JOURNAL READING

Presented by:
M. Rizqi Firyal
71 2016 048
 Approximately 20% of all shoulder
dislocations occur in patients aged >60 years.
 Older patients who sustain a primary
shoulder dislocation are much less likely than
younger patients to suffer from recurrence.
 However, older patients are more likely than
younger patients to sustain injuries to the
rotator cuff, axillary nerve, or brachial
plexus.
 Rotator cuff tears are significantly more
common than nerve palsies, and rotator cuff
tears can be mistaken for nerve palsies.
 Older patients with persistent shoulder pain
and dysfunction after dislocation should be
carefully evaluated for rotator cuff
pathology.
 Although dislocation is a common injury in
the older population, these concomitant
injuries—especially of the rotator cuff—are
often missed
 Although the incidence of shoulder
dislocation is similar between young and
elderly persons, most of the literature has
traditionally focused on young patients
because of the high rate of recurrent
dislocations in this population.
 Shoulder dislocations in older patients tend
to occur as the result of low-energy
mechanisms and are associated with less risk
of recurrent dislocation; however, pain and
disability can persist for years as a result of
associated rotator cuff tears and nerve
injuries.
 Carefulpatient evaluation and treatment
selection are important to provide adequate
care to older patients with shoulder
dislocation.
 Approximately 20% of shoulder dislocations
occur in patients aged ≥60 years.
 The rate of recurrent shoulder dislocation is
reportedly as high as 90% in patients in their
20s and 30s, but it is <10% in patients aged
≥40 years.
 Differences in mechanism of injury are
largely responsible for the increased
incidence of instability in younger patients
and the increased likelihood of rotator cuff
tear in patients aged ≥40 years.
 In young patients, McLaughlin and MacLellan
describe an anterior mechanism of injury in
the dislocated shoulder.
 In younger patients with strong, healthy
rotator cuff tissue, a high-energy insult
results in failure of the weaker anterior
static restraints (ie, labrum, capsule).
 McLaughlin speculated that, in older
patients, the posterior mechanism
constraints, composed of the rotator cuff,
are more susceptible to injury as the result
of weakening of the cuff tendons caused by
degeneration associated with aging.
 Asa consequence, young patients present
with Bankart tears, that is, displaced tears of
the anterior-inferior labrum and inferior
glenohumeral ligaments, whereas older
patients typically present with rotator cuff
tears (Figure 1).
 Figure 1
 A and B, Illustrations of the posterior
mechanism of injury in shoulder dislocation
in an elderly patient.
A low-velocity fall
on the
outstretched hand
causes the
humeral head to
subluxate
anteriorly.
 The force created
(large arrows)
results in stretching
of the anterior
capsule and
subscapularis
tendon and tearing
of the weaker
posterior rotator
cuff or
supraspinatus
tendon.
 This difference in injury mechanisms explains
the different recurrence rates between the
two populations.
 In the young, Bankart tears render the
shoulder inherently unstable with the loss of
the static restraints.
 In patients aged ≥40 years, the rotator cuff
usually tears.
 However, the rotator cuff plays a lesser role
in shoulder stability, and, in general, only
massive tears result in recurrent instability.
 Therefore, older patients tend to redislocate
at a much lower rate than do their
younger counterparts.
 Hence, surgical management of shoulder
dislocation in older patients should focus on
reconstruction of the rotator cuff rather than
on capsulolabral reconstruction.
 Careful physical examination is crucial
because shoulder dislocation can be missed
on initial presentation.
 Upon arrival to an emergency department or
physician’s office, a patient with a suspected
shoulder dislocation should receive a
standard radiographic trauma series
consisting of a true AP view of the shoulder
in the scapular plane (ie, Grashey), an
axillary lateral view, and a true
scapulolateral view.
 Images should be critically evaluated for
evidence of glenohumeral joint reduction
and for subtle signs of previous dislocation
(ie, glenoid rim fractures, erosions), such as
a Hill-Sachs lesion or a bony Bankart lesion.
 The greater tuberosity of the humerus should
also be closely evaluated because subtle
fractures may be missed on overpenetrated
radiographs.
