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Glenohumeral Dislocation

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Other Names

  • Shoulder Dislocation
  • Anterior Shoulder Dislocation
  • Inferior Shoulder Dislocation
  • Posterior Dislocation
  • Luxatio Erecta

Background

  • This page refers to all types of dislocations of the Glenohumeral Joint
    • Including anterior (most common), inferior (Luxatio Erecta) and posterior

Epidemiology

Anterior

  • Accounts for 45 - 50% of all joint dislocations[1]
  • 24% of all shoulder injuries among high school athletes[2]
  • 2010: Incidence presenting to ED was 23.9 per 100,000 person-years[3]
  • Incidence of first time dislocations is 8 - 21.9 per 100,000 person-years[4][5]
  • Re-dislocation rate 7.9%
  • Prevalence ~2%
  • 90-98% are anterior dislocations[6]
  • Bimodal distribution: Individuals in 20s and 60s[7]
  • Male to female ratio of 3:1

Posterior

  • Represents 2-4% of all shoulder dislocations (need citation)
  • Seizures associated with 39% of cases[8]
  • Diagnosis is missed or delayed in 24 - 79% of cases[9]
  • Standard AP radiographs appear normal in 50% of cases (humeral head appears to be normally aligned with the glenoid)[10]
  • Bilateral approximately 15% of the time

Inferior

  • Very rare, represents 0.5% of all shoulder dislocations (need citation)

Pathophysiology

Etiology

Anterior

  • Classically described as a posteriorly directed force to the abducted and externally rotated arm
  • Force vector may be direct or indirect
  • May also occur due to fall on outstretched arm
  • These vectors force humeral head anterior and downwards relative to the Coracoid Process

Posterior

  • Forced posteriorly while internally rotated and abducated
  • Commonly associated with seizure disorder or electrocution (uncommon)
    • For this reason, bilateral should be suspected

Inferior

  • High energy mechanism
  • Shoulder is hyperabducted, levering the humeral head into the acromion, damaging inferior joint and allowing for inferior disengagement of glenohumeral joint

Pathoanatomy

Associated Injuries


Risk Factors

  • Sports[2]
    • Basketball
    • Soccer
    • Wrestling
    • Football
  • Recurrent Dislocations
    • Risk increases with lower age at initial dislocation[12]
    • Significant mechanism

Differential Diagnosis


Clinical Features

Anterior

  • History
    • Patient often supporting injured arm with uninjured arm
    • Arm may be held in abduction, external rotation
    • Shoulder may have a 'squared off' appearance with loss of normal rounded contour compared to unaffected arm
    • May also observe bulging acromion, filling of deltopectoral groove
  • Physical
    • Examiner may be able to palpate empty glenoid, bulge in deltopectoral groove
    • Arm often slightly abducted, patient refuses active or passive adduction
    • Be sure to test integrity of axillary nerve and brachial plexus

Inferior

  • History
    • Patient will be unable to move shoulder
  • Physical
    • Held in fixed, abducted, overhead position
    • Thorough neurovascular exam

Posterior

  • History
    • Frequently patient may be unable to provide an adequate history
    • For this reason, a thorough physical exam must be coupled with a high index of suspicion
  • Physical Exam
    • Shoulder is often internally rotated
    • Prominent coracoid process, posterior "fullness" in the axilla
    • Passive external rotation may be blocked

Evaluation

Radiographs

  • Standard Radiographs Shoulder
    • Initial imaging modality of choice
    • Lateral: can show direction of dislocation, concomitant lesions (fractures, hill-sachs lesion, bankart lesion)
    • Axillary and Scapular Y: provide best view of the glenohumeral articulation or lack thereof
    • Neer's view (Lamy's view): evaluate coracoacromial arch
    • Garth's view: Helpful to evaluate for hill-sachs lesions
    • Velpeau view:

CT

  • Helpful for evaluating fracture patterns or extent of impaction damage

Classification

Radiographic

  • Anterior
    • Subcoracoid (most common)
    • Subglenoid
    • Subclavicular
    • Intrathoracic (very rare)
  • Posterior
  • Inferior

Management: Anterior Dislocation

Acute Management

  • See: Anterior Shoulder Reduction
  • Field Management
    • No concensus opinion or National Athletic Trainers’ Association (NATA) position statement outlining the standard for on field care of glenohumeral dislocations
    • 2008 joint consensus statement by the American Academy of Orthopaedic Surgeons (AAOS) and American Orthopaedic Society for Sports Medicine (AOSSM) lacked clear guidelines for the approach and treatment of glenohumeral dislocations[13]
    • Reduction in field, see: Shoulder Reduction
    • Removal from play
  • In ED
    • In first time dislocation, radiographs before reduction
    • In recurrent dislocation, ok to consider reduction first
    • Sedation: consider oral/IV medications, Hematoma block, nerve block
    • Consider Suprascapular Nerve Block
  • Post reduction management
    • Place in Shoulder Immobilizer
    • Thorough neurovascular exam
    • Obtain post-reduction radiograph (regardless of field reduction or ED reduction) to confirm anatomic and evaluate other injuries
      • 37.5% of fractures only visible on radiographs after reduction[14]

