Irreducible anterior dislocation of the shoulder

A38-yearoldright-handedmanemployedasastablehandfellapproximately3 mfromaladderlandingonhis left shoulder. He was seen in the Accident andEmergency department where clinical examinationsuggestedthathehadsustainedanisolatedanterior—inferior dislocation of his left shoulder with no neu-rovascularcompromise.Hehadnoprevioushistoryofshoulder problems. Plain radiographs confirmed ananterior—inferior dislocation of the gleno-humeraljoint with an avulsed bony fragment, thought to bethe greater tuberosity (Fig. 1). Closed reduction ofthe dislocation was then attempted by senior Acci-dentandEmergencydoctorsbut,despiteheavyseda-tion, multiple attempts were unsuccessful.The patient was referred to the on-call orthopae-dic team. A further closed reduction was attemptedin theatre under general anaesthesia and fluoro-scopiccontrolbut,again,provedtobeunsuccessful.The decision was then made to proceed to an openreduction.The patient was prepared and draped in thebeach-chair position and the shoulder approachedusing a lateral incision splitting the proximal fibresof deltoid and coming down onto the rotator inter-val. The operative findings were of a comminutedbony avulsion of the insertion of subscapularis. Thelateral insertion of the capsule had also been torn(similar to an HAGL injury-humeral avulsion of thegleno-humeral ligament). The bony avulsion site atthe lesser tuberosity was identified on the humeralhead. The head had dislocated anteriorly and infer-iorly through the tear and was lying in front of thesubscapularis, capsule and bony avulsion fragment,which were infoldedinto thejointspace. This inter-position of the subscapularis and bony fragmentwere preventing the head from reducing (Fig. 2).Withsomedifficulty,thesubscapularisandcapsulewere flicked anteriorly and superiorly forward overthehumeralhead,whichcouldthenbereduced.Thebony avulsion fragment, originating from the upperpart of the lesser tuberosity, and attached to thesubscapularis tendon was reduced and held in situusing a 4.5 mm partially threaded cancellous screwwithaspikedwasher(Fig.3)andtherotatorinterval,which had also been torn, and was closed usinginterrupted No. 1 Ethibond sutures. Following this,thepatient’sshoulderappearedtobestablethrough-out a full range of motion on fluoroscopic screening.Post-operativelythepatientwaskeptinashoulderimmobilizer for 3 weeks before commencing a