Voluntary Anterior Dislocation of the Shoulder in a 10-Year-Old Child Treated Surgically

Abstract

Dear Sir, Voluntary dislocation of the gleno-humeral joint, a rare condition, is said to exist when a person is able to dislocate one or both shoulders in one or more direction willfully. It is difficult to treat as several patients have psychiatric co-morbidity and use this unique ability to grab social attention. Treatment usually suggested consists of skillful neglect or a prolonged physiotherapy programme for 3–6 months, aimed at strengthening the rotators and deltoid. Some studies are however encouraging surgical management of this condition (especially in psychologically normal patients) [1–4]. A 10-year-old child presented with ability to dislocate his right shoulder anteriorly, repeatedly at his will. There was no significant history of trauma, any gross congenital anomaly, paralytic disorder or local infection. The patient also had a distressing sensation of instability in shoulder during carrying weight and overhead activities. On clinical examination there was no local swelling, muscular wasting, deformity of shoul-der, clavicle, sternoclavicular or acromioclavicular joints, scar or sinus. Scapulae were symmetrical and at normal level bilaterally. No local tenderness or crepitus was appreciated. Range of motion at both shoulders was full and painless. Sulcus test and apprehension sign were present on the affected side. There was no evidence of any distal neurovascular deficit or generalized ligamentus laxity. The patient was able to demonstrate anterior dislocation and reduction of his right shoulder voluntarily. [Fig. 1] X-rays of shoulders and CT scan with 3D reconstruction were normal. Psychiatric consultation didn't reveal any personality disturbance. A physiotherapy programme to strengthen the rotator cuff muscles didn't help much. Written informed consent was taken from the patient and his parents for surgery and also for publication. We managed this patient by an inferior capsular shift procedure with postoperative chest arm immobilization. As described by Neer and Foster the shoulder was exposed through delto-pectoral approach [3]. Capsular volume was found to be increased with marked redundancy inferiorly. The opening between the superior and middle glenohumeral ligaments was closed with non-absorbable sutures. A T-shaped incision was made between the middle and inferior-glenohumeral-ligaments, detaching the capsule and ligaments from the neck of the humerus anteriorly, inferiorly and to the posterior part of the neck. Double-breasting was then performed to eliminate the redundancy with arm in slight flexion and 10° external-rotation and the subscapularis stump closed over it. Post-operatively patient was kept on shoulder immobili-zation for 6 weeks after which an arm sling was given and shoulder pendular exercises begun. External-rotation, ab-duction and flexion were not allowed. Abduction and flex-ion were allowed at 3 months and rotations at 4 months, discarding arm-sling. The rehabilitation goal for motion was