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PubMed1998

[Treatment strategy in first traumatic anterior dislocation of the shoulder. Plea for a multi-stage concept of preventive initial management].

The purpose of this paper is to outline the treatment protocol for the first time traumatic anterior shoulder dislocator, with options including conservative, arthroscopic and open surgical treatment. Regarding the subclassification of the first time traumatic anterior dislocater, it is imparitive to differentiate between the unidirectional dislocator with and without hyperlaxity. This subclassification takes into account the structural quality of the stabilizing ligamentous structures of the glenohumeral capsule. The patient with hyperelastic ligaments exhibit elastic deformation of the glenohumeral ligaments at the time of dislocation and thus, sustain less interstitial structural damage to the ligament. Therefore, these patients benefit from non-operative treatment. There are extrinsic and intrinsic factors which determine the outcome of the primary traumatic anterior shoulder dislocation. Extrinsic factors are those that are not related to changes in the shoulder morphology. The most important extrinsic factor is the age of the patient at the time of injury. The younger the patient at the time of injury the greater the risk of recurrence. As a rule, those patients 25 years of age or less, at the time of initial injury are less likely to spontaneously stabilize without surgical intervention, than they are to develop recurrence. Secondly, the type and level of sport participation is related to recurrence. Although the severity of the trauma can not be quantified, it certainly has an influence on recurrence. Immobilization remains controversial. A rehabilitation program is more likely to be successful in atraumatic instability. Patient compliance is important regardless of the type of treatment selected. Intrinsic factors include injury to the various anatomic structures about the shoulder, occurring at the time of primary anterior shoulder dislocation. A deep Hill Sachs lesion is more likely to result in recurrence secondary to both the impaction of the bone, as well as, the reduction of the area of articular surface. A displaced bony Bankart is a highly unstable situation secondary to the loss of the butress to retain the humeral head. In contrast to a Hill Sachs lesion or a bony Bankart, a concomittent fracture of the greater tuberosity is unlikely to result in recurrent dislocation. Isolated laberal detachment is not related to recurrence, but a complete disruption of the laberal ligament complex is highly correlated with recurrence. A rare subluxation erecta, as a special form of traumatic inferior instability, has a high recurrence rate. With increasing age there is a higher risk of concomittent rotator cuff tear. In most situations surgical repair of the rotator cuff tear results in resolution of the instability. The essential issue in determining the treatment protocol is to define concomittent hyperlaxity in the injured shoulder. Concomittent hyperlaxity precludes initial surgical treatment. The orthopedic surgeon treating the patient at the time of injury needs to design a concise treatment protocol for the patient based on the assessment of the extrinsic and intrinsic factors. An unreducable shoulder dislocation or associated vascular injury requires emergent intervention. Absolute indications for surgical treatment include: persistent dislocation, bony Bankart, a grossly displaced greater tuberosity fracture, and rupture of the subscapularis tendon. Surgical stabilization of primary anterior traumatic dislocation is indicated if the following strict criteria are met: adequate trauma, no self reduction, unidirectional instability without hyperlaxity, Hill Sachs lesion, age below 26 years, high level of sport activity and the special situation of luxatio erecta. Post primary stabilization is indicated for persistent subluxation, subjective instability or demonstrated pathologic instability tests. Rotator cuff tears due to traumatic dislocation in the elderly population require surgical repair.

Arthroscopy↗
PubMedDate not supplied

Development of arthrosis following dislocation of the shoulder: a case-control study.

The goal of this study was to document whether an association exists between shoulder dislocation and the development of arthrosis and to quantify this association, if present. Patients with osteoarthrosis who had undergone hemi-shoulder or total shoulder arthroplasty (TSA) were studied. Patients who had undergone total knee arthroplasty for arthrosis and who had no history of shoulder symptoms served as control subjects. All patients were asked if they had ever sustained a shoulder dislocation. Ninety-one TSA patients and 282 control subjects responded. The odds ratio for developing arthrosis after a shoulder dislocation was 19.3 (P =.000006). With the 5 patients who had shoulder surgery prior to TSA excluded, the odds ratio was 10.5 (P =.003). The risk of developing severe arthrosis of the shoulder is between 10 and 20 times greater for individuals who have had a dislocation of the shoulder.

Aged↗
PubMed1980

Immobilization after primary dislocation of the shoulder.

