Dislocation of the glenohumeral joint is a painful injury that requires immediate management. Failure to relocate the joint in a timely fashion usually results in significant destruction of the bone and cartilage of the joint, as well as severe contracture and scar formation in the soft tissues. The incidence of chronic dislocation is unknown, with most reports in the literature citing a limited number of cases. The management of these injuries may vary considerably based on the severity of the destruction.

33.2 Definition

There has been controversy over what actually defines a chronic dislocation, with the time frame varying from 24 h to 6 months. In this chapter, we will be addressing the shoulder that has been dislocated for more than 72 h, is irreducible by nonoperative means, and has fixed, severe bone and soft tissue damage that is not amenable to simple repair. In most cases this would mean the shoulder has been dislocated for a period of weeks to months [1, 2, 3, 4].

33.3 Patho-anatomy

In the chronic dislocation, there is much more to consider in the management of this severe injury. In both anterior and posterior dislocations, there is usually a severe bone defect on both the humeral and glenoid side. In anterior dislocations, the defects are usually equal on both sides of the joint and may include up to 1/2 the glenoid and humeral head. Posteriorly, the defect is usually much more severe on the humeral side. The bone of both the humeral head and the glenoid may be severely osteoporotic. The articular cartilage can be absent and thin or may have lost its connection to the subchondral bone and simply slip off the surface of the glenoid when tested. There is usually severe contracture and scar in the associated soft tissues. In posterior dislocations, the subscapularis may be shortened and scarred to the glenoid, while in anterior dislocations, the posterior rotator cuff and capsule will be contracted and fixed to the glenoid in such a way as to prevent the location of the humeral head after anterior soft tissue takedown.

In fixed posterior dislocations, the axillary nerve is at risk at the quadrangular space beneath the teres minor muscle and tendon during release. In the chronic anterior subcoracoid dislocations, the posterior cord of the brachial plexus may be scarred to the displaced humeral head.

33.4 Clinical Evaluation

Most patients with chronic dislocation present with only mild pain, but with significant loss of motion. In the early phases, the limitation of motion may be quite severe but will have improved over time due to scapula-thoracic compensation and, unfortunately, increase in the bone defects on the humerus and glenoid.

33.4.1 History

In this patient the history is quite an important factor. The initial time the patient noted dysfunction is essential, but interestingly may be quite unclear. Many cases are associated with other issues such as seizures, syncope, and polytrauma. In general chronic posterior dislocation, patients have been previously managed for their shoulder problem by medication or therapy for “stiff shoulder.” In the anterior group, about 40% seem to be similarly associated with seizures, but less have had prior treatment.

These patients often have surprisingly little pain. The main complaints are loss of motion and function.

33.4.2 Physical Examination

Inspection

Visualization of the undressed shoulder and comparison to the opposite side remains the hallmark of the physical examination. One will see a prominent acromion on the opposite side of the dislocation as well as significant muscle atrophy. The deltoid muscle is usually quite severely atrophied but can often be stimulated to contract unless there is concomitant posterior cord or axillary nerve injury.

Palpation

The asymmetry is often easily confirmed by palpating the humeral head in the dislocated position. The posterior dislocation can be felt along the back of the shoulder distal to the acromion. There will also be a palpable defect lateral to a prominent coracoid process.

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