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PubMed1992

The effect of shoulder muscle training in patients with recurrent shoulder dislocations.

Thirty-three shoulders in 29 patients with recurrent shoulder dislocations, of both traumatic and nontraumatic type, have been studied. The patients suffered from muscle weakness, and had also a hypotrophy of the supra- and infraspinatus muscles. A special training program using an isokinetic pulley-weight apparatus, for muscle strength, coordination and endurance training of the rotator-cuff muscles and the deltoid were given all patients. Shoulder flexors, internal and external rotator muscles were trained three times a week, during a period of 8 weeks. At follow-up one year after completion of the specific training program all shoulders except five were improved. Five shoulders had remaining instability. Four of these patients had generalized joint laxity and a much decreased humeral head retroversion, and were later on stabilized with a rotational osteotomy of the proximal humerus. One of the shoulders with remaining instability was of traumatic type with normal skeletal anatomy. This patient was later on stabilized with a Putti-Platt procedure. We conclude that most of the patients were relieved from pain, and had decrease or cessation of their dislocations. Factors indicating a less good result of training were an abnormal skeletal anatomy, and/or a multidirectional type of instability.

Adult↗

PubMed1991

Proximal humeral osteotomy to correct the anatomy in patients with recurrent shoulder dislocations.

Surgical treatment of patients with traumatic shoulder dislocations is usually successful, but soft-tissue surgery in patients with nontraumatic shoulder dislocation often fails to stabilize the joint. Previous studies have shown that decreased humeral head retroversion might be one cause of anterior shoulder instability. Eleven patients with anterior recurrent dislocations, five traumatic and six nontraumatic, and all with a small humeral head retroversion angle, have been operated on using a proximal humerus osteotomy to correct the abnormal anatomy. After surgery, the humeral head retroversion was normalized to a mean angle of 34 degrees. All shoulders became stable. External rotation increased 7 degrees on the average, and internal rotation decreased 10 degrees on the average. One year after surgery, shoulder function was excellent in all operated shoulders.

Adult↗

PubMed1989

Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes.

We evaluated the natural history of anterior shoulder dislocations in a young athletic population (cadets at the United States Military Academy) and compared conventional means of nonoperative treatment with early arthroscopic treatment (staple capsulorraphy or anterior glenoid abrasion). The rate of recurrent instability after a shoulder dislocation was 92% (35 of 38) in cadets treated nonoperatively. Strict adherence to a supervised nonoperative treatment program had no effect on the recurrence rate. All recurrences of instability occurred within 14 months of the initial injury. In comparison, arthroscopic treatment of acute shoulder dislocations has been successful thus far in 78% (7 of 9) of cadets followed for at least 14 months. With the high rate of recurrence of shoulder instability in young athletes, we believe that arthroscopic surgical intervention after the initial shoulder dislocation can dramatically lower the recurrence rate and should be considered as a treatment option in young athletes.

Adolescent↗

PubMed2006

Correlation between Bankart and Hill-Sachs lesions in anterior shoulder dislocation.

BACKGROUND: Bankart lesions and Hill-Sachs lesions are commonly associated with anterior shoulder dislocations. The presence of Bankart lesion indicates the need for surgical repair. Magnetic resonance imaging (MRI) has been shown to be sensitive in detecting these two lesions. The aim of this study is to investigate the correlation between Bankart lesions and Hill-Sachs lesions on MRI for patients with traumatic anterior shoulder dislocations. METHODS: Between 2003 and 2005, 61 patients from Alfred and Sandringham Hospitals had an MRI as part of the investigation for traumatic anterior shoulder dislocations. The MRI scans were reviewed and subsequently confirmed by a radiologist to show the presence or absence of Bankart and Hill-Sachs lesions. The data were then analysed by a statistician. RESULTS: Although patients with one of these lesions were more than two-and-a-half times as likely to have the other, small study numbers precluded this result from achieving statistical significance. (odds ratio, 2.67 (0.83-8.61), P = 0.10). Younger age was a strong predictor of a recurrence of shoulder dislocation (odds ratio, 0.93 (0.89-0.98), P = 0.005). The presence of Bankart or Hill-Sachs lesions on MRI for the primary shoulder dislocation group was similar to the recurrent group (73% vs. 72% for Bankart lesion and 67% vs. 70% for Hill-Sachs lesion). CONCLUSION: There is a strong correlation between both lesions. This apparent trend can be useful in predicting the presence of a Bankart lesion when a Hill-Sachs lesion is identified on a plain radiograph. This study suggests the consideration of surgical repair after identification of a Hill-Sachs lesion on plain radiographs, especially for younger patients where the rate of re-dislocation is high.