A total of 226 patients with primary shoulder dislocation were followed up for 1 year, the primary object being to observe the effect of immobilization on the incidence of redislocation. The shoulders were immobilized in a mitella for 1 week in all the 127 patients older than 50 years of age, and in 53 of the patients under 50 years of age. The shoulders of the remaining 46 patients (under 50 years) were completely immobilized with a stockinette-Gilchrist bandage for a period of 3 weeks. Thirteen per cent (30/226) suffered from one to four redislocations each during the follow-up period. Because most recurrences occurred in the patients under 30 years of age, these patients were compared with the older ones in the analysis. The frequency of redislocation was higher in the group of 53 patients under 30 years than in the older subgroup (P less than 0.001). Twenty-six of these 53 patients (under 30 years), who had been immobilized for 1 week, presented a higher frequency of redislocation than the remaining 27 patients subjected to 3 weeks' immobilization (P less than 0.05). Manual labourers experienced more numerous redislocations than office workers (P less than 0.01). The greater the initial trauma to the shoulder, the lower was the incidence of recurrence. There were only two among the 57 patients with early complications of the primary shoulder dislocation who had a redislocation (P less than 0.001). Residual stiffness was encountered more often in the patients over 30 years than in the younger ones (P less than 0.001). Following primary shoulder dislocation, 1 week's immobilization in a sling is sufficient in patients over 30 years, while in the case of most of the younger patients 3 weeks' complete immobilization of the shoulder is recommended.

Adolescent↗
PubMed2005

Recurrent bilateral dislocation of the shoulders due to nocturnal hypoglycemia: a case report.

A 20-year-old male was admitted to emergency room with convulsion. He had insulin-dependent diabetes mellitus for 8 years. He had suffered nocturnal hypoglycemia after strenuous exercise without additional calories. After recovery, the patient complained of bilateral anterior shoulder dislocation. Patient's history revealed another episode of bilateral shoulder dislocations after an hypoglycemic convulsion 3 years ago.

Adult↗
PubMed1976

Recurrent anterior dislocation of the shoulder. Long-term follow-up of the Putti-Platt and Bankart procedures.

Follow-up of 176 patients among 223 who underwent 232 repairs for recurrent shoulder dislocation (average follow-up, 10.2 years) revealed a recurrence rate of 11%. Among the twenty with recurrence, important factors were youth, athletic activity, inadequate immobilization, a history of contralateral dislocation, and a family history of shoulder dislocation. Redislocation occurred two years or more after operation in seven of the twenty patients with recurrence. Surgical repair permitted good function without significant pain in most cases.

Adolescent↗
PubMed1994

Iatrogenic displacement of fracture-dislocations of the shoulder. A report of seven cases.

We report seven cases in which open or closed reduction of a shoulder dislocation associated with a fracture of the humeral neck led to displacement of the neck fracture. Avascular necrosis of the humeral head developed in all six patients with anatomical neck fractures. All five anterior dislocations also had a fracture of the greater tuberosity and both posterior dislocations had a fracture of the lesser tuberosity. The neck fracture had not initially been recognised in three of the seven cases. In five cases attempted shoulder reduction led to complete displacement of the head segment, which was treated by open reduction and minimal internal fixation. In the other two cases, shoulder reduction caused only mild to moderate displacement which was accepted and the fracture was treated conservatively. We conclude that biplane radiography is essential before reduction of a shoulder dislocation. Neck fractures must always be ruled out, especially where there are tuberosity fractures. In our series, careful closed reduction under general anaesthesia with optimal relaxation and fluoroscopic control did not prevent iatrogenic displacement. Prophylactic stabilisation of the neck fracture should be considered before reduction of such a fracture-dislocation. It may be, however, that the prevention of displacement by prophylactic stabilisation does not always prevent late avascular necrosis; we observed this in one case.

Adult↗
PubMedDate not supplied

[Posttraumatic pseudoaneurysm of the axillary artery after anterior dislocation of the shoulder: a case report].

We present a case of a young patient, 44 years old, with a pseudoaneurysm of the axillary artery after anterior shoulder dislocation. The early diagnosis of axillary artery lesions after trauma is difficult in some cases. It's important to mention the possibility of accidental vascular surgery during reduction of the shoulder dislocation. In consequence, in all patients with a penetrating or blunt trauma of the shoulder is required a neurological and vascular examination; in any suspicions, an additional arteriography and computer tomography is indicated. Early repairs of vascular and neurological lesions are very important for the outcome of these patients.