Nonoperative

  • Hard indications
    • Uncomplicated first time shoulder dislocation
  • Soft indications
    • Recurrent, uncomplicated shoulder dislocations
  • Management
    • Relative rest from offending activities or sports
  • Shoulder Immobilizer
    • Consider immobilizing in external rotation
      • Itoi et al (2001): external rotation better approximates the labral tear and glenoid neck[15]
      • Itoi et al (2003): External rotation group had 0% re-dislocation rate compared to 30% with internally rotated immobilization[16]
      • Not generally accepted, in clinical practice, external rotation is far less functional
    • Duration unclear
  • Physical Therapy
  • If suspected nerve damage
    • Requires baseline EMG within first few weeks of injury
    • Requires MRI of cervical spine to evaluate brachial plexus, nerve root

Operative

  • Indications
    • Complete, isolated loss of axillary nerve function that doesn't recover within 3-6 months
      • Alnot et al: 20% recover spontaneously, 80% require surgery[17]
    • Brachial plexus injury that does not fully recover
      • Kosiyatrakul et al: nearly 2/3 of patients report full recovery of brachial plexus without surgery[18]
    • Unable to perform closed reduction (rare)[19]
      • Incarceration of humeral head in glenoid
      • Interposition of torn sub-scapularis tendon
      • Fracture of greater tuberosity with incarceration
      • Glenoid fracture with incarceration
      • Interposition of long head of biceps tendon
      • Massive rotator cuff tear with incarceration
  • Technique
    • Arthroscopic repair
    • Open repair
  • Other considerations
    • Arthroscopic Lavage
      • Controversial, goal is to eliminate hemarthrosis, promote normal positioning of capsule-labral complex
      • Benefits are positive but minimal[20]
    • Thermal capsulorrhaphy
      • Chen et al (2004): No difference in outcomes (need citation)

Management: Posterior Dislocation

Acute Management

  • See: Posterior Shoulder Reduction
  • Closed reduction must be performed under sedation
  • Posterior dislocation reductions require gentle manipulation so as to not cause humeral head fractures

Nonoperative

  • Chronic posterior dislocation may be tolerated in elderly, low demand patients[21]
    • As long as pain is controlled and they can sufficiently perform activities of daily living
  • May also be appropriate in patients with cognitive impairment, severe comorbidtiies

Operative

  • Indications
    • Inability to successfully perform closed reduction
    • Instability after closed reduction

Management: Inferior

Acute Management

Nonoperative

  • Indications
    • Inactive, elderly adults

Operative

  • Indications
    • Young, active individuals
  • Technique
    • Arthroscopic or open repair

Rehab and Return to Play

Rehabilitation

  • After period of immobilization
  • Supervised physical therapy
  • Prevent glenohumeral joint contraction
  • Dynamic Exercises to improve dynamic stabilizers and proprioceptions

Posterior

  • Weeks 0-4: Shoulder is braced in 20° external rotation, abduction
    • This is to allow healing of the capsule
  • Individual should be performing pendulum exercises 3-4 times per day
  • Weeks 4+: Begin unlimited progressive range of motion and isometric cuff strengthening

Return to Play

  • Kuhn (2006): Little evidence to guide return to play[22]
  • Some evidence to support RTP after range of motion and strength approach normal

Posterior

  • If successfully progressing through rehab
  • Non-contact sports can be considered at 3 months
  • Contact sports can be considered at 4-6 months

Complications

  • General
    • Posterior: Up to 65% of posterior dislocations have bony or soft tissue injuries[23]
  • Shoulder Instability
    • Hovelius et al: In patients managed nonoperatively, more than 50% of patients report some degree of instability over a period of 25 years[24]
  • Nerve injury ranges from 13.5 - 45% of cases[25][26]
  • Vascular Injuries
    • Very rare, most commonly seen with Luxatio Erecta, up to 39% (need citation)
    • Axillary Artery Thrombosis, a potentially late finding
    • Axillary Artery Injury
      • Stayner et al: ~2% of anterior dislocations[27]
  • Rotator Cuff Tear
    • Anterior: Seen in 14-63% of cases[28]
    • Posterior: 2-13% of cases[8]
  • Hill Sachs Lesion
    • Hovelius et al: 54% of anterior dislocations associated with hill sachs lesion[12]
    • Posterior: About 25-30% of cases[8]
  • Bankart Lesion
  • Proximal Humerus Fracture
    • Posterior: seen in about 40% of cases[8]
  • Degenerative
  • Recurrent Dislocation
    • Age at first dislocation is greatest risk factor, particularly in individuals less than 20 years of age
    • In patients under 18, 1 year risk is 77%[29]
    • Contact and collision sports increase risk (need citation)
  • "Terrible Triad" in geriatric patient
    • Shoulder Dislocation, Rotator Cuff Tear, brachial plexus injury