 Physical examination is done with the goal of
measuring joint stability and diagnosing
associated injuries.
 Inspection may reveal muscular atrophy,
which may be an indicator of a chronic
problem such as chronic rotator cuff tear or
nerve palsy.
 Obvious deformity, such as loss of the
contour of the coracoid, indicates an
anterior dislocation, whereas a prominent
coracoid may suggest posterior shoulder
dislocation.
 Examination of shoulder passive range of
motion is crucial.
 Loss of passive range of motion may be
suggestive of fracture, shoulder
subluxation/dislocation, or glenohumeral
joint stiffness, such as arthritis or adhesive
capsulitis.
 Inabilityto externally rotate the arm may
suggest posterior shoulder dislocation in
which the dislocated humeral head is
mechanically blocked by the glenoid.
 Isolated loss of active range of motion may
suggest rotator cuff tear rather than nerve
palsy.
 Theacromioclavicular joint, greater
tuberosity, biceps groove, and coracoid are
potential sources of shoulder pain and should
be palpated.
 The rotator cuff should be thoroughly
examined.
 Resisted thumb down shoulder abduction in
the scapular plane suggests supraspinatus
pathology.
 Similarly, weakness on resisted external
rotation in adduction and at 90° of abduction
is suggestive of infraspinatus and teres minor
pathology, respectively.
 Several physical examination tests have been
described to assess for subscapularis tears,
but the most commonly used tests are the
belly press and modified lift-off.
 Provocative testing is completed with
testing for shoulder
apprehension/relocation signs to obtain
evidence of existing shoulder instability.
 Finally,a thorough neurovascular
examination is performed, with special
attention paid to the axillary nerve.
 Axillary nerve palsy usually presents as a
painless loss of shoulder abduction and loss
of sensation in the proximal-lateral aspect of
the arm.
 The arm is evaluated for brachial plexus
injury, which usually manifests as sensory
and/or motor weakness distally in the arm.
 Vascular injury is assessed by inspecting for
evidence of expanding hematoma, which
may indicate arterial/venous injury after a
recent dislocation.
 Distal
radial and ulnar pulses should be
evaluated and compared with those of the
contralateral side.
 Radiographs play a limited role in direct
evaluation of rotator cuff pathology.
 However, they can identify associated
pathologies, such as tuberosity excrescences.
 A high-riding humeral head may also suggest
underlying chronic rotator cuff pathology.
 MRIhas become the preferred modality to
evaluate rotator cuff tears and assess
associated shoulder injuries (Figure 2).
 Figure 2
 AP (A) and
scapular Y (B)
radiographs of a
70-year-old man
with anterior
shoulder
dislocation.
 Figure 2
 AP (A) and
scapular Y (B)
radiographs of a
70-year-old man
with anterior
shoulder
dislocation.
 Figure 2
 (C) T2-weighted
coronal magnetic
resonance image
of the same
patient
demonstrating a
massive, retracted
supraspinatus tear
(arrow).
 Ultrasonography is a cost-effective and
noninvasive imaging modality for evaluating
rotator cuff tears.
 In one study, ultrasonography correctly
identified 45 of 46 full-thickness rotator cuff
tears and predicted the degree of retraction
and width of rotator cuff tears with accuracy
similar to that of MRI.
 Ultrasonography allows for dynamic
evaluation of the rotator cuff and may be
especially helpful in patients in whom MRI
findings are equivocal.
 Resultsare operator dependent, however,
and ultrasonography does not provide
adequate information regarding
glenohumeral bone loss and arthritis, which
can influence treatment decisions in persons
with rotator cuff tears.
 In patients in whom medical comorbidities or
indwelling metallic implants preclude MRI,
CT arthrography is a reasonable modality to
assess rotator cuff and labral integrity and
can be used to evaluate muscle atrophy.
 In a study of 33 patients assessed 4 to 6
weeks following primary shoulder
dislocation, Ribbans et al visualized labral
tears in 100% of the young patients (aged <50
years) and in 75% of the older patients (aged
≥50 years) with dislocation.
 Rotator cuff tear was found in 63% of older
patients and none of the younger patients.
