Shoulder dislocation

A shoulder joint is made up of three bones: collarbone, shoulder blade, and upper
arm bone. The top of an upper arm bone is shaped like a ball. This ball fits into a
cuplike socket in the shoulder blade. A shoulder dislocation is an injury that happens
when the ball pops out of the socket. A dislocation may be partial, where the ball is
only partially out of the socket. It can also be a full dislocation, where the ball is
completely out of the socket.
• Normally the head of the humerus remains centered in the glenoid fossa. This allow
for the joint surfaces to align congruently with one another. In addition, the
glenohumeral joint reaction force is contained within the glenoid arc . However, in
the case of shoulder dislocation, there is a disruption in the net glenohumeral joint
reaction force . This causes the humeral head to fall outside the glenoid arc .
 Mechanism of Injury
• The most common is due to trauma from a direct posterolateral force on the
shoulder. Individuals may also present with a direction of instability that can
predispose them to a dislocation. In this case, the muscles are "unprepared" or the
force "overwhelms" the muscle .
• Mechanism of inferior dislocation:
• There are 3 different types of shoulder dislocation:
• Anterior (forward). The head of the arm bone (humerus) is
moved forward, in front of the socket (glenoid). ...
• Posterior (behind). The head of the arm bone is moved behind
and above the socket. ...
• Inferior (bottom).
• Anterior Shoulder Dislocation
An anterior dislocation accounts for 97% of recurrent or first time
dislocations. It is the most common dislocation and is caused by the
arm being positioned in an excessive amount of abduction and
external rotation. In this position, the inferior glenohumeral complex
serves as the primary restraint to anterior glenohumeral
translation. Due to a lack of ligamentous support and dynamic
stabilization, the glenohumeral joint is most susceptible to dislocation
in the 90 degree abduction and 90 degree external rotation .
• Supporting structures that may be deficient in an anterior dislocation
are the anterior capsule, long head of biceps, subscapularis, superior
and middle glenohumeral ligaments. When there is a thinning in the
anterior capsule, it may present between the superior and middle
glenohumeral ligaments. As a result of its inherent weakness, the
humeral head is more prone to dislocate at this interval.
• When an anterior dislocation results from a traumatic event, the
anteroinferiorly displaced humeral head stretches and typically tears
resulting in a loss of integrity of the anterior ligamentous capsule,
often resulting in a detachment of the anterior inferior labrum . In
severe cases, concurrent rotator cuff injuries may occur.
• Posterior Shoulder Dislocation
Posterior dislocation is less common as it accounts for 3% of shoulder
dislocations. It is caused by an external blow to the front of the shoulder. There is
an indirect force applied to the humerus that combines flexion, adduction, and
internal rotation. This is usually the result of one falling on an out stretched hand
(FOOSH injury), MVA, or seizures. Due to the traumatic mechanism of injury,
posterior dislocations may also have concurrent labral or rotator cuff pathology.
• Clinical Presentation
• Anterior Dislocation
• Following an acute anterior glenohumeral dislocation :
• a. Arm held in an abducted and ER position
b. Loss of normal contour of the deltoid and acromion prominent
posteriorly and laterally
c. Humeral head palpable anteriorly
d. All movements limited and painful(springy movements mainly occur)
e. Palpable fullness below the coracoid process
and towards the axilla
• On thorough examination, the patient may also present with damage to
rotator cuff musculature, bone, vascular, and nervous structures.
Vascular structure damage is a result of traction of the brachial plexus
and axillary blood vessels that occur during a dislocation. A clinician
can determine if an axillary artery injury is present by looking for
reduced pulse pressure or a transient coolness in the hands. Peripheral
nerve injuries following an anterior dislocation is common because of
the proximity of the brachial plexus.
• Posterior Dislocation
• With acute posterior glenohumeral dislocation:
• a. Arm is abducted and IR
b. May or may not lose deltoid contour
c. May notice posterior prominence head of humerus
d. Tear of subscapularis muscle (weak or cannot internally rotate)
• Diagnostic Procedures
• Refer to rule out a fracture if dislocation is suspected.