See Also


References

  1. Chalidis B, Sachinis N, Dimitriou C, Papadopoulos P, Samoladas E, Pournaras J. Has the management of shoulder dislocation changed over time? Int Orthop. 2007;31(3):385–389.
  2. 2.0 2.1 Bonza JE, Fields SK, Yard EE, Dawn Comstock R. Shoulder injuries among United States high school athletes during the 2005–2006 and 2006–2007 school years. J Athl Train. 2009;44(1):76–83.
  3. Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010;92(3):542–549.
  4. Shields, David W., et al. "Epidemiology of glenohumeral dislocation and subsequent instability in an urban population." Journal of shoulder and elbow surgery 27.2 (2018): 189-195.
  5. Kirkley, Alexandra, et al. "Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder." Arthroscopy: The Journal of Arthroscopic & Related Surgery 15.5 (1999): 507-514.
  6. Smith TO. Immobilisation following traumatic anterior glenohumeral joint dislocation: a literature review. Injury. 2006;37(3):228–237.
  7. Cutts S, Prempeh M, Drew S. Anterior shoulder dislocation. Ann R Coll Surg Engl. 2009;91 (1): 2-7. doi:10.1308/003588409X359123
  8. 8.0 8.1 8.2 8.3 Rouleau, Dominique M., and Jonah Hebert-Davies. "Incidence of associated injury in posterior shoulder dislocation: systematic review of the literature." Journal of orthopaedic trauma 26.4 (2012): 246-251.
  9. McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;24(3): 584-590.
  10. Gor DM. The trough line sign. Radiology. 2002;224 (2): 485-6. doi:10.1148/radiol.2242010352
  11. Wuelker N, Korell M, Thren K. Dynamic glenohumeral joint stability. J Shoulder Elbow Surg. 1998;7(1):43–52.
  12. 12.0 12.1 Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am 1996; 78: 1677–84.
  13. Herring SA, Bergfeld JA, Bernhardt DT, et al. Selected issues for the adolescent athlete and the team physician: a consensus statement. http://www.aaos.org/about/papers/advistmt/1032.asp. Accessed August 15, 2011.
  14. Kahn, Joseph H., and Supriya D. Mehta. "The role of post-reduction radiographs after shoulder dislocation." The Journal of emergency medicine 33.2 (2007): 169-173.
  15. . Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I, Sato K. Position of immobilisation after dislocation of glenohumeral joint. A study using magnetic resonance imaging. J Bone Joint Surg Am 2001; 83: 661–7.
  16. . Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I et al. A new method of immobilisation after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg 2003; 12: 413–5
  17. Bonnard, C., et al. "Isolated and combined lesions of the axillary nerve: a review of 146 cases." The Journal of bone and joint surgery. British volume 81.2 (1999): 212-217.
  18. Kosiyatrakul, Arkaphat, et al. "Recovery of brachial plexus injury after shoulder dislocation." Injury 40.12 (2009): 1327-1329.
  19. Khiami, F., A. Gérometta, and P. Loriaut. "Management of recent first-time anterior shoulder dislocations." Orthopaedics & Traumatology: Surgery & Research 101.1 (2015): S51-S57.
  20. Wintzell, Göran, et al. "Arthroscopic lavage compared with nonoperative treatment for traumatic primary anterior shoulder dislocation: a 2-year follow-up of a prospective randomized study." Journal of shoulder and elbow surgery 8.5 (1999): 399-402.
  21. Cicak N: Posterior dislocation of the shoulder. J Bone Joint Surg Br 2004;86(3): 324-332.
  22. Kuhn JE. Treating the initial anterior shoulder dislocation – an evidence based medicine approach. Sports Med Arthrosc 2006; 14: 192–8.
  23. Rouleau, Dominique M., Jonah Hebert-Davies, and C. Michael Robinson. "Acute traumatic posterior shoulder dislocation." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 22.3 (2014): 145-152.
  24. Hovelius, Lennart, et al. "Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: a prospective twenty-five-year follow-up." JBJS 90.5 (2008): 945-952.
  25. De Laat, E. A., et al. "Nerve lesions in primary shoulder dislocations and humeral neck fractures. A prospective clinical and EMG study." The Journal of bone and joint surgery. British volume 76.3 (1994): 381-383.
  26. Robinson, C. M., et al. "Injuries associated with traumatic anterior glenohumeral dislocations." JBJS 94.1 (2012): 18-26.
  27. Stayner L, Cummings J, Anderson J, Jobe C. Shoulder dislocation in patients older than 40 years of age. Orthop Clin North Am 2000; 31: 231–9.
  28. Cutts, Steven, Mark Prempeh, and Steven Drew. "Anterior shoulder dislocation." The Annals of The Royal College of Surgeons of England 91.1 (2009): 2-7.
  29. Mather III, Richard C., et al. "A predictive model of shoulder instability after a first-time anterior shoulder dislocation." Journal of shoulder and elbow surgery 20.2 (2011): 259-266.
Created by:
John Kiel on 4 July 2019 08:23:58
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Last edited:
14 August 2022 16:18:48
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