Shoulder Dislocation

By: Lisa Zhang

HPI: Patient is a 27 year old male with no PMH presenting with shoulder pain and inability to perform full range of motion after falling on his right outstretched arm in a botched attempt to jump across a rock fissure while hiking. There is generalized aching pain throughout the shoulder joint as is very tender to movement. He remembers a similar sensation when he dislocated his right shoulder during a basketball match in high school. He denies any numbness or tingling in his right extremity, no other complaints. He is well hydrated and otherwise healthy.

Physical Exam: Vital signs normal. Patient sitting in mild distress, right arm flexed and adducted.

Right Upper Extremity: Square-like shoulder, asymmetrical to left. ROM of shoulder is severely pain limited, flexion and extension preserved at elbow and wrist. No ecchymosis, open wounds, or abrasions. Able to make okay sign, cross fingers, and thumbs up sign. Sensation intact in median, ulnar, and radial nerve distribution. Sensation intact over axillary nerve distribution (badge of shoulder). Distal pulses present.

What next?

SHOULDER DISLOCATION

Definition: Separation of the humeral head with the scapula at the glenohumeral joint. Accounts for nearly 50% of all major joint dislocations.

Anatomy:

Unstable joint with only 20-30% of joint articulation with the glenoid
Important structures to look out for:
- Axillary nerve: runs inferior to humeral head and wraps around surgical neck. Look out for damage represented by loss of sensation at the "badge" of the shoulder and deltoid muscle function (Perron 2003)
- Axillary artery: close proximity to humeral head, damage most common associated with inferior dislocations. Should also be considered when reducing chronic dislocation and in elderly patients (Perron 2003)

Classification:

Anterior (97%) (Rowe 1956)
- Mechanism of Injury: Fall on outstretched hand. Blow to the outstretched abducted externally rotated arm (e.g. blocking a shot in basketball)
- Presentation: arm slightly abducted and internally rotated. Prominent acromion
Posterior (<3%)
- Mechanism of Injury: 50% from trauma. Also associated with seizures where latissimus dorsi, pectoralis major, subscapularis pull humeral head internally and posteriorly (Rouleau 2012)
- Presentation: Internally rotated and adducted
Inferior (<1%)
- also known as luxation erecta
- Mechanism of Injury: High energy injury leading to hyperabduction. Seen in patients who fall and suddenly grab onto above head. 60% will have neurological dysnfuction (Groh 2010)
- Presentation: arm fully abducted above head, fixed

radiology

Plain radiography: Initial radiographs to diagnose and rule out fractures (25% of all cases), post-reduction to confirm successful reduction and exclude new fractures

Get 3 views: Anterior Posterior, Scapula Y, and Axillary

Anterior Posterior

Anterior: Straightforward, anteriorly dislocated and rests under the coracoid process (above)
Posterior: posterior shoulder dislocation on AP is subtle and may go undetected in up to 50% of casesLight bulb sign - humeral head internally rotates and obscures tuberosities, giving appearance of smooth bulbular head

Scapula Y

The scapular "Y" view is beamed parallel to the scapular body. The "Y" is formed by the body, spine, and coracoid process.
Anterior: Humeral head medial to scapula (above)
Posterior: Humeral head lateral to scapula

AXILLARY

The axillary view is taken with the arm abducted
Anterior: Humeral head lies anterior to the coracoid process
Posterior: Anterior: Humeral head lies posterior to the coracoid process
Inferior: Humeral head displaced inferior to glenoid and arm fixed above head superiorly

Hill Sachs Lesion: fracture of humeral head against glenoid rim

Anterior: found on posterolateral edge; 40-90% incidence, nearly 100% in all recurrent dislocations (Provencher, 2012)
Posterior: found on anterolateral edge (reverse Hill Sachs); ~80% incidence

Bankart Lesion: a bone fragment or the labrum is avulsed when glenoid labrum is disrupted during dislocation. 5% are bone fragments; 90% are soft tissue (Cleeman 2000)