Adolescent↗

PubMed2006

Treating the initial anterior shoulder dislocation--an evidence-based medicine approach.

This manuscript presents the best available evidence to answer questions regarding the treatment of the patient with an initial anterior shoulder dislocation. The highest levels of evidence available offer the following conclusions: (1) of the many methods to reduce the dislocated shoulder, little data exist to identify the best method. Recommendations are based on low levels of evidence (levels 4 and 5). (2) Premedication with intra-articular lidocaine has fewer complications and requires a shorter time in the emergency room than intravenous sedation with no detectable differences in reduction success rates (level 1). (3) Postreduction immobilization in external rotation may reduce recurrence (level 2), but immobilization in internal rotation does not (level 1). (4) Arthroscopic surgery significantly reduces recurrence compared to a nonoperative approach (level 1), and (5) there are limited data on features that would allow a safe return to play. Expert opinion suggests that return is allowed when motion and strength are nearly normal, and the athletes can engage in sport-specific activities, however, the athlete is at risk for recurrence while playing (levels 4 and 5).

Anesthetics, Local↗

PubMed1995

Arthroscopic Bankart suture repair for recurrent traumatic unidirectional anterior shoulder dislocations.

We report our experience with arthroscopic repair of the Bankart lesion following traumatic unidirectional anterior shoulder dislocation. Thirty consecutive patients (7 women, 23 men; average age, 26.5 years) were followed for an average of 38 months (minimum 2-year follow-up) after arthroscopic Bankart suture repair for recurrent shoulder dislocation. The study included patients who had pure shoulder dislocations (excluding those with instability secondary to subluxation, multidirectional instability, or an atraumatic origin), had experienced an initial frank shoulder dislocation (documented radiographically or requiring the assistance of medical personnel for reduction), and had a Bankart lesion, visualized arthroscopically. Clinical evaluation using the Rowe functional grading system showed 11 patients rated as excellent, 8 as good, 3 as fair, and 8 as poor. Six of 8 patients were rated as poor because they frankly redislocated following their arthroscopic shoulder stabilization. Our study shows a 27% failure rate in this group. Critical reevaluation of the transglenoid arthroscopic Bankart procedure is mandatory to identify the appropriate patient population for this procedure.

Adult↗

PubMed2003

Treatment of shoulder dislocation: is a sling appropriate?

Acute anterior shoulder dislocations, when managed non-operatively, have traditionally been treated by placing the arm in a sling. There is no formal evidence that this treatment is of benefit. Three recently reported studies, one in cadavers and two in patients, suggest that the detachment of the structures in the front of the shoulder is made worse when the shoulder is placed in internal rotation, as when the arm is in a sling. By contrast, the structures are realigned when the arm is placed in external rotation. Shoulder dislocations, if managed non-operatively, should not be treated by placing arms in a sling. Rather, placing them in a splint or using a pillow so that the the arm is externally rotated should be considered.

Humans↗

PubMed1980

[Recurrence frequency following traumatic shoulder dislocation].

99 cases of primary traumatic shoulder dislocation were evaluated in regard of the influence of the time of immobilization on recurrency. 3 weeks of strict immobilization gave a recurrency rate as low as 6.4% whereas a shorter immobilization resulted in 12% of recurrency within 1--6 years. A survey from 46 other clinics as well as the literature has given no evidence of clear rules of treatment and thus the discussion of treatment remains open.

Adult↗

PubMed1993

[The initial traumatic shoulder dislocation. Prospective study].

The goal of this prospective study was to investigate possible factors which might prevent the recurrence of dislocation after a first time traumatic shoulder dislocation. Of the 504 patients initially recorded, 376 were followed up clinically and radiologically after 1 year, and 324 were followed up after 5 years. 20% (64/324) of the patients examined after 5 years sustained a recurrent dislocation of the shoulder. We can confirm age dependency in the occurrence dislocations (50% of the patients > 30 yrs; 15% > 30 yrs). However, we were unable to find a relationship between the duration of immobilization and the incidence of recurrence redislocation (20% recurrence for 0, 1, 2, 3, > 3 weeks of immobilization). A simultaneous avulsion fracture of the tuberculum majus seems to improve the prognosis for recurrent shoulder dislocation (3/114 = 3%), whereas other bony injuries detected using conventional radiology do not appear to influence the incidence of recurrence. A shoulder stabilisation operation had to be carried out in a total of 10% of the follow-up cases. Based on our experience, we recommend a sufficiently long immobilization period of the freshly injured shoulder. In young patients, extensive and invasive procedures (arthro-MRI, pneumo-arthro-CT, shoulder arthroscopy) should be carried out after the first redislocation.