 Concomitant rotator cuff tear with anterior
dislocation of the shoulder is well
documented in older patients.
 The incidence of rotator cuff tear in
conjunction with shoulder dislocation in
patients aged ≥40 years ranges from 35% to
86%.
 In older patients, a posterior mechanism of
failure is observed with weakening and
disruption of the rotator cuff, but the
anterior capsuloligamentous complex
remains intact.
 Tearing of these structures is more prevalent
in the older patient because rotator cuff
degeneration is correlated with increasing
age.
 Infact, Yamaguchi et al demonstrated a 50%
chance of bilateral rotator cuff tear in
patients aged ≥66 years.
 As a result, in older patients, the
degenerative cuff is more likely to tear than
are the much stronger capsular attachments.
A study by Porcellini et al supports this
hypothesis.
 They found a strong correlation between
dislocation and supraspinatus tear in 150
patients between 40 and 60 years of age who
underwent arthroscopy for rotator cuff tears,
instability, or both.
 No correlation was observed between
dislocation and capsular or Bankart lesions.

 Although older patients with anterior

shoulder injuries are at higher risk of nerve
injury than are younger patients, care must
be taken not to misdiagnose rotator cuff
tears as nerve palsies in older patients.
 In a study of 31 patients (average age, 57.5
years) who were unable to abduct their arms
following reduction of an anterior
glenohumeral dislocation, 29 were presumed
to have an axillary nerve injury; however,
this was actually the case for only 4 patients.
 All31 patients underwent single-contrast
arthrography of the shoulder, and each study
showed extravasation of the contrast
material, confirming a rotator cuff tear.
 Rotatorcuff injury should be ruled out in all
patients older than age 40 years who present
with signs and symptoms of nerve palsy after
shoulder dislocation.
 Many older patients have age-related
attritional tears that were asymptomatic
prior to shoulder dislocation.
 Therefore, it is crucial to obtain a careful
history of any preexisting symptoms of
rotator cuff dysfunction.
 Itis important to obtain a thorough history of
preinjury pain and disability to elucidate
whether the patient had a symptomatic
rotator cuff.
 Once adequate assessment is made of past
and current disabilities attributable to the
rotator cuff, a treatment decision can be
made.
 In our practice, older patients who have
minimal pain and intact strength are treated
nonsurgically.
 Only tears that cause significant pain and/or
disability are managed surgically.
 Associated
Injuries

Terrible Triad
Associated Peripheal Brachial
of the
Fractures Nerve Injury Plexus Injury
Shoulders
 Associated
Injuries

Chronic
Vascular Recurrent
Unreduced
Injury Instability
Dislocations
 Bony injuries associated with shoulder
dislocations include compression fractures of
the humeral head (ie, Hill-Sachs lesion),
anterior glenoid rim fractures, and greater
tuberosity fractures.
 Older patients, especially elderly patients
with osteoporosis, may sustain large Hill-
Sachs lesions from even lowvelocity falls.
 These lesions may predispose them to
increased instability and to the need for
shoulder arthroplasty to address loss of
articular congruity and relatively easy
engagement during forward elevation and
external rotation, which leads to anterior
shoulder subluxation or dislocation.
 The Hill-Sachs posterolateral humeral head
defect is a compression fracture caused by
the anterior glenoid rim as the humeral head
dislocates from the glenoid fossa.
 This lesion is seen in most anterior inferior
shoulder dislocations and is largest in
recurrent and chronic dislocations.
 Special radiographic views, such as the AP in
internal rotation view and the Stryker notch
view, are useful to identify humeral head
defects.
 MRI can show bony pathology, but CT, with or
without threedimensional reconstruction, is
best to determine the extent of the lesion.
 Greater tuberosity fractures are the most
common fractures associated with anterior
shoulder dislocation, and occurrence
increases with increasing age.
 Several authors have found that patients
with isolated greater tuberosity fracture
have a better prognosis than do patients with
rotator cuff tear.
 There is a decrease in the incidence of
recurrent shoulder dislocation in older
patients with greater tuberosity fracture
because the rotator cuff mechanism is
effectively repaired when the fracture
unites.