1.Pre-reduction radiographs are necessary to determine direction of the
dislocation and to asses for any associated fractures. If a glenoid rim
fracture is observed on the initial radiograph. a CT scan can be done to
determine the size of the fracture. An MRI can be used to rule in or rule
out any soft tissue pathologies. As clinicians, it is important for us to
know the results of imaging to help guide us in our treatment process.
Medical diagnostics will largely depend on local protocol, but may
include plain radiographs (A/P, stryker notch or Westpoint views), CT or
MRI scans.
 Treatment

• Anterior Dislocation
There is limited evidence or consensus on optimal treatment. Non surgical
management may be preferred initially, but surgical repair may be warranted for
those whom fail conservative care or require extreme usage of the upper extremity
(i.e.-elite level athletes). Post operative protocols are largely surgeon dependent
and may vary based of several factors including: age, tissue quality, repair type,
and fixation. For an anterior dislocation, the recommended intervention non
surgically would be to have a closed reduction via a physician. An anterior
dislocation can be surgically repaired via stabilization procedures. Following
either intervention plan, the physician should be contacted for a specific protocol.
In addition, after either intervention the management is similar. However, if it is a
surgical procedure, knowing what type of surgery was performed as well as the
precautions post surgery.
• Arthroscopic Shoulder Surgery
• Surgery for a dislocated shoulder is often required to tighten
torn or stretched tendons or ligaments. A surgeon may also
repair a torn labrum, the ring of cartilage that surrounds the
shoulder socket and stabilizes the humerus. Together, these
soft tissues hold the joint in place.
• For most dislocations, shoulders can be repositioned without
surgery using a closed reduction procedure. The doctor will
administer an anesthetic to help minimize the pain and then
manually reposition the humerus into the shoulder socket
• The Milch technique is a common method for the reduction of a
dislocated shoulder. In this method, the patient lies supine while the
clinician slowly pulls the arm first to a 90° abduction, followed by a slow
external rotation to 90°.
• Immobilization
• It has traditionally been thought to be immobilized with internal rotation,
but according to Miller, immobilization has been beneficial in external
rotation because there is more contact force between the glenoid labrum and
the glenoid. Research suggests immobilization at 10 degrees of external
rotation has a lower recurrence rate than internal immobilization at 10
degrees. There is currently no consensus on the duration of immobilization
in a sling.But, typical time periods in a sling range for 3-6 weeks if under
the age of 40 and 1-2 weeks if older than the age of 40. During the
immobilization period, the focus is on AROM of the elbow, wrist and hand
and reduction of pain. Isometrics can be incorporated for the rotator cuff and
biceps musculature.
• Posterior Dislocation
• Management for posterior dislocation follows the same progression as
anterior protocol, except for the following guidelines:
a. Posterior glide is contraindicated
b. Avoid flexion with adduction and internal rotation
c. Immobilized 3-6 weeks if less than 40 years of age and 2-3 weeks if
greater than 40 years of age
d. Strengthening will focus primarily on posterior musculature such
as: infraspinatus, teres minor and posterior deltoid
• The goal of treatment after anterior shoulder dislocation is to
restore pain‐free, functional range of movement whilst
maintaining shoulder stability. This is usually achieved by non‐
surgical means, starting with closed reduction, where the
humeral head (ball) is manoeuvred back onto the glenoid
(socket)
• Differential Diagnosis
• Fracture (clavicle, glenoid, humeral head, greater tuberosity, and
proximal humerus)
• Rheumatoid Arthritis
• Rotator Cuff Injury
• Acromioclavicular Joint Dislocation
• Labral Pathology
• Shoulder Subluxation
• Axillary Nerve/Suprascapular Nerve Palsies
 Rehabilitation can last up to 6
weeks.