Delayed Shoulder Dislocation Diagnosis and Treatment Options

Is it a shoulder dislocation?

Dear Dr.
Shih,
I have a friend who was in a car accident in June 2003.
He was taken to Shin Kong Hospital, where the doctor diagnosed him with a 0.5 cm clavicle fracture that did not require surgery.
However, he has been unable to lift his arm or bend it since then, and he has experienced continuous pain for 1-2 months.
Later, he visited National Taiwan University Hospital, where the doctors suggested that he might have sustained a nerve injury.
They referred him to a doctor at Chang Gung Memorial Hospital, who diagnosed a possible nerve rupture.
After surgery, it was found that the nerve was only strained, and the doctor mentioned that he would need two years of rehabilitation.

Unfortunately, after two months of rehabilitation, there has been no progress, and his muscles continue to atrophy.
After four months, he went to Mackay Memorial Hospital, where the doctor immediately suggested that this might be a shoulder dislocation.
He also consulted with a traditional Chinese medicine practitioner, who confirmed the shoulder dislocation diagnosis.
My friend can only move his arm back and forth; he cannot lift it, bend it, or exert any strength.
I would like to ask you, Dr.
Shih, if it is indeed a dislocation, how should it be managed after four months of delay in diagnosis?

KINKI, 20~29 year old female. Ask Date: 2003/10/23

Dr. Shi Guozheng reply Orthopedics

If the shoulder is dislocated, X-rays should show a high possibility of nerve injury, but joint injuries can also prevent shoulder movement.
If the dislocation has occurred for four months, treatment becomes very difficult.

Reply Date: 2003/10/23

More Info

Delayed shoulder dislocation, particularly following a traumatic event like a car accident, can lead to a complex clinical scenario that requires careful evaluation and management. In your friend's case, the initial diagnosis of a clavicle fracture and subsequent symptoms of limited range of motion and pain suggest that there may have been an underlying shoulder dislocation that was not recognized at the time of the initial assessment.

When a shoulder dislocation occurs, it typically involves the humeral head moving out of the glenoid cavity of the scapula. This can cause damage to the surrounding soft tissues, including ligaments, tendons, and nerves. In your friend's situation, the delayed recognition of the dislocation may have contributed to ongoing pain, weakness, and muscle atrophy due to disuse.

Diagnosis
The diagnosis of a delayed shoulder dislocation can be challenging. It often requires a combination of clinical examination and imaging studies. A thorough physical examination should assess the range of motion, strength, and any signs of nerve injury. Imaging studies, such as X-rays or MRI, can help confirm the diagnosis and evaluate any associated injuries, such as rotator cuff tears or nerve damage.

In your friend's case, the progression from a clavicle fracture diagnosis to a potential nerve injury and finally to a suspected shoulder dislocation indicates that the clinical picture was evolving. The fact that your friend has been experiencing muscle atrophy and limited range of motion suggests that the shoulder joint has not been functioning properly for an extended period.

Treatment Options
1. Physical Therapy: If the shoulder dislocation is confirmed, the first step in treatment is often to restore range of motion and strength through physical therapy. A physical therapist can design a rehabilitation program tailored to your friend's specific needs, focusing on gentle stretching and strengthening exercises.

2. Surgical Intervention: If conservative management does not yield improvement, or if there is significant structural damage (such as a rotator cuff tear or severe instability), surgical intervention may be necessary. Surgery could involve repairing any torn ligaments or tendons, stabilizing the joint, or addressing any nerve injuries.

3. Nerve Repair: If nerve damage is confirmed, surgical options may include nerve repair or grafting, depending on the extent of the injury. Nerve recovery can take time, and rehabilitation will be crucial in maximizing recovery.

4. Pain Management: Throughout the treatment process, managing pain is essential. This may involve medications, injections, or alternative therapies to help alleviate discomfort.

5. Long-term Rehabilitation: Given the duration of the symptoms and the potential for muscle atrophy, a long-term rehabilitation plan will be necessary. This may involve ongoing physical therapy, home exercises, and regular follow-ups with healthcare providers to monitor progress.

Conclusion
In summary, your friend's situation is complex and requires a multidisciplinary approach to treatment. It is crucial for your friend to work closely with orthopedic specialists, physical therapists, and possibly neurologists to develop a comprehensive treatment plan. Early intervention is key to preventing further complications and maximizing recovery. If your friend has not yet had a thorough evaluation by an orthopedic surgeon, it would be advisable to seek one out for a definitive diagnosis and treatment plan.

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