Shoulder Dislocations Overview


Article Author:
Rachel Abrams


Article Editor:
Halleh Akbarnia


Editors In Chief:
Amie Kim
Todd May
Matthew Varacallo


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/4/2019 3:59:39 PM

Introduction

Shoulder dislocations represent 50% of all major joint dislocations, with anterior dislocation being most common. The shoulder is an unstable joint due to a shallow glenoid that only articulates with a small part of the humeral head.[1][2][3]

Etiology

The shoulder joint is the most regularly dislocated joint in the body. The shoulder can dislocate forward, backward, or downward, and completely or partially, though most occur anteriorly. Fibrous tissue that joins the bones can be stretched or torn, complicating a dislocation. It takes a strong force, such as a blow to the shoulder to pull the bones out of place. Extreme rotation can pop the shoulder out of its socket. Contact sports injuries often cause a dislocated shoulder. Trauma from motor vehicle accidents and falls are also a common source of dislocation.[4][5][6][7]

Epidemiology

The shoulder is the most regularly dislocated joint in the body; the dislocation may anteriorly, posteriorly, inferiorly, or anterior-superiorly. Anterior locations are the most common. Patients with prior shoulder dislocation are more prone to redislocation. Reoccurance occurs because the tissue does not heal properly or it becomes lax. Younger patients have a much higher frequency of redislocation; most like due to higher activity level. Patients who tear their rotator cuffs or fracture the glenoid also have a higher incidence of redislocation.

Pathophysiology

Types of Dislocation[5][8][9][10]

Anterior dislocation is the most common, accounting for up to 97% of all shoulder dislocations.

  • Mechanism of injury is usually a blow to an abducted, externally rotated and extended extremity.
  • It may also occur with posterior humerus force or fall on an outstretched arm.
  • On exam, the arm is usually abducted and externally rotated, and the acromion appears prominent
  • There are associated injuries in up 40% of anterior dislocations including nerve damage, or tears and fractures associated with the labrum, glenoid fossa, and/or humeral head.

Posterior dislocations account for 2% to 4% of shoulder dislocations.

  • Usually, the injury is caused by a hit to the anterior shoulder and axial loading of the adducted internally rotated arm.
  • It may also be a result of violent muscle contractions (seizures, electrocution).
  • On exam, the arm is usually held in adduction, and internal rotation and patient is unable to rotate externally.
  • Higher risk of associated injuries such as fractures of surgical neck or tuberosity, reverse Hill-Sachs lesions (also called a McLaughlin lesion which is an impaction fracture of anteromedial aspect of humeral head), and injuries of the labrum or rotator cuff.

Inferior dislocations (also known as luxatio erecta) are the most uncommon type (less than 1%).

  • Usually caused by hyperabduction or with axial loading on the abducted arm.
  • On exam, the arm is held above and behind the head and patient is unable to adduct arm.
  • Often associated with nerve injury, rotator cuff injury, tears in the internal capsule, and the highest incidence of axillary nerve and artery injury of all shoulder injuries.

History and Physical

History

Patients may report:

  • A popping sensation
  • Sudden onset of pain with decreased range of motion
  • The sensation of joint rolling out of the socket.

Remember to ask about any previous dislocations. When the shoulder dislocates, the nerves can get stretched out. Some patients report stinging and numbness in the arm at the time of the dislocation.

Physical

The physical examination should confirm a suspected dislocation.

  • Range of motion is diminished and painful
  • Anterior dislocation, the anterior arm is abducted and externally rotated In thin patients, there may be a prominent humeral head felt anteriorly, and the void can be seen posteriorly in the shoulder
  • Posterior dislocations are easy to miss because the arm is in internal rotation and adduction. In thin patients, the prominent head can be palpated posteriorly. Practitioners can miss posterior shoulder dislocations because the patient appears only to be guarding the extremity.

Performing a detailed neurovascular examination before reduction is imperative. Injury to the axillary nerve during shoulder dislocation is as high as 40%. Practitioners should record the neuromuscular examination before and after any dislocated shoulder.

Evaluation

Diagnosis and Management

Carefully examine the patient for neurovascular compromise. Axillary nerve injury is most common. The axillary nerve innervates deltoid and teres minor and provides sensation to lateral shoulder. Axillary nerve compromise presents in over 40% of dislocations, but usually, resolves with reduction. Although dislocation is often obvious, pre-reduction imaging for associated fractures can be useful and should be done when trauma is known. Clinically important fractures occur in about 25% of dislocations.[11][12]

  • Fractures of tuberosity, surgical neck fractures may occur and should not be reduced in emergency department
  • Bankart lesion develops when the glenoid labrum is disrupted with or without the addition of avulsed bone fragment (bony Bankart). Soft Bankart lesions involving the inferior anterior labrum are more common.
  • Hill-Sachs deformity is a compression fracture of the posterolateral humeral head primarily with anterior dislocations.
  • Reverse Hill-Sachs lesions seen in posterior dislocations (also called a McLaughlin lesion) which is an impaction fracture of the anteromedial aspect of the humeral head.

