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A technique using a cannulated tap in a percutaneous manner allows for easy reduction of the dislocated humeral head with minimal soft-tissue trauma and presents a useful alternative to repeated attempts at open or closed reduction.
In case of the most common anterior-inferior dislocation of the shoulder joint the humeral head is forced out of the glenoidal cavity and tears the capsule. In about 20% of cases the dislocation is complicated by tears of the rotatory cuff, avulsion fractures and lesions of vessels and nerves. Reduction as soon as possible according to the method of Arlt or Hippokrates is recommended to avoid further damage. X-ray examination in 2 directions is necessary to confirm the position of the head. Clinical examination must be done to detect lesions of nerves or vessels caused by the procedure. In cases of recurrent dislocation a Hill-Sachs lesion and/or a Bankart lesion is responsible for instability of the shoulder joint. The elevation of the margin of the glenoid by autologous bone grafting (Eden-Hybinette, Trillat) and/or the derotation of the humeral head (Weber) reliably avoids redislocation. Except rare infections no severe complications are known. The operative correction of the severe disability should be recommended to all patients suffering from recurrent dislocation of shoulder joint.
Opinion varies as to the incidence of nerve lesions in anterior dislocation of the shoulder after low-velocity trauma. Most studies are retrospective or do not use EMG. We have investigated the incidence and the clinical consequences of nerve lesions in a prospective study by clinical and electrophysiological examination. Axonal loss was seen in 48% of 77 patients. The axillary nerve was most frequently involved (42%). Although recovery as judged by EMG and muscle strength was almost complete, function of the shoulder was significantly impaired in patients with lesions of the axillary and suprascapular nerves. Unfavourable prognostic factors are increasing age and the presence of a haematoma. It is not necessary to carry out EMG routinely; an adequate programme of physiotherapy is important. In patients with a severe paresis, EMG is essential after three weeks.
At this time the principal role of the arthroscope in the management of dislocating shoulder seems to be the identification of the intra-articular pathology. The findings should enable a surgeon to carry out an appropriate open repair, and the results of such surgery are excellent. Is there a place for arthroscopic repair? Some patients sometimes request it; others have had a failed open repair, or wish to avoid a scar. The author has devised a removable "Rivet," which fixes a loose labrum and the inferior glenohumeral ligament back on to a roughened glenoid margin. Use of this technique avoids some of the hazards that occur with implanting a staple or similar device in the joint. The "Rivet" is removed after 4-6 weeks. Ten patients have been so treated, with a follow-up of 6 months to 2 years. There was one failure, with a return of dislocation.
Proximal humerus fractures are common in the older population. These fractures can be associated with dislocation of the shoulder. Four-part fracture-dislocations and head-splitting 3-part fractures are generally indicated for shoulder hemiarthroplasty in the older population. When such surgery is warranted, inspection of the glenoid during the procedure is indicated, as loss of evaluation may lead to postoperative shoulder instability. There is value in alerting orthopedic surgeons to the possibility of anterior glenoid rim fracture in association with proximal shoulder fracture-dislocation. We focus on this issue and advise that the lesion can be visualized and confirmed at open reconstruction and does not need multiple radiographic views.
Ultrasound evaluation expands the possibilities of diagnostic imaging techniques for patients with shoulder instabilities. Static ultrasound investigation documents the acute or chronic dislocated shoulder. Dynamic evaluation demonstrates the direction of instability. Concomitant Hill-Sachs lesions or rotator cuff tears can be diagnosed with high diagnostic accuracy. Clinically relevant documentation of labrum defects (Bankart lesions) by ultrasound is not possible with the technique currently available.
Thirty-five patients who had operations for recurrent anterior dislocation of the shoulder were reviewed, with a further 26 answering a questionnaire; the results were not as good as reported by others. The mean follow up was 26.9 years. Ten out of 43 patients had recurrent dislocations after the Putti-Platt and 6 out of 18 after the Eden-Hybbinette operation. Osteoarthritis developed in 15 shoulders of 26 patients who were followed-up after the former procedure and in 8 out of 9 shoulders after the latter. These sequelae depend on the age at the first dislocation rather than the number of dislocations. The overall satisfaction rate was acceptable for both procedures.
