Anterior shoulder dislocation is one of the most common traumatic injuries encountered during sports activities, characterized by the displacement of the humeral head anteriorly from the glenoid cavity. This dislocation occurs when the humeral head moves beyond the glenoid margin, often causing rupture of the joint capsule and surrounding ligaments, which results in severe pain and functional loss of the arm1. Anterior shoulder dislocations are frequently observed in athletes and individuals who engage in physical activities. Reduction of the dislocation can be especially challenging in muscular patients due to increased muscle resistance during manipulation2.
The standard treatment for anterior shoulder dislocation involves prompt reduction to restore the humeral head to its proper position. Traditional reduction methods often include the use of sedatives or anesthetics to achieve muscle relaxation and pain control, allowing for a manual manipulation of the joint. However, in patients with significant muscle mass, sedatives may not provide sufficient muscle relaxation, making reduction more difficult and potentially increasing the risk of recurrent dislocation3,4. In such cases, regional anesthesia techniques, such as brachial plexus block (BPB), can serve as a highly effective alternative5. BPB works by blocking sensation in the shoulder and arm regions while inducing muscle relaxation, thereby enabling pain control and muscle relaxation simultaneously.
Ultrasound guidance enhances the accuracy of BPB by allowing precise visualization of the brachial plexus, optimizing the efficacy of the administered medication, and eliminating the need for systemic sedation6. This case report presents a successful reduction of anterior shoulder dislocation using BPB in a muscular patient, with a focus on the management of a Hill-Sachs lesion identified post-reduction. The report underscores the importance of managing such complications to ensure stability and prevent recurrence in active individuals.
A 29-year-old male patient presented to the emergency department with a sudden onset of left shoulder dislocation following a bench press exercise. He had no prior history of shoulder dislocations and had significant muscle mass from regular weight training. Upon arrival, the patient reported severe pain, and his left shoulder appeared deformed with the arm held in an abducted and externally rotated position. No neurological or vascular impairments were observed; however, immediate reduction was deemed necessary.
Radiographic imaging confirmed an anterior dislocation of the humeral head from the glenoid cavity (Fig. 1A). The humeral head had displaced beyond the anterior glenoid margin, indicating potential injury to the joint capsule and ligaments. This radiographic finding was consistent with a typical anterior shoulder dislocation1.
Fig. 1. (A) Pre-reduction X-ray image showing anterior dislocation of the right shoulder. The humeral head is displaced anteriorly from the glenoid fossa, indicating a typical anterior shoulder dislocation. (B) Post-reduction X-ray image demonstrating successful reduction of the humeral head into the glenoid fossa after performing brachial plexus block. The humeral head is now in its correct anatomical position.
Written informed consent was obtained from the patient for publication of this case report.
Considering the patient’s significant muscle mass, traditional manual reduction methods were anticipated to be challenging. Therefore, a BPB was chosen to alleviate pain and induce muscle relaxation. The patient was positioned laterally, and under ultrasound guidance, the brachial plexus was identified. A total of 5 mL of bupivacaine was administered at the C5, C6, and C7 nerve roots, which were clearly visualized on the ultrasound (Fig. 2)2.
Fig. 2. Ultrasound-guided image of the brachial plexus at the level of the interscalene groove. The C5, C6, and C7 nerve roots are clearly visualized between the middle scalene muscle and anterior scalene muscle, with the needle positioned for the brachial plexus block injection.
Following BPB, the patient experienced rapid pain relief and muscle relaxation. Using a C-arm for guidance, gentle external rotation was performed, successfully reducing the dislocation without additional force (Fig. 1B). The reduction was accomplished smoothly, with the patient experiencing minimal discomfort and no neurological or vascular complications during the procedure.
Post-reduction imaging revealed a mild Hill-Sachs lesion on the posterolateral aspect of the humeral head (Fig. 3). The lesion was consistent with typical findings in anterior shoulder dislocations. Given the size and depth of the lesion, conservative management with physical therapy was recommended to enhance shoulder stability and minimize recurrence risk.
Fig. 3. (A) Post-reduction C-arm image showing the alignment of the right shoulder after successful reduction. The humeral head is properly positioned within the glenoid fossa, confirming successful reduction. (B) Post-reduction C-arm image with a different rotation to assess for associated injuries. A Hill-Sachs lesion is visible on the postero-lateral aspect of the humeral head (indicated by an arrow), which is a typical defect seen following anterior shoulder dislocation.
Anterior shoulder dislocation is the most common type of dislocation, particularly among young and active individuals, due to the relatively high instability of the shoulder joint1. This dislocation occurs when the humeral head is displaced anteriorly beyond the glenoid rim, often resulting in damage to the joint capsule, ligaments, and glenoid labrum. Prompt reduction is essential to restore joint alignment, relieve pain, and prevent long-term complications.
In muscular patients, increased muscle resistance can complicate the reduction process, making traditional methods more challenging3. Manual reduction techniques often require sedatives or general anesthesia to facilitate muscle relaxation. However, sedatives may be insufficient in patients with significant muscle mass, and they carry risks such as respiratory depression or delayed recovery4.
BPB offers an effective alternative by inducing muscle relaxation and providing localized pain control without the need for systemic sedation. One of the main advantages of BPB is its ability to target the brachial plexus precisely under ultrasound guidance, allowing for effective muscle relaxation with minimal drug use5. This approach reduces procedural risks and facilitates smoother reductions, even in cases where traditional techniques may fail. In this case, ultrasound-guided BPB enabled successful reduction without excessive external force or additional sedatives, contributing to patient comfort and rapid recovery.
Hill-Sachs lesions are a common finding following anterior shoulder dislocations, resulting from the impaction of the humeral head against the anterior glenoid rim. While these osseous defects can predispose patients to recurrent instability, they generally do not complicate the initial reduction process6. In fact, some studies suggest that Hill-Sachs lesions may facilitate reduction by altering the shape of the humeral head, allowing for easier repositioning.
In this case, post-reduction imaging revealed a mild Hill-Sachs lesion. Given its size and minimal impact on joint stability, conservative management through physical therapy and regular follow-up was recommended. Larger or more severe lesions, however, may require surgical intervention to prevent recurrent dislocations7. Although Hill-Sachs lesions are important to recognize, the primary focus during reduction should remain on effective techniques, such as BPB, to achieve successful and atraumatic joint realignment.
This case highlights the utility of BPB in managing anterior shoulder dislocations, particularly in muscular patients where traditional methods may be less effective. The use of BPB minimizes procedural risks, enhances patient comfort, and reduces the need for systemic sedation, making it a valuable tool in emergency and outpatient settings.
In conclusion, BPB is a valuable tool for managing anterior shoulder dislocation in muscular patients where traditional reduction techniques may be less effective. This case highlights the successful application of BPB, demonstrating its ability to facilitate smooth reduction and enhance patient comfort. While Hill-Sachs lesions are common, their management should not overshadow the primary focus on effective reduction techniques. BPB offers a minimally invasive, efficient solution for shoulder dislocations in athletic populations.
No potential conflict of interest relevant to this article was reported.
Conceptualization, Data curation: SWK, IL. Formal analysis: DL, IL. Investigation, Methodology: HC, IL. Project administration, Resources: KWL, IL. Software, Supervision, Validation, Visualization: IL. Writing–original draft: IL. Writing–review & editing: all authors.
