato E. Pisanu G. Greco V. Marmotti A. et al.Outcomes of 188 Proximal Humeral Fractures Treated with a Dedicated External Fixator with Follow-up Ranging from 2 to 12 Years.J Bone Joint Surg Am. 2019; 101: 1654-1661https://doi.org/10.2106/jbjs.18.00734Crossref PubMed Google Scholar,28Zhang J. Ebraheim N. Lause G. Surgical treatment of proximal humeral fracture with external fixator.J Shoulder Elbow Surg. 2012; 21: 882-886https://doi.org/10.1016/j.jse.2011.07.005Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar; they have been used for treating a floating shoulder,25Vogels J. Pommier N. Cursolle J.C. Belin C. Tournier C. Durandeau A. PreFix™ external fixator used to treat a floating shoulder injury caused by gunshot wound.Chir Main. 2014; 33: 370-374https://doi.org/10.1016/j.main.2014.07.002Crossref PubMed Scopus (2) Google Scholar but to our knowledge, they are rarely used in cases of shoulder dislocation. The decision to use an external fixator during the revision procedure was based on the fact that the intraoperative glenohumeral reduction was very difficult to achieve and to maintain. Additionally, extensive scar tissue and significant trauma to the subscapularis muscle were identified. Finally, as seen following the primary surgery, the patient’s adherence to immobilization instructions was insufficient, and the patient was deemed unreliable in that regard. It remains unclear if a trauma, seizure, or other event caused the redislocation following the surgery. However, the patient’s age, delay to examination by a physician, and severity of the pathology mandated a comprehensive surgical plan. Poor patient adherence to postoperative immobilization, increased time to surgical management, and baseline hypermobility were important contributing factors leading to failure of the primary open reduction and fixation. This case report shows a complication associated with reduced access to health care during the times of COVID-19 and how this delay can lead to worsening pathology, more challenging surgery, and lower success rate of treatments undergone. Additionally, we showed a unique and successful method of providing shoulder stability and maintaining reduction in a chronic atraumatic and recurrent shoulder dislocation in a young patient with poor compliance.

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