Adult↗

PubMed1989

A study of glenohumeral orientation in patients with anterior recurrent shoulder dislocations using computerized axial tomography.

Thirty-six patients with recurrent anterior shoulder dislocations and 11 normal patients who had no history of shoulder problems were evaluated by a G.E. 8800 fourth generation computerized axial tomographer to quantitate humeral head retrotorsion and glenoid tilt. The study objective was to determine if osseous orientation was a major etiologic factor in patients with recurrent anterior shoulder dislocations. The normal position of the humeral head as determined by CT scan is 30 degrees retroversion with respect to its distal articular axis. In dislocations this value changes to a more anteverted position of 24 degrees retroversion. Glenoid tilt could not be given a single value since it changes from retroversion superiorly toward more anteversion inferiorly. This change in glenoid tilt was greater in the dislocators with inferior sections measuring 2 degrees anteversion in the dislocators and 1 degree retroversion in the uninvolved shoulder and in the normal population. The change in humeral retroversion and glenoid tilt in the recurrent dislocators was statistically significant when compared with the uninvolved shoulder and to the normal population. Thus, the glenoid humeral orientation appears to be a significant predisposing factor to recurrent anterior shoulder dislocations.

Adult↗

PubMed1996

Arthroscopic stabilization of acute initial anterior shoulder dislocation: the West Point experience.

Arthroscopic stabilization for acute initial shoulder dislocation has been the subject of thorough investigation at West Point over the past decade in an attempt to improve on the natural history of shoulder instability in our young athletic population. From January 1986 to December 1995, 127 patients were treated for acute initial shoulder dislocation at the United States Military Academy. Of the 55 patients treated nonoperatively, 47 (85%) have had recurrence of instability. Seventy-two patients were treated operatively during three separate phases in the evolution of arthroscopic management at our institution. The initial phase (1986 to 1988) of operative treatment included either arthroscopic abrasion or staple repair. The low recurrence rate (2 of 9) was promising. In the operative technique for the second phase (1988 to 1991) transglenoid sutures were used. Of the 21 patients treated in this manner, 18 (86%) had no recurrent instability at last follow-up (average, 32 months). In the third phase (1991 to 1993), patients were treated with a bioabsorbable tack and interscalene anesthesia, and in the sitting position. Thus far, 39 of the latest 42 cadetathletes with acute initial anterior shoulder dislocations have had stabilization with this bioabsorbable cannulated fixation device. The average age was 19.5 years (range, 17 to 23 years). Follow-up averaged 22 months. There were no perioperative complications. Of these 39 patients, 35 (90%) have a stable shoulder and have returned to preinjury performance status. One of 2 patients with recurrent subluxation and 1 of 2 patients with a traumatic redislocation required an open Bankart repair. In young athletes known to have high recurrence rates with nonoperative treatment, acute arthroscopic stabilization appears to be an effective minimally invasive treatment option that favorably alters the natural history of shoulder instability.

Adolescent↗

PubMed1995

Treatment of shoulder dislocation with ipsilateral humeral shaft fracture.

A case presentation of shoulder dislocation with ipsilateral humeral shaft fracture is presented along with a review of the literature regarding nine reported cases. In the current case, closed treatment of the humeral shaft fracture was undertaken with an unsuccessful attempt at closed reduction of the anterior shoulder dislocation, resulting in a radial nerve deficit. Successful treatment required open reduction of the humeral fracture with compression plating followed by closed reduction of the shoulder dislocation. We compare this treatment (with outcome) to other methods of treatment.

Adult↗

PubMed1996

Clinically significant abnormalities in postreduction radiographs after anterior shoulder dislocation.

STUDY OBJECTIVE: To determine the incidence of clinically significant fractures or other abnormalities seen on postreduction shoulder radiographs which were not seen on postreduction should radiographs which were not seen on the prereduction films obtained for anterior shoulder dislocations. METHODS: Retrospective chart review of 131 patients who presented with a total of 175 anterior shoulder dislocations to the emergency department of an urban, university-affiliated, Level 1 Trauma Center with an emergency medicine residency program. All patients had complete medical records, radiographs before and after reduction, and no fractures reported on the prereduction films. RESULTS: There were three avulsion fractures (1.7%; 95% confidence interval [CI], 0% to 4.5%) detected on postreduction radiographs. In all three cases, a radiologist who was blinded to the original interpretations and the purpose of the study also noted the fractures on the prereduction films, although these fractures were not detected on the original interpretations. There were 14 new Hill-Sachs deformities (8%; 95% CI, 4% to 12%). In one case (.6%; 95% CI, 0% to 2.8%), the postreduction radiograph demonstrated a persistent dislocation, which was subsequently reduced in the ED. This was the only postreduction finding that altered acute management. CONCLUSION: Postreduction radiographs rarely reveal any clinically significant abnormality after an anterior shoulder dislocation has been reduced. Emergency physicians and orthopedic surgeons should question whether the time and expense of obtaining routine postreduction films in the ED for anterior shoulder dislocations is justified. A prospective study is needed to validate our findings.