 Hoveliuset al observed no recurrence in
patients with a greater tuberosity fracture
compared with a 32% recurrence rate in
patients without a fracture.
 Itis our current standard practice to manage
nondisplaced fractures nonsurgically and to
operate on fractures displaced >5 mm,
especially those displaced into the
subacromial space.
 However, the decision for surgical versus
nonsurgical treatment should take into
account the activity level of the patient.
 Special attention should be paid to the
individual patient’s preoperative function as
well as his or her postinjury goals.
 Patients who are poor surgical candidates
and those with low postinjury functional
goals should be treated nonsurgically.
 Glenoid fractures associated with humeral
head dislocations are typically avulsion
fractures that occur when the humeral head
impacts the anterior capsule and labrum.
 In older patients, the glenoid fractures
because the bone is weaker and
osteoporotic.
 Iffracture is suspected or if there is
evidence of potential instability, an axillary
radiograph and/or CT scan may reveal the
glenoid lesion, which can be associated with
recurrent instability.
 Nerve injury associated with anterior
shoulder dislocations is more common in
older persons than in their younger
counterparts.
 Theaxillary nerve is the most commonly
affected, with a reported incidence of 9.3%
to 63%, followed by the suprascapular nerve
(29%), musculocutaneous nerve (19%), radial
nerve (22%), and ulnar nerve (8%).
 The increased incidence in older patients
may be attributable to age-related
degenerative changes in neural tissue, which
render the nerve more susceptible to injury
in closed trauma.
 Clinical features of axillary nerve palsy
include deltoid weakness or wasting that may
be accompanied by sensory deficit on the
lateral shoulder.
 Although suggestive, these features are not
diagnostic in older patients.
 It is critical to rule out massive rotator cuff
tear before diagnosing a nerve palsy.
 Forpatients with persistent symptoms 3 to 4
weeks after dislocation and with MRI findings
that are negative for rotator cuff tear, it is
reasonable to obtain electrodiagnostic
studies to evaluate the axillary nerve.
 Gumina and Postacchini used
electrophysiologic studies to evaluate nerve
palsies in patients with shoulder dislocations.

 Of the 545 patients with anterior shoulder

dislocations, 108 were aged ≥60 years.
 Of these 108 patients, 9.3% experienced
weakness on shoulder abduction and
decreased sensation in the deltoid region.
 Electrophysiologic studies established that
seven patients (6.5%) had neurapraxia of the
axillary nerve, whereas three (2.8%) had
axonotmesis.
 All recovered completely within 1 year
without further intervention.
 Formal management of these lesions is
usually unnecessary.
 Most patients with nerve dysfunction
spontaneously recover without intervention.
 The brachial plexus lies immediately
anterior, inferior, and medial to the
glenohumeral joint.
 This anatomic relationship places the
brachial plexus at risk during anterior
shoulder dislocation.
 Brachial plexus injuries resulting from
anterior shoulder dislocation are typically
infraclavicular lesions and mainly affect the
axillary nerve and the posterior cord.
 The primary mechanism of injury is
stretching of the brachial plexus, which can
occur during anterior dislocation, causing
neurapraxia that typically resolves
completely in 4 to 6 months in 80% of cases.
 Ifno sign of nerve recovery is documented on
electromyography at 3 to 4 months,
exploration of the plexus is recommended.
 The concurrent incidence of anterior
shoulder dislocation, rotator cuff tear, and
brachial plexus injury has been coined the
terrible triad of the shoulder.
 The first documented case reports noted the
difficulty of diagnosing rotator cuff tear in
the presence of brachial plexus palsy.
 This has important functional consequences
because the results of early rotator cuff
repair are better than those of delayed
repair.
 In a study of six patients with a mean age of
57 years and with terrible triad injury,
approximately 74° of forward flexion and 9
lb of forward flexion strength was gained by
a mean of 5.6 years after rotator cuff repair.
 Five patients recovered from their nerve
injury.
 Vascular injury to the axillary artery is an
uncommon but well-described sequela to
anterior shoulder dislocation in the elderly.
 More than 90% of axillary artery injuries
resulting from shoulder dislocations occur in
patients aged >50 years.
