Shoulder Dislocation

Most frequently dislocated joint (due to greatest ROM).

Common during athletic activities

Males > Females

Classification:

  • Anterior (most common)
  • Posterior (IR’s >> ER’s in seizures/electric shocks)
  • Inferior (rare)

Mechanism:

Anterior dislocation (AD): Anterior directed blow to posterior shoulder in a maximally abducted and externally rotated arm

Posterior dislocation (PD): Posterior directed blow to anterior shoulder in a FL/ Add/ IR arm

Presentation:

Sudden onset pain + deformity of shoulder following trauma

Patient keeping arm splinted at the side with opposite hand

Physical Examination:

  • ATLS protocol (secondary survey: Check NV status esp. Axillary n, brachial plexus, axillary a)

NB: Document NV status pre- and post- reduction

  • AD: Prominent humeral head anteriorly, flattening of rounded contour of posterior shoulder, unable to mobilise arm
  • PD: Arm held IR at the side (no ER possible), may see anterior flattening & posterior prominence (NB: may not see due to ↑bulk of post. shoulder)

Investigations:

  • Standard AP (Lightbulb sign = PD), scapular-Y and axillary (most important) views (Reveal direction/♯/block’s for reduction)

NB: If unable to get axillary, ask for Velpau view

Treatment:

Analgesia (Entonox + light sedation), O2

Closed reduction manoeuvres in A&E:

Anterior Dislocation: Hippocrates, Stimson, Kocher (↑re-dislocation rate), traction-counter traction, Milch)

Posterior Dislocation: Longitudinal lateral traction ➔ ER

If unsuccessful prep for theatre (have low threshold for assoc. GT ♯to take to theatre)

Obtain post-manipulation radiographs(NB: Document pre- & post- NV status – axillary nerve function, regimental patch)

Poly sling + ♯ clinic 6/52, then mobilise with Physio

May need CT/MRI arthrogram if Hill-Sacks/ Bankart lesion/ RC tears/brachial plexus injury suspected post-reduction in ♯clinic

Reserve further operative procedure after 2nd dislocation or recurrent instability

Complications:

  • Immediate:
    • Fractire
    • NV injury (higher in >40)
    • Unable to reduce closed
  • Acute:
    • NV injury (iatrogenic)
    • Re-dislocation (higher in younger pt’s up to 90%)
    • Rotator Cuff / labral tears
    • Hill-Sacks/ Bankart lesion
  • Chronic:
    • Recurrent instability (higher in younger pt’s)
    • Stiffness (higher in >40)
    • AVN

Indicators for recurrence:

  • < 25 yrs
  • High energy injury
  • Large Glenoid rim ♯
  • Large Hill-Sachs lesion
  • Non-compliance w/ restrictions of shoulder movements

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