Reduction of the Dislocated Shoulder

Often conscious sedation with fentanyl, midazolam, ketamine, etomidate, or propofol used. This is done with continuous monitoring with capnography. If conscious sedation not needed, an intraarticular injection of 10 cc of local lidocaine or similar anesthetic may be helpful.

Contraindications to reduction in ED

Anterior Dislocation

  • Fractures of humeral neck can lead to avascular necrosis
  • Subclavicular and/or intrathoracic dislocations include a subacute dislocation in an elderly patient and an associated surgical neck fracture
  • Avoid multiple attempts in injuries that include neurovascular compromise (including brachial plexus involvement, axillary nerve, a musculocutaneous nerve, etc.).  If prompt reduction cannot occur without further injury, may need surgical help.  
  • The suspected arterial injury may need urgent angiography first.

Posterior Dislocation

  • Delayed presentation to the emergency department (more than 6 weeks)
  • Multipart or displaced fracture/dislocations

Inferior Dislocation

  • Humeral neck or shaft fractures should be done in a surgical setting
  • Any potential of vascular injury

Treatment / Management

Reduction techniques for anterior shoulder dislocation

Scapular Manipulation  (80% to 100% successful)

  • Upright or prone
  • In upright position, the patient is sitting up, may rest unaffected shoulder against upright head of bed
  • Stand behind patient and use one thumb over tip of scapula and push medially while pushing acromion inferiorly with the other thumb
  • Assistant simultaneously provided traction by grabbing patient’s wrist with one hand and flexed elbow with other hand and pushing down on elbow
  • The reduction may be subtle, without obvious “clunk.”
  • Reduced risk of associated fractures

External Rotation Technique 

The external rotation technique reduces anterior glenohumeral dislocation by overcoming spasm of the internal rotators of the humerus, unwinding the joint capsule, and enabling the external rotators of the rotator cuff to pull the humerus posteriorly.

  • Easy and can do alone
  • With patient supine, elbow flexed to 90 degrees, elbow held with one hand, and wrist is held with another hand
  • Slowly, have patient allow the arm to fall to the side, externally rotating forearm. The patient pauses with pain and allows muscles to relax. Over 5 to 10 minutes, the arm externally rotates, and reduction occurs
  • Reduction usually occurs with arm externally rotated between 70 to 110 degrees

Cunningham Technique

  • Patient is seated with examiner seated in front of patient, and the patient places ipsilateral hand on top of examiner’s shoulder
  • The clinician rests one arm in patient’s elbow crease and uses the other hand to massage the patient’s biceps, deltoid, and trapezius muscles
  • Have patient relax and instruct to pull their shoulder blades together and straighten their back
  • Popular technique now since rarely conscious sedation needed

Milch Technique  (add Milch technique if external rotation unsuccessful)

  • Patient is supine, fingers over the shoulder with thumb in axilla to stabilize
  • Arm is externally rotated and then abducted over patient’s head while maintaining external rotation with simultaneously placing direct pressure over the humeral head

Stimson Technique

  • No assistant needed and no need for conscious sedation
  • Patient is prone with affected arm hanging off the side of bed with 5 lb to  15 lb of weight
  • Reduction is usually achieved within 30 minutes

Traction Countertraction

  • A sheet is wrapped under the axilla, and one assistant provides continuous traction at the wrist or elbow while the other provides countertraction with the sheet from the opposite side

Spaso Technique

  • Patient is supine while examiner grasps wrist or distal forearm and lifts vertically with gentle vertical traction and external rotation

Fares Technique

  • Patient is supine with upper extremity at their side
  • The examiner holds patient’s wrist and gently pulls the arm to provide traction
  • The arm is abducted while continuously moving arm in anteriorly and posteriorly in small oscillating movements (about 10 cm)
  • If shoulder has not reduced by 90 degrees of abduction, add external reduction

Fulcrum Technique

  • Patient is supine or sitting, and a rolled towel or sheet is placed in axilla
  • The distal humerus is adducted with simultaneous posterolateral force on the humeral head
  • Requires increased force, may have increased complications

Kocher’s and Hippocratic Techniqueoot placed in patient’s axilla before traction) no longer recommended due to higher risk of complications

Posterior Shoulder Reduction

  • The patient is in the supine position. An assistant applies anterior pressure to humeral head while examiner applies axial traction to the humerus with internal and external rotation of humerus

Disposition After Shoulder Reduction

  • Place patient in a sling
  • Neurovascular exam
  • Post-reduction imaging
  • Follow-up with an orthopedic surgeon

Pearls and Other Issues

 

Enhancing Healthcare Team Outcomes

Shoulder dislocations are best managed by a multidisciplinary team that also includes therapists and orthopedic nurses. When evaluating patients with shoulder dislocations, clinicians need to be aware of the potential of associated neurovascular injury. Carefully examine the patient for neurovascular compromise. Axillary nerve injury is the most common. The axillary nerve innervates deltoid and teres minor and provides sensation to lateral shoulder. Axillary nerve compromise presents in over 40% of dislocations, but usually, resolves with reduction. Although dislocation is often obvious, pre-reduction imaging for associated fractures can be useful and should be done when trauma is known. Clinically important fractures occur in about 25% of dislocations.

