key: cord-0992935-a8im6g29 authors: Moisan, Philippe; Barimani, Bardia; Martineau, Paul title: Difficult access to medical care in times of COVID-19: Late presentation of locked anterior shoulder dislocation; Case Report date: 2022-04-27 journal: JSES Rev Rep Tech DOI: 10.1016/j.xrrt.2022.04.003 sha: 992c8c9f61ffb86ed5e7637cba4d3527b40d8ea8 doc_id: 992935 cord_uid: a8im6g29 This article presents a case of missed locked anterior shoulder dislocation in the context of limited access to care during the COVID-19 pandemic. 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. X-rays of the shoulder showed an anterior shoulder dislocation with a large Hills-Sachs and coracoid process fracture. The shoulder was stabilized using a Bristow procedure and the Hill-Sachs lesion was treated with a hemi cap resurfacing hemiarthroplasty. In addition, a biceps tenodesis was performed. On the follow-up visit the shoulder reduction was lost and the patient was consented for a revision procedure which consisted in a Bristow procedure and external fixation of the shoulder to maintain reduction. At the one-year follow-up the patient had gained significant range of motion and was painless. Timely treatment of a dislocated shoulder is important, with reduction within 24 hours of 34 the injury being essential to preserve the joint, requiring less sedation and attempts at 35 reduction. [26] Failure to reduce a dislocated shoulder within 24 hours carries the risk that 36 closed reduction will be difficult or even, impossible to achieve safely. Dislocations that 37 present sub-acutely (after 7 to 10 days) often require deep sedation, multiple attempts and 38 have been associated with brachial plexus and axillary artery injury. [22, 24] Case 64 A previously healthy 25-year-old man with no orthopedic history presented to the 65 emergency room of our hospital with a four-month history of worsening left shoulder pain. 66 The patient is known for cocaine and benzodiazepine use, takes no prescribed medication 67 and has no relevant past medical or surgical history. Four months prior to presenting to our 68 emergency room the patient woke up with acute pain in both shoulders and the sensation 69 of severely limited movement in both of his shoulders. He was able to relocate the right 70 shoulder by himself but not the left shoulder. He contacted his family doctor and was only 71 able to get a telephone appointment due to the COVID-19 pandemic. After questioning, 72 the physician concluded that the pain was likely muscular and recommended rotator cuff 73 strengthening exercises. The patient proceeded to do some strengthening exercises he 74 J o u r n a l P r e -p r o o f found on the internet. During the next 4 months, he was able to mobilize his right shoulder 75 but complained of worsening left shoulder pain at rest and some range of motion limitation. 76 He presented to our hospital four months after the initial onset of symptoms. 77 78 An X-ray of the shoulder was performed in the emergency room ( Figure 1 and Bristow procedure, and an external fixator application. During the procedure, the 107 surgeon noted that the subscapularis muscle appeared significantly medialized and torn as 108 if the shoulder was subjected to a forceful movement such as trauma or seizure. The 109 subscapularis was irreparable and thus a pectoralis major transfer was performed. The 110 shoulder external fixator was applied by placing two self-tapping 5 mm Steinmann pins in 111 the midshaft of the humerus anterolaterally, the clavicle anteriorly and the acromion 112 anterolaterally which were then connected with 8 mm carbon fiber rods. After an extensive 113 revision procedure, the patient was discharged with an external fixator for 6 weeks and a 114 brace (Figure 4 ). At the 6 weeks follow-up, the external fixator was removed and the 115 shoulder had remained reduced. allowing shoulder stability with a minimally invasive technique [3, 28] , has been used for 153 treating a a floating shoulder [25] but to our knowledge is rarely used in cases of shoulder 154 dislocation. The decision to use an external fixator during the revision procedure was based 155 on the fact that the intra-operative glenohumeral reduction was very difficult to achieve 156 and to maintain. Additionally, extensive scar tissue and significant trauma to the 157 subscapularis muscle was identified. Finally, as seen following the primary surgery, the 158 patient's adherence to immobilization instructions was insufficient and the patient was 159 deemed unreliable in that regard. 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