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Anterior shoulder dislocations

How to reduce the humerus


By: Kayur Patel, Yiannis Pilavakis, Susan Alexander Published: 05 January 2011 DOI: 10.1136/sbmj.c6383 Cite this as: Student BMJ 2011;19:c6383

Respond to this article In this article:


Risk factors Mechanism of dislocation Anatomy of the shoulder Pathological lesions Post-reduction Management Surgical treatment Prognosis Summary Answers to questions

Figures:

Fig 1 What are these views called? What are the radiological findings? How would you manage this patient? Fig 2 Shoulder ligaments (a), anteroposterior view of normal shoulder (b), and shoulder bones (c) Fig 3 Radiograph of a relocated right shoulder

Boxes:

Box 1: Complications of anterior shoulder dislocations Box 2: Groups at risk for shoulder dislocations Box 3: Signs and symptoms of anterior shoulder dislocation

A 67 year old woman slipped on ice when she was shopping and landed on her outstretched arm. She developed immediate pain, swelling, and bruising over her right shoulder. No other injuries were found. Two radiographs were taken of her right shoulder (figs 1a and b). 1

Fig 1 What are these views called? What are the radiological findings? How would you manage this patient?

(1) What are these views called? (2) What are the radiological findings? (3) How would you manage this patient?

Anterior glenohumeral dislocation is the commonest major joint dislocation seen in the emergency department, and yet it is often misdiagnosed and mismanaged.[1] The incidence is estimated to be 12.3 per 100000, and it represents 90% of all shoulder dislocations.[2] An acute traumatic shoulder dislocation requires urgent treatment to prevent long term complications (box 1). Top

Box 1: Complications of anterior shoulder dislocations


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Soft tissue injuries


Bankart lesion Hill-Sachs lesion Rotator cuff tear (14-63%)[3]

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Neurovascular compromise

Axillary nerve injury (10%)[4] Axillary artery rupture (1-2%)[5]

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Shoulder instability

Recurrent dislocations Fractures Fracture of the greater tuberosity Fracture of the scapula Fracture of the shaft of the humerus

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Risk factors

Shoulder dislocation affects both sexes and can occur at any age, but it has a bimodal distribution with 16-30 year old men having the highest risk. The other groups at risk are men and women over the age of 60, where dislocation is often caused by low energy falls.[6] Box 2 shows other groups at risk. Top

Box 2: Groups at risk for shoulder dislocations


Young men Older people Participants in contact sports People with previous shoulder dislocations People with disorders of collagen synthesisfor example, Ehlers Danlos syndrome

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Mechanism of dislocation
The direction of dislocation is described with respect to the position of the humeral head after the injury has occurred. Dislocations can be anterior, posterior, or inferior. The most common mechanism of a traumatic dislocation is when the arm is forced into abduction, hyperextension, and external rotation. Most people sustain this injury from a fall onto an outstretched arm. This results in an anterior dislocation. Posterior dislocations are less common and usually occur as a result of an epileptic fit, seizures (for example, in hypoglycaemia), high energy trauma, or after electrical contact, which is rare.[7] [8] [9] [10] Inferior dislocations (luxatio erecta) are rare and result in the head of the humerus lying beneath the glenoid fossa. It might occur after injury to a hyperabducted arm, which can lever the head of the humerus out of the glenoid fossa.[11] Top

Anatomy of the shoulder


To understand the clinical findings in an anterior shoulder dislocation, it is important to be familiar with shoulder anatomy (figs 2a, b, and c). 2 The shoulder joint is the most mobile joint in the body. It consists of an articulation between the head of the humerus and a relatively shallow glenoid fossa of the scapula. The stability of the joint is reliant on static and dynamic factors. Static factors include the bony morphology of the scapula and humerus, and the fibrocartilaginous glenoid labrum which surrounds and thereby deepens the glenoid socket. The superior, middle, and inferior glenohumeral ligaments are condensations of the anterior capsule. These ligaments, together with the coordinated action of the rotator cuff muscles, control dynamic stability. The four rotator cuff muscles include:

Supraspinatusabducts the arm Infraspinatus and teres minorexternally rotate the arm Subscapularisinternally rotates the arm.