Forty of 42 consecutive open capsulorrhaphies with suture anchors for treatment of traumatic recurrent anterior dislocation of the shoulder were reviewed after a minimum follow-up of 2 years. Two patients were lost to follow-up. Follow-up was conducted according to the rating systems of Rowe and the Society of American Shoulder and Elbow Surgeons. The surgical outcome was satisfactory in 38 patients (95%). Eighteen of the 22 patients who were involved in competitive overhead or collision sports before surgery returned to their preoperative sports levels. One patient, whose operation was unsuccessful, experienced recurrent dislocation. In one patient a deep infection that occurred as a complication of the surgical technique healed after suture anchor removal. Although a longer follow-up is necessary, this technique appears to have encouraging results as it avoids the risks related to the use of screws and staples.
We describe a case report of an axillary artery injury after recurrent anterior dislocation of the shoulder. Review of 22 reported cases reveals that 27% are recurrent dislocations, 86% occurred in patients older than 50, 86% of the injuries are in the third part of the axillary artery, and 68% presented with an axillary mass.
The authors report the clinical and radiographic results of 57 patients operated on for recurrent dislocation of the shoulder by the Delitala method. The age at operation ranged from 16 to 45 years. The follow-up was an average of 10 years (minimum 1, maximum 25 years) and the results were good or excellent in most of the cases. The failures included one case of recurrence and two of stiffness.
Two rare event occurred in one patient: luxation erecta, an unusual form of dislocation at the shoulder, and axillary artery injury, hitherto undescribed in this type of dislocation. The arterial injury consisted of rupture of the intima with secondary thrombosis and occlusion. Following resection of the contused artery and saphenous vein graft replacement normal circulation was restored.
Vascular complications are rare in cases of simple anterior dislocation of the shoulder but the axillary artery or its branches may be damaged. Very few cases are found in the literature reporting false aneurysms of axillary artery secondary to blunt trauma to the shoulder. A case of pseudoaneurysm of the axillary artery in a 75-year-old woman is reported. Diagnosis was suspected because large pectoral haematoma with haemodynamic instability appeared a few hours later after manual reduction of the dislocation. The pseudoaneurysm was confirmed with selective angiography of the axillary artery. Arteriography should be performed whenever vascular injury is suspected. Delayed recognition of these lesions may lead to permanent neurologic deficits despite adequate vascular repair of the axillary artery. A coordinated vascular and orthopaedic approach and prompt surgical treatment may assure full upper limb function. Although endovascular treatment of these lesions could seem attractive, we prefer to use open surgical techniques because they allow us to treat frequent concomitant injuries and perform decompression of the axillar fossa because of the large haematoma.
We describe 11 cases of posterior fracture-dislocation of the shoulder that required open reduction and fixation. Difficulties with access through anterior approaches led us to use the superior subacromial approach. This is an extension of the approach often used to expose the rotator cuff; the joint is opened by splitting the supraspinatus tendon 5 mm behind the cuff interval. The glenoid, proximal humerus and any fracture fragments can be seen from above, allowing reduction of the dislocation and osteosynthesis to be performed with minimal risk of damage to the humeral head and its blood supply. The proximity of the axillary nerve limits the exposure of the proximal humeral shaft. The superior subacromial approach is ideal for posterior dislocation with fracture of the articular segment, but is not suitable when there is a fracture of the proximal humeral shaft.
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From January 1990 to December 1998, 48 patients with 50 recurrent anterior dislocations of the shoulder were treated using a modified Boytchev procedure. The age of the patients varied from 18 to 35 years (average 24.7 years). The follow-up period was in average 88 (26-132) months. Six patients were lost in follow-up. Forty-two shoulders showed excellent results. There was one traction injury of the musculocutaneous nerve and one patient with immediate recurrence of the dislocation. Superficial wound infection occurred in five cases, all of which were controlled by antibiotics.
The evaluation of 10 patients with subluxing and dislocating shoulder is presented. Routine radiography with special views detected the presence of Hill Sachs lesions in seven patients, but was not conclusive for three patients. Soft tissue and bone anomalies were documented by computed arthrography in all 10 patients. Computed arthrography represents a valuable tool in the diagnosis of obscure unstable shoulders.
BACKGROUND: . The combination of posterior dislocation and fracture of the anatomical neck represents an extremely rare injury. METHODS: . A patient with posterior dislocation of the shoulder and ipsilateral fracture of the humeral anatomical neck was treated with open reduction and internal fixation with two Kirschner wires. He was followed up for 11 years. RESULTS: . The functional results were excellent, and X-ray and MRI investigations revealed the absence of avascular necrosis of the humeral head. CONCLUSION: . Early and accurate open reduction with minimal osteosynthesis resulted in excellent function of the injured shoulder without avascular necrosis.