Adult↗
PubMed1997

Anterior dislocation of the shoulder in elderly patients.

Of 545 consecutive patients with anterior shoulder dislocations, 108 (20%) were aged 60 years or more at the time of injury. We reviewed and radiographed 95 of these elderly patients after a mean follow-up of 7.1 years. Axillary nerve injuries were seen in 9.3% of the 108 patients, but all recovered completely in 3 to 12 months. There were single or multiple recurrences of dislocation in 21 patients (22.1%), but within this group age had no influence on the tendency to redislocate. Tears of the rotator-cuff were diagnosed by imaging studies or clinically in 58 patients (61%), including all who had redislocations. Sixteen patients required surgery. Eight with a single dislocation and a cuff tear had only repair of the torn cuff. Of the eight patients with multiple dislocations requiring operation, five also had a torn cuff and needed either a stabilising procedure and a cuff repair or repair of the cuff only. All patients who were operated on had a satisfactory result, with the exception of those with multiple redislocations and a cuff tear who had repair of the cuff only. Anterior shoulder dislocation in elderly subjects is more common than is generally believed; 20% suffer redislocation and 60% have a cuff tear. Operation may be needed to repair a torn cuff or to stabilise the shoulder. Patients with multiple redislocations will probably require both procedures.

Aged↗
PubMed1988

Traumatic disruption of the subclavian artery and brachial plexus in a patient with Ehlers-Danlos syndrome.

A 17-year-old girl with Ehlers-Danlos syndrome underwent simple reduction of a dislocated shoulder that was complicated by disruption of the subclavian artery and brachial plexus. The shoulder dislocation was a recurrent condition that had been treated successfully on several previous occasions without complication. During the relocation process, only minor upper extremity manipulation caused injury to the brachial plexus and subclavian artery. Management of an iatrogenic vascular injury was made difficult by the fragile consistency of the anterial wall that would not hold sutures. Amputation of the patient's arm ultimately was required.

Adolescent↗
PubMed1982

Chronic unreduced dislocations of the shoulder.

We evaluated the results of treatment in twenty-three patients with twenty-four shoulder dislocations that had gone unreduced for at least three weeks. Fourteen dislocations were posterior, eight were anterior, and one each was superior and inferior. Seventy-nine per cent of the posterior dislocations had not been recognized by the initial treating physician. Fourteen shoulders (58 per cent) were operated on. Of seven that were treated by open reduction with preservation of the humeral head, the results in two were graded as excellent; in three, as good; and in two, as fair. A Neer total shoulder-replacement prosthesis was used in one patient with an excellent result, and a Neer humeral-head prosthesis was used in two patients with a good and a fair result. In four patients, the humeral head was removed and a Jones procedure was performed, with one good and three fair results. There were no poor results after surgical treatment and it was not necessary to arthrodese any shoulder. We did not find it necessary to transfix the shoulder joint by screws or pins, or to use plaster spica casts to maintain stability of the shoulder following open reduction. Supporting the arm at the side in a position posterior to the coronal plane for a posterior dislocation, and anterior to the coronal plane for an anterior dislocation, proved to be comfortable and effective. There were no postoperative dislocations using this simple method. These results show that the over-all prognosis for surgical treatment of the chronic unreduced dislocation shoulder is more favorable than has previously been reported. A rating system based on 100 units was used to evaluate our final results, and is recommended as a standard system for future comparative studies.

Adult↗
PubMed1988

Voluntary dislocation of shoulder.

Voluntary dislocation of the shoulder is rarely seen by primary care physicians, but they must be able to recognize it and treat it correctly. Patients often use this ability to attract attention to themselves. Since the dislocations are painless and are performed at will, surgical intervention is not required. Proper treatment involves preventing repetition of the dislocations and providing emotional support for the patient.

Child↗
PubMed2001

The often overlooked posterior dislocation of the shoulder.

Unlike most shoulder dislocations, the posterior dislocation is truly a diagnostic challenge to the treating physician because it may be missed more often than it is recognized. In fact, more than 60% of posterior dislocations are misdiagnosed initially by the treating orthopedic surgeon, and the correct diagnosis is often delayed for months or years. A history of seizures, electroshock, or a fall onto a flexed, adducted arm should alert the physician to the possibility of posterior dislocation. A careful physical examination with comparison to the unaffected arm must be performed with particular attention given to subtle posterior fullness and anterior flatness of the shoulder, along with a lack of external rotation and abduction. A radiographic trauma series made in the scapular plane must always be obtained in cases of shoulder trauma to rule out posterior dislocation. A computed tomographic scan may also be necessary. The correct diagnosis of this injury will facilitate proper orthopedic evaluation and treatment and will reduce the incidence of missed posterior shoulder dislocation and its associated morbidity.

