Medical Analysis Report

1. Radiological Findings

Based on the provided anteroposterior X-ray of the shoulder joint, the humeral head of the right shoulder joint is significantly displaced inferiorly relative to the glenoid, suggesting an “inferior dislocation” (also referred to as “inferior dislocation of the humeral head” or “luxatio erecta”).

Specific findings include:

• Position of the humeral head: Lower than the glenoid, with abnormal alignment relative to the acromion.
• The humeral shaft presents pronounced overabduction/elevation, with the elbow joint approximately at head level.
• Abnormal joint space: The humeral head-glenoid relationship is incongruent, suggesting possible capsular damage.
• No obvious fracture line is visible in the images, but a possible rotator cuff tear or minor proximal humerus fracture should be considered.

2. Possible Diagnoses

Based on the patient’s history (trauma-induced shoulder dislocation) and imaging findings, potential diagnoses include:

• Inferior dislocation of the shoulder (luxatio erecta): The patient’s arm is in a position of high abduction, with the humeral head located inferior to the glenoid, a typical acute traumatic presentation.
• Proximal humerus fracture-dislocation: If a fracture occurred due to external force, a fracture line is usually visible on imaging. Although none is distinctly seen here, mild fracture cannot be ruled out.
• Rotator cuff injury (e.g., supraspinatus, infraspinatus, or teres minor tear): Inferior dislocations are often accompanied by rotator cuff tears, especially in high-energy trauma.

The most common scenario remains a simple inferior shoulder dislocation, but vigilance is required regarding soft tissue damage, as well as potential neurovascular injury (e.g., axillary nerve, brachial plexus) or axillary artery compromise.

3. Final Diagnosis

Considering the patient’s age, trauma history, radiographic findings, and examination results, the most likely diagnosis is:

• Inferior dislocation of the right shoulder (luxatio erecta), possibly accompanied by a rotator cuff or soft tissue injury.

The dislocation is known to have been successfully reduced in the emergency setting, and neurovascular status is normal. If persistent shoulder pain or functional limitation is noted, an MRI or ultrasound of the shoulder joint should be conducted to evaluate rotator cuff integrity.

4. Treatment Plan and Rehabilitation

For this patient, the key points of treatment and rehabilitation are as follows:

• Treatment Strategy:
  • Emergency reduction: Already performed. If the joint is stable and no clear fracture is present, a shoulder brace or protective sling may be used for 2–3 weeks to protect the joint and soft tissues.
  • Medication: Early use of anti-inflammatory analgesics (e.g., NSAIDs) to reduce pain and inflammation.
  • Imaging follow-up: Perform a repeat X-ray or MRI during immobilization or at the start of rehabilitation to assess reduction quality and rule out a potential rotator cuff tear.
  • Surgical indication: If a large rotator cuff tear, recurrent dislocation, or a fracture resulting in instability is present, consider surgical repair or reconstruction.
• Rehabilitation/Exercise Prescription (FITT-VP Principle):
  • Initial Phase (Protection, about 2–3 weeks):
    • Immobilize the shoulder joint, avoiding large-range abduction or external rotation.
    • Undertake low-intensity, short-duration exercises for the lower limbs and contralateral upper limb to maintain overall function.
    • Under the guidance of a physician or physical therapist, perform gentle active finger and wrist movements.
  • Functional Recovery Phase (about 3–6 weeks):
    • Gradually increase passive range of motion exercises for the shoulder, adhering to a pain-free principle.
    • Frequency: 3–4 times per week; Duration: 15–20 minutes per session; Intensity: mild stretching without pain.
    • Expand the range of motion progressively, adding active forward flexion and external rotation to improve joint flexibility.
  • Strengthening Phase (about 6–12 weeks):
    • Once joint range of motion is sufficiently restored, introduce shoulder muscle strengthening exercises (e.g., internal/external rotation with resistance bands, light dumbbell lateral raises, shallow-angle abduction).
    • Frequency: 2–3 times per week; Duration: 20–30 minutes per session; adjust intensity based on pain and fatigue.
    • Focus on strengthening the rotator cuff and scapular stabilizers.
  • Exercise Progression and Individualization:
    • If the patient has osteoporosis or poor cardiopulmonary function, perform an assessment and consider reducing exercise intensity or frequency.
    • Increase the load gradually within a safe range, closely monitoring for pain, swelling, or other discomfort.

Disclaimer: This report is for reference only and does not replace in-person consultation or professional medical advice. If you have any concerns or changes in your condition, please consult an orthopedic or rehabilitation specialist promptly.