 The proposed mechanism is aging-related
sclerotic changes in arteries and loss of
elasticity, causing tearing rather than
stretching of the arteries.
 A mechanism has been described in which
the hyperabducted humeral head exposes
the axillary artery and pushes it against the
pectoralis major muscle, which acts as a
fulcrum and contributes to arterial injury.
 The third part of the axillary artery, defined
as the segment below the lower edge of the
pectoralis minor muscle, is the location of
injury in up to 86% of patients.
 Most axillary artery injuries occur when
chronically dislocated shoulders in older
patients are reduced closed.
 In chronic unreduced shoulders, the axillary
artery is scarred down and tethered by the
pectoralis minor muscle.
 Theexcessive force required to reduce a
chronically dislocated shoulder is enough to
cause injury to the axillary artery.
 Signsand symptoms of damage to the axillary
artery include pallor, paresthesia, decreased
temperature, diminished or absent radial
pulse, and an expanding axillary hematoma.
 Prompt diagnosis and management are
crucial to prevent irreparable harm to the
extremity.
 Exploration is obligatory in any patient with
hematoma, ischemia, and absence of a radial
pulse.
 Inpatients with diminished distal pulses,
angiography should be obtained because
collateral flow could be responsible for the
presence of a radial pulse.
 Vascular surgery consultation is warranted in
these patients.
 In the presence of subclavian or axillary
artery injury, the treating surgeon should
also have a high index of suspicion for
associated brachial plexus injury.
 Ifthere is concern for brachial plexus injury,
brachial plexus exploration should be
performed at the time of arterial exploration
rather than waiting 2 to 3 months, as is
classically taught.
 The recurrence rate after initial shoulder
dislocation is much lower in older patients
than in younger ones, possibly because older
patients tend to sustain rotator cuff ruptures
whereas younger patients tear the anterior
stabilizing structures and glenohumeral
ligaments.
 In one study of patients aged ≥40 years, only
4% experienced recurrent shoulder
dislocations.
 Another study found the average age of
patients with recurrent dislocations to be 55
years, with an incidence of 11%.
 Inthe patient with a combined displaced
anteroinferior labral tear (ie, Bankart tear)
and acute rotator cuff injury, the surgeon
should consider performing a combined
repair to promote shoulder stability.
 Our algorithm is to repair the labrum with
minimal capsular shift and address the
rotator cuff tear.
 Postoperative stiffness is a concern with such
a combined repair; thus, the appropriate
therapy should be promoted to begin early
motion within a protected range.
 Chronic shoulder dislocation is uncommon.
 These injuries are typically found in older
patients, and trauma is the most common
etiology.
 Shoulder dislocation is considered chronic
when the glenohumeral joint is dislocated for
several days.
 Theprimary complaint of patients with
chronic shoulder dislocations is loss of
motion with pain.
 On physical examination, old anterior
dislocations present with restriction of
abduction and internal rotation and old
posterior dislocations demonstrate
restriction of abduction and external
rotation.
 The most common neurologic deficit involves
the axillary nerve and presents as deltoid
weakness.
 Disuse atrophy can be apparent depending on
the length of time the shoulder has been
dislocated.
 Suspected chronic shoulder dislocation
should be confirmed radiographically.
 Further imaging with standard and three-
dimensional CT is useful to evaluate the
associated bony injuries.
 Not all patients with chronically dislocated
shoulders require treatment.
 Patients with a functional upper extremity
despite slight discomfort and limited motion
may opt to leave the shoulder dislocated.
 Nonsurgical treatment should be considered
for patients who are poor surgical risks.
 Pain relief is the primary indication for
reduction of a chronically dislocated
glenohumeral joint.
 Restoration of motion is secondary.
 The first treatment option to consider is
closed reduction.
 Patient age, duration of dislocation, vascular
status, and degree of humeral osteoporosis
must be considered before performing this
maneuver.
 Closedreduction should not be attempted on
a shoulder with a ≥20% impression defect of
the humeral head or on a shoulder that has
been dislocated longer than 4 weeks.
 Closedreduction should be done under
general anesthesia with total muscle
relaxation and minimal traction without
leverage to avoid fracture of the proximal
humerus or rupture of the axillary artery.