Dislocations may occur when a sufficient force is applied to the arm that exceeds the limit of the stabilising structures (figs 2a, b, and c).

Fig 2 Shoulder ligaments (a), anteroposterior view of normal shoulder (b), and shoulder bones (c) Top

Pathological lesions
In an anterior dislocation the head of the humerus is forced forwards or anteriorly. When glenoid labrum and the capsule of the shoulder joint is torn from its attachment to the bone of the anterior glenoid it is known as the Bankart lesion.[12] As the humerus is pushed further forward, the posterior aspect of the head engages with the anterior glenoid, and this may cause a depression fracture in the head. This is known as the HillSachs lesion. Both Bankart and Hill-Sachs lesions are associated with an increased risk of redislocation.[6] [13] [14] During dislocation, the attachment of the rotator cuff muscles can be torn off the humeral head. This is more common in older people; therefore anyone over 50 years presenting with a dislocation is presumed to have an associated cuff tear, until proved otherwise.[3] Fractures may also occur at the time of injury and can affect the scapula, the shaft of the humerus, or the greater tuberosity (figs 1 and 3). Top

Post-reduction
Figures 3a and b are the post-reduction films from the patient in figure 1. They show a relocated right shoulder and a fracture of the greater tuberosity in an otherwise normal radiograph. 3

Fig 3 Radiograph of a relocated right shoulder Top

Management
Anterior shoulder dislocations are simple to diagnose, and appropriate steps in management should be followed (fig 4). If the patient has been involved in a high energy

incident, the advanced trauma and life support protocol must be initiated to assess and stabilise the airway, cervical spine, breathing, and circulation.

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History

A detailed history of the traumatic event must be taken, and it is important to establish if a previous dislocation to either shoulder has occurred. The typical history of such a patient consists of a clear traumatic event followed by a sudden onset of severe pain and an inability to move the arm. With recurrent episodes, the shoulder can be dislocated with minimal trauma. Sometimes even turning over in bed may precipitate a dislocation. Occasionally, patients might be able to relocate the joint themselves. Top

Examination
The affected arm is usually supported in adduction and internal rotation and patients will try to resist any movement to the arm. On examination, the normal contour of the deltoid may be lost, there could be swelling or bruising of the shoulder, the humeral head may be palpated anteriorly, and the acromion may be palpated posteriolaterally (box 3). Top

Box 3: Signs and symptoms of anterior shoulder dislocation


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Signs

Affected arm held in adduction and internal rotation Loss of normal contour of deltoid Swelling or bruising around joint Humeral head felt anteriorly Acromion palpated posteriorly and laterally

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Symptoms

Sudden onset of severe shoulder pain Inability to move the affected arm

Complications of an anterior shoulder dislocation must be considered during management (box 1). It is vital to exclude a neurovascular injury before and after reduction. To assess vascular integrity, palpate the radial and ulnar pulses, examine for an axillary haematoma, measure capillary refill time, and check the temperature and colour of the fingers. The axillary nerve is damaged in about 10% of anterior shoulder dislocations because of its close association with the inferior glenohumeral capsule.[6] To exclude

injury to this nerve, test sensation over the lateral aspect of the upper arm, the so called regimental badge distribution. Top

Imaging
Two plain radiographs of the shoulder should be requested. An anteroposterior view is standard and the second view may be axillary, axial, Y view or West Point views, depending on local policy. In a normal anteroposterior radiograph the humeral head should be seen fitting directly in line with the glenoid (figs 3a and b). Loss of this congruity can be seen in an anterior dislocation (figs 1a and b). In posterior dislocations, the anteroposterior view can be misleading as the humeral head may appear to be congruent with the glenoid. It is essential to take an axillary view to confirm in which direction a dislocation has occurred. The clavicle is clearly seen on this view, and if the humeral head is on the same side of the glenoid as the clavicle, then an anterior dislocation has occurred. If the humeral head is sitting on the opposite side of the glenoid to the clavicle, then a posterior dislocation has occurred. Top

