Shoulder Dislocation Injury (Dislocated Shoulder)

When the shoulder dislocates, the round part of the upper arm bone, called the humeral head, is forced out of shoulder’s socket. A shoulder dislocation is often painful and requires a medical professional to move the humeral head back into place.

Shoulder dislocations occur when the humeral head is forced out of the shoulder socket. Read Guide to Shoulder Anatomy

The Shoulder Joint Is Flexible but Vulnerable

The main shoulder joint’s ball-and-socket structure offers the most mobility of any joint in the body. This joint, technically known as the glenohumeral joint, is held in place by a network of muscles, tendons, and ligaments—primarily the ring of tendons known as the rotator cuff and a membrane that encases the shoulder joint, the joint capsule.

See Soft Tissues of the Shoulder

The tradeoff for the flexibility of the shoulder joint is the potential for the joint to become unstable. The glenoid, or socket, is relatively shallow and flat, so there is potential for the humeral head to become displaced, especially at the front (anterior) of the joint. Most of the time, it requires a trauma force to dislodge the shoulder joint.

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Shoulders Can Dislocate in Different Directions

A shoulder dislocation or subluxation can occur in several directions:

An anterior dislocation is the most common type of shoulder dislocation.

1. Anterior (forward) dislocation is when the humeral head moves toward the front of the body. Anterior dislocations make up over 90% of dislocated shoulders.

   ¹
   Dumont GD, Russell RD, Robertson WJ. Anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment. Curr Rev Musculoskelet Med. 2011;4(4):200-7.
   This injury can be caused by sports or a fall on an outstretched arm.

2. Posterior (backward) dislocation occurs when the humeral head moves toward the back of the body. It accounts for 2 to 4% of shoulder dislocations, and is usually caused by a hit during an athletic event, electric shock, or seizure.

   ²
   Pedowitz R, Chung CB, Resnick D. Magnetic Resonance Imaging in Orthopedic Sports Medicine. Springer Science & Business Media; 2008.
   However, posterior subluxations (partial dislocations) are very common in athletes such as offensive lineman or weightlifters.

3. Inferior (downward) dislocation occurs the least often—accounting for only 0.5% of shoulder dislocations

   ³
   Saseendar S, Agarwal DK, Patro DK, Menon J. Unusual inferior dislocation of shoulder: reduction by two-step maneuver: a case report. J Orthop Surg Res. 2009;4:40.
   —and results in a downward movement of the humeral head. This type of dislocation can be caused by weight or force being applied to the arm as it is extended away from the body.

Knowing the direction of dislocation helps the physician craft a diagnostic approach and create a treatment plan.

In This Article:

• Shoulder Dislocation Injury (Dislocated Shoulder)

• Dislocated Shoulder Symptoms

• Causes and Risk Factors for a Dislocated Shoulder

• Diagnosing a Dislocated Shoulder

• Treatment for a Dislocated Shoulder

• Surgery for Dislocated Shoulder

Separated Shoulder vs. Dislocated Shoulder

The acromioclavicular joint facilitates raising the arm up over the head and the glenohumeral joint allows for circular movement of the arm.

It is important to distinguish between a dislocated shoulder and a separated one, since these are two different shoulder injuries.

A dislocated shoulder affects the glenohumeral shoulder joint, in which the humeral head comes out of the shoulder’s socket. By contrast, a separated shoulder involves another joint in the shoulder, the acromioclavicular joint. This joint is at the top of the shoulder, where the collarbone and shoulder blade come together. A separated shoulder means injury to the ligaments keeping these bones together.

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Both dislocated and separated shoulders are commonly seen in athletes.

Dr. D. Christopher Young is an orthopedic surgeon specializing in sports medicine, knee, and shoulder. He practices at OrthoVirginia and has more than 30 years of experience. Dr. Young has served as the head team physician for the University of Richmond and was recognized with the