Anesthesia and sedation

Pain management is usually titrated towards the patient's pain tolerance and predictive ease of reduction

No pain management: In cases of anterior dislocations that are recent, recurrent, and relatively nontraumatic. Works best with reduction techniques that do not require significant traction (O'Connor 2006)

Intraarticular lidocaine (IAL): cheap, localized pain relief with less systemic complications and faster recovery. Best used within <6 hours of injury event. Approach laterally or posteriorly with US or without

IV sedation (IVS): excellent at achieving muscle relaxation and pain relief, complicated by systemic symptoms and expensive. Often used due to pain intolerance or difficult reduction

Note: A 2011 clinical review of IAL vs IVS showed no statistically significant differences in outcomes (success rate, ease of reduction, and pain control) between the IAL and IVS. There were also fewer reported complications in the IAL groups (Waterbrook 2011)

REduction Techniques

Pearls: Apply constant, steady pressure. Most patients will be in a lot of pain and tense up their muscles, making it harder to maneuver the joint. Constant steady pressure along with muscle massage will help relax the muscles and make for an easier reduction.

External Rotation + Milch

1. Patient seated or supine position2. Begin with elbow of arm adducted to side, elbow at 90 degree flexion and arm internally rotated3. With slow and steady pressure, externally rotate arm while applying downward traction throughout4. Once fully external rotation, abduct the arm to above the head, maintaining traction and flex of elbow

Stimson + Scapular Manipulation

1. Patient lying down in prone position, allow affected arm to dangle over the edge2. Apply downward traction OR attach a 10-15 lb weight to wrist (i.e. 1L saline bag, sandbags). Be cautious of cutting off the vascular supply at the wrist3. Palpate inferolateral edge of scapular wing, then apply upward medial pressure4. With Stimson maneuver using weights, procedure may take 20-25 minutes

Cunningham

1. Place patient in sitting position, sit facing the patient at a slight diagonal2. Have patient place hand on affected shoulder onto the physician's nearest shoulder3. Place hand at AC junction of elbow, apply slight downward traction4. Use other hand to massage the deltoid, bicep and trapezius muscles5. Reduction occurs with gradual muscle relaxation

So how's our guy?

The patient's right arm was successfully reduced using the external rotation maneuver. Given the acuity of his dislocation and his previous history, the patient did not require local anesthetic or sedation. Films were taken pre and post reduction revealing no fractures. Neuro exam post-reduction showed now neurovascular damage. Patient was sent home in a sling with instructions to immobolize the shoulder for 3-4 weeks, avoid excessive external rotation and abduction, and consider rehab to strengthen the joint.

Citations:

Cleeman E et al. Shoulder dislocations in the young patient. Orthop Clin North Am. 2000 Apr;31(2):217-29. PMID: 10736391Groh GI et al. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg 2010;19(3):423-426. PMID: 19836975O'Connor DR et al. Painless reduction of acute anterior shoulder dislocations without anesthesia. Orthopedics 2006 Jun;29(6):528-32Perron AD et al. Acute complications associated with shoulder dislocation at an academic Emergency Department. J Emerg Med. 2003 Feb;24(2):141-5.Provencher MT et al. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg. 2012 Apr;20(4):242-52. doi: 10.5435/JAAOS-20-04-242.Rouleau DM et al. Incident of associated injury in posterior shoulder dislocation: Systematic review of the literature. J Orthop Trauma 2012 ;26(4):246-251. PMID: 22183196Rowe CR: Prognosis in dislocations of the shoulder. J Bone Joint Surg Am 1956; 38(5):957-977 PMID 13367074Waterbrook, A. L., & Paul, S. (2011). Intra-articular Lidocaine Injection for Shoulder Reductions: A Clinical Review. Sports health, 3(6), 556–559. doi:10.1177/1941738111416777

Home

Page updated

Google Sites

Report abuse