Adult↗

PubMedDate not supplied

Bilateral shoulder dislocation: an unusual occurrence.

Bilateral shoulder dislocation is an unusual clinical entity. Proposed mechanisms are via various traumatic insults, atraumatic occurrences, and through extreme muscular contractions. A case involving traumatic dislocation as a result of a diving incident is reported. A brief review of this rare clinical condition is presented.

Adult↗

PubMed2003

Questionnaire reveals variations in the management of acute first time shoulder dislocations in the Netherlands.

AIM: To collect information about the management of patients with acute first time shoulder dislocation by (orthopaedic) surgeons in the accident and emergency departments of Dutch hospitals. DESIGN: Questionnaires were sent to 131 (orthopaedic) surgeons of 74 Dutch hospitals. METHOD: We enquired whether patients with acute first time shoulder dislocation are managed according to protocols in accident and emergency departments; which radiographs are deemed necessary before and after reduction; which reduction methods are generally performed; and what kind of pain relief or sedatives are generally administered. Furthermore, we enquired into the method and duration of immobilization after reduction. RESULTS: The response rate was 73%. Sixty-five per cent of the hospitals are used to managing acute first time shoulder dislocation according to protocols. Making prereduction and postreduction radiographs is standard practice in almost all hospitals. The most favoured methods of reduction are those according to Kocher and Hippocrates. In 85% of cases sedatives are administered before reduction, and in addition to that systemic analgesia is administered in 30%, whereas intra-articular analgesia is preferred in 25% of cases. CONCLUSION: Apparently, a protocol for the management of acute first time shoulder dislocation is not standardly available in all hospitals. On the basis of current literature and the results of this questionnaire it may be useful to establish a guideline for diagnostic procedures and the management of acute first time shoulder dislocation in accident and emergency departments.

Acute Disease↗

PubMed1984

Acute shoulder dislocations: factors influencing diagnosis and treatment.

The Bankart lesion is the most important single causative factor in traumatic anterior shoulder dislocations (85%). Capsular rupture occurs in approximately 15% of traumatic anterior shoulder dislocations and may or may not heal with redundancy. If so, recurrent dislocation in possible. Surgical repair of traumatic anterior dislocations requires that the capsule be opened for correct identification of the lesion and correct repair. Limitation of external rotation is not necessary for repair of anterior shoulder dislocations and should be considered as an untoward complication. While multiple procedures are available, all of which may be satisfactory at one time or another, no one procedure repairs all traumatic anterior shoulder dislocations.

Arthrography↗

PubMed2006

Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED.

Shoulder dislocations are often associated with significant pain, and many emergency physicians choose conscious sedation to achieve reduction. Concerns about oxygenation, airway protection, and aspiration may make some patients poor candidates for conscious sedation. Ideally, complete pain control and muscle relaxation could be achieved without airway compromise. Interscalene nerve blocks are routinely used for shoulder surgery in the operating suite. The equipment required to locate the nerve plexus blindly is typically not available in the ED setting. Recent work has shown that ultrasound guidance is ideal for the interscalene block and would make it possible in the ED. We present 4 cases of patients receiving ultrasound-guided interscalene blocks for pain control and muscle relaxation during shoulder reduction. Complete pain control, muscle relaxation, and joint reduction were achieved in each case.

Humans↗

PubMed1988

Double-contrast computed tomographic examination techniques in habitual and recurrent shoulder dislocation.

Preoperative planning of recurrent shoulder dislocation requires an accurate knowledge of bone and soft tissue lesions affecting the joint. A new method of double-contrast CT examination is presented which allows an accurate evaluation of the soft tissue structures important for the stability of the joint. Forty-two patients were examined with this technique, twenty-seven of whom (28 shoulders) were operated on, the procedure being selected on the basis of the CT findings. In all cases the preoperative CT findings corresponded to the intraoperative findings.

Contrast Media↗