Casts, Surgical↗
PubMed1992

Computed tomography of posterior fracture-dislocations of the shoulder: case reports.

Computed tomographic (CT) evaluation of seven posterior shoulder dislocations in five patients is reported. Computed tomography provided better visualization of the trough fracture in the humeral head than did conventional x-ray films or tomography. It also demonstrated fracture fragments not seen on conventional roentgenograms. The two cases of bilateral dislocation and one case of unilateral dislocation were caused by seizures. The two other cases of unilateral dislocation were caused by trauma.

Adult↗
PubMed1998

[Subnormal functional activity in a neglected posterior dislocation of the shoulder].

The incidence of posterior shoulder dislocation ranges between 2 and 5% of glenohumeral dislocations. The mechanisms most frequently involved are trauma, grand-mal seizures and electrocutions. This lesion remains a diagnostic trap, due to paucity or even lack of clinical signs, and to the apparent normality of the anteroposterior radiograph of the shoulder. Nevertheless, careful clinical examination and an axillary radiograph often allow for a correct diagnosis. We report a case of traumatic posterior dislocation, unnoticed for 7 weeks. A satisfactory functional adaption of the dislocated shoulder to everyday life and the general condition of the patient lead us to select the notreatment option.

Activities of Daily Living↗
PubMed1999

Position of immobilization after dislocation of the shoulder. A cadaveric study.

BACKGROUND: After reduction of a shoulder dislocation, the torn edges of a Bankart lesion need to be approximated for healing during immobilization. The position of immobilization has traditionally been adduction and internal rotation, but there is little direct evidence to support or discredit the use of this position. The purpose of the present study was to determine the relationship between the position of the arm and the coaptation of the edges of a simulated Bankart lesion created in cadaveric shoulders. METHODS: Ten thawed fresh-frozen cadaveric shoulders were used for experimentation. All of the muscles were removed to expose the joint capsule. A simulated Bankart lesion was created by sectioning the anteroinferior aspect of the capsule from the labrum. With linear transducers attached to the anteroinferior and inferior portions of the Bankart lesion, the opening and closing of the lesion were recorded with the arm in 0, 30, 45, and 60 degrees of elevation in the coronal and sagittal planes as well as with the arm in rotation from full internal to full external rotation in 10-degree increments. RESULTS: With the arm in adduction, the edges of the simulated Bankart lesion were coapted in the range from full internal rotation to 30 degrees of external rotation. With the arm in 30 degrees of flexion or abduction, the edges of the lesion were coapted in neutral and internal rotation but were separated in external rotation. At 45 and 60 degrees of flexion or abduction, the edges were separated regardless of rotation. CONCLUSIONS: The present study demonstrated that, in the cadaveric shoulder, there was a so-called coaptation zone in which the edges of a simulated Bankart lesion were kept approximated without the surrounding muscles.

Aged↗
PubMed1982

Acute irreducible anterior dislocation of the shoulder.

In the past 6 years, three patients were treated for acute anterior shoulder dislocation which could not be reduced by closed means. Interposition of the labrium was found to be the cause for irreducibility in one patient. The obstructions to reduction in the other two cases were dislocation of the biceps tendon into the joint in one and interposition of the biceps tendon and the greater tuberosity into the joint in the other. The condition manifests in adults more than 40 years old. Redislocation or subluxation has not been observed.

Aged↗
PubMed1975

False aneurysm as a late complication of anterior dislocation of the shoulder.

A review of the leterature since 1947 fails to show a report of a false aneurysm with uncomplicated anterior shoulder dislocation. If this potential late complication is to be diagnosed and treated before the patient is released from followup medical care, careful attention must be given to alterations in the radial pulse prior to reduction. Patients who demonstrate an abnormal radial pulse which reverts to normal following reduction should have an angiogram. Pathological findings to the underlying axillary artery must be repaired promptly. Anterior dislocations of the shoulder account for approximately 50% of all dislocations and tend to be most frequent in healthy males. Late vascular complications associated with this injury are infrequent and can therefore be easily overlooked as illustrated in this report.

Aneurysm↗