 Ifclosed reduction is not possible, open
reduction should be considered.
 This surgery is difficult for many reasons.
 First,there is potential difficulty in reducing
the humeral head into the glenoid fossa
because of fibrosis and capsular bowstringing
across the glenoid.
 Second, contraction of rotator cuff muscles
and the usual humeral head defect make
maintenance of the reduction difficult.
 Neviaserrecommends a stripping operation
wherein the capsule, rotator cuff, and
fibrous adhesions are stripped before
reduction is attempted.
 Large humeral head defects (>45% of the
humeral head) are best managed with
hemiarthroplasty.
 With this procedure, retroversion of the
humeral component can be decreased to
reduce the tendency of the head to
subluxate posteriorly in posterior dislocation.
 In a study of 11 patients (12 arthroplasties)
treated with hemiarthroplasty for chronic
shoulder dislocation, significant
improvement in flexion (P = 0.021),
abduction (P = 0.007), and external rotation
(P = 0.003) range of motion was noted at an
average 37-month follow-up.
 Reverse shoulder arthroplasty should be
considered for patients aged ≥70 years who
present with chronic, symptomatic shoulder
dislocations with humeral head bone loss and
rotator cuff deficiency.
 Management of shoulder dislocation in the
older patient begins in the emergency
department with prompt closed reduction of
the dislocation.
 Most acute dislocations are readily reducible
under sedation in the emergency
department.
 Chronic dislocations (ie, treated 3 to 4 weeks
postinjury) may require closed reduction in
the operating room under complete muscular
paralysis.
 In one study, 88% of patients had
uneventful closed reduction in the
emergency department, 5% needed general
anesthesia, and only 3% required open
reduction.
 Thorough neurovascular examination should
be performed, and vascular surgery
consultation should be obtained if
warranted.
 The patient is discharged in a sling for
comfort.
 Early range-of-motion exercises and physical
therapy are started within the first week to
prevent posttraumatic shoulder stiffness.
 Patients begin with passive pendulum and
Codman exercises and add progressive
passive and active range of motion under the
supervision of a therapist for 3 to 4 weeks.
 Patientswho fail physical therapy in 3 to 4
weeks and have persistent cuff weakness
should be evaluated with MRI to screen for
underlying pathology.
 However, if on initial presentation significant
cuff weakness exists, earlier imaging may be
indicated.
 Surgeons must maintain a very high index of
suspicion, especially in older and elderly
patients who acutely lose function after
shoulder dislocation.
 The most common injury is a traumatic
rotator cuff tear in the setting of attritional,
degenerative tissue.
 Failure to identify this injury could result
in chronic, painful dysfunction.
 The main difference between primary
shoulder dislocation in older patients versus
young patients is that older patients with
known traumatic rotator cuff injury are more
likely to be treated surgically.
 In older patients with shoulder dislocation,
early diagnosis and repair of the traumatic
rotator cuff tear yields optimal outcomes.
 Other authors have also shown better
outcomes with surgical management than
non-surgical management of rotator cuff
tear.
 Patients aged ≥40 years who are treated
surgically for shoulder dislocations have
shown equivalent redislocation rates
compared with patients aged <40 years who
have undergone surgical treatment (P>0.05).
 An increase in Constant scores has been
reported in patients aged 40 to 60 years who
were treated arthroscopically for rotator cuff
tears.
 The pathology of shoulder dislocation in
older patients is significantly different from
that in younger patients.
 Whereas dislocation leads to capsulolabral
tears in the young, it typically results in
rotator cuff tears or fractures in the elderly.
 Older patients are more likely than younger
patients to sustain injuries to the axillary
nerve or brachial plexus.
 This is because of lesser compliance in the
older shoulder.
 However, neural injury should not be
assumed in all cases.
 Patients should be assessed for rotator cuff
tear.
 Treatment should be focused on early closed
reduction and physical therapy with the goal
of restoring motion and strength.
 For older patients who fail nonsurgical
treatment, early diagnosis and treatment of
the associated rotator cuff tear can lead to
satisfactory outcomes.