Reduction
Several methods to reduce a dislocated shoulder are described, but Hippocratic and Kochers methods are commonly used. No single method gives superior results.[15] Doctors should use the technique they are most comfortable with. A dislocated shoulder is commonly reduced by senior doctors in the emergency department. Orthopaedic referral is required when relocation has been unsuccessful. Adequate analgesia must be given before any attempt at relocation. After manipulation, a second radiograph is mandatory to confirm reduction. Hippocratic methodThis technique in shoulder reduction was first described by Hippocrates (460-377BC). With the patient supine, hold the hand of the affected side. Apply a slow, steady traction force to the extended arm. Another person is required to stand at the head of the patient and hold a sheet that is passed around the armpit of the affected side for counter traction. Kochers methodThe arm is placed in its anatomical position. Gently support the arm at the wrist and elbow before flexing the elbow to 90. Then, externally rotate the arm until you encounter resistance. Apply a lateral distraction force to the humerus to unlock it from the glenoid, followed by internal rotation to return the arm to the resting position. [16]

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Immobilisation
The shoulder should be immobilised by placing the arm in a sling for four to six weeks. The current consensus is to place the arm in internal rotation. However, there is debate as to whether external rotation is associated with lower rates of redislocation.[6] [17] No relation exists between the duration of immobilisation and risk of recurrence.[13] Followup in the next available orthopaedic clinic should be arranged to monitor progress and plan rehabilitation. Top

Rehabilitation
The aim of rehabilitation is to strengthen the muscles of the rotator cuff and to improve the control of scapular movements. This is done with the assistance of a specialised physiotherapist. Top

Surgical treatment
Shoulder arthroscopy or keyhole surgery has revolutionised the treatment of shoulder instability; however, open surgery remains the gold standard.[6] [18] Reconstruction of the anterior glenoid labrum and tightening of the anterior glenohumeral capsule form the basis of surgical repair for shoulder instability. A series of metallic or bioabsorbable anchors is drilled into the glenoid and sutures are passed from these, through the anterior capsular-labral complex, lifting and securing the labrum back into place. Surgery is indicated for patients with recurrent dislocations, but the decision to operate should be taken by a specialist shoulder surgeon. Top

Prognosis
The main risk after the initial injury is further dislocations. The age of the patient at the time of the primary dislocation is the chief prognostic factor in determining the risk of recurrent instability. The risk of recurrence is increased if the dislocation occurs before 20 years of age.[13] Other risk factors include early return to competitive contact sports and poor compliance with rehabilitation.[19] Management of an adolescent athlete should be more aggressive, and such patients often benefit from surgery.[20] Long term studies have indicated that a shoulder dislocation is

associated with osteoarthritis of the glenohumeral joint.[13] In severe cases, this may require surgical replacement of the joint to relieve pain and restore function. Top

Summary
Anterior-inferior shoulder dislocation is a common emergency presentation. Management must be systematic and include a thorough history and examination of the entire affected limb to exclude neurovascular injury. Anteroposterior and axillary radiographs of the shoulder should be taken to confirm the diagnosis and rule out associated fractures. Urgent relocation of the joint should be carried out with subsequent imaging to confirm reduction. The arm should be immobilised in a sling, and the patient should be referred to a specialist orthopaedic clinic for further management. Surgery may ultimately be required to stabilise the joint and restore function. Top

Answers to questions

(1) These are anteroposterior and axillary radiographs of the right shoulder. (2) The anteroposterior radiograph shows an inferior dislocation of the right shoulder with a fracture of the greater tuberosity. The axillary view confirms the dislocation is anterior. This is therefore an anterior-inferior dislocation of the right shoulder with a fracture of the greater tuberosity. (3) This patient should be managed in line with figure 4. (4) This patient had her shoulder reduced in the emergency department and the arm was placed in a sling in internal rotation. Follow-up at the next available upper limb orthopaedic clinic was organised.

Kayur Patel, final year medical student1, Yiannis Pilavakis, final year medical student1, Susan Alexander, orthopaedic registrar 2
1

Imperial College London, 2Central Middlesex Hospital

Correspondence to: kayur.patel05@imperial.ac.uk Competing interests: None declared Patient consent obtained Provenance and peer review: not commissioned; externally peer reviewed.

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