Conservative treatment does yield good outcomes but recurrences are known to occur in about 1-5% of patients.[13]


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Shoulder Dislocations Overview - Questions

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Which of the following about shoulder dislocation is false?



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Posterior dislocation of the shoulder most commonly occurs after which of the following?



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Which is false of a shoulder dislocation?



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After suffering a severe seizure, a patient is seen in the emergency room with an inability to move his right shoulder. He complains of pain when he tries to move the shoulder. The arm is internally rotated and adducted. You decide to order plain x-rays. In which view on the x-ray is this type of dislocation frequently missed?



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What is the most common dislocation of the shoulder?



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A patient presents with right shoulder pain with the arm held in slight abduction and external rotation. The physical reveals a "squaring off" and loss of deltoid contour. Which is most likely?



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After a motorcycle accident, a patient is seen with the arm held in fixed internal rotation and adduction. Which of the following injuries is most likely?



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Inferior dislocation of the head of the humerus may damage which of the following nerves?



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In an anterior shoulder dislocation, the humeral head in most cases will lie in what position?



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What nerve is the most commonly injured by an anterior shoulder dislocation?



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Which of the following mechanisms is most likely to result in an anterior glenohumeral dislocation?



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A patient had a right anterior shoulder dislocation 4 weeks ago. Which home exercise would be best?



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A 17-year-old male complains of left shoulder pain and decreased ability to move the arm after a fall at home. On exam, the arm is abducted and externally rotated with sensation intact to light touch. There is resistance to any range of motion. What is the likely diagnosis?



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What test is indicated for shoulder dislocation?



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Which best represents the most common exam finding in association with the correct type of shoulder reduction?



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What is the best reduction technique for posterior shoulder dislocation in the Emergency Department?



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Shoulder Dislocations Overview - References

References

Enger M,Skjaker SA,Melhuus K,Nordsletten L,Pripp AH,Moosmayer S,Brox JI, Shoulder injuries from birth to old age: A 1-year prospective study of 3031 shoulder injuries in an urban population. Injury. 2018 May 22;     [PubMed]
Wolfe JA,Christensen DL,Mauntel TC,Owens BD,LeClere LE,Dickens JF, A History of Shoulder Instability in the Military: Where We Have Been and What We Have Learned. Military medicine. 2018 May 1;     [PubMed]
Lizzio VA,Meta F,Fidai M,Makhni EC, Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability. Current reviews in musculoskeletal medicine. 2017 Dec;     [PubMed]
Stromberg JD, Care of Water Polo Players. Current sports medicine reports. 2017 Sep/Oct;     [PubMed]
Farrar NG,Malal JJ,Fischer J,Waseem M, An overview of shoulder instability and its management. The open orthopaedics journal. 2013;     [PubMed]
Saw R,Finch CF,Samra D,Baquie P,Cardoso T,Hope D,Orchard JW, Injuries in Australian Rules Football: An Overview of Injury Rates, Patterns, and Mechanisms Across All Levels of Play. Sports health. 2018 May/Jun;     [PubMed]
Cameron KL,Mauntel TC,Owens BD, The Epidemiology of Glenohumeral Joint Instability: Incidence, Burden, and Long-term Consequences. Sports medicine and arthroscopy review. 2017 Sep;     [PubMed]
Vasiliadis AV,Kalitsis C,Biniaris G,Saridis A, Anterior Shoulder Dislocation during Breaststroke Swimming Technique: A Case Report and Review of the Literature. Case reports in orthopedics. 2019;     [PubMed]
Phadke A,Bakti N,Bawale R,Singh B, Current concepts in management of ACJ injuries. Journal of clinical orthopaedics and trauma. 2019 May-Jun;     [PubMed]
Carr JB 2nd,Chicklo B,Altchek DW,Dines JS, On-field Management of Shoulder and Elbow Injuries in Baseball Athletes. Current reviews in musculoskeletal medicine. 2019 Mar 18;     [PubMed]
Roberts S,Dearne R,Keen S,Littlewood C,Taylor S,Deacon P, Routine X-rays for suspected frozen shoulder offer little over diagnosis based on history and clinical examination alone. Musculoskeletal care. 2019 Mar 29;     [PubMed]
Srinivasan S,Pandey R, Current Concepts in the Management of Shoulder Instability. Indian journal of orthopaedics. 2017 Sep-Oct;     [PubMed]
Olds MK,Ellis R,Parmar P,Kersten P, Who will redislocate his/her shoulder? Predicting recurrent instability following a first traumatic anterior shoulder dislocation. BMJ open sport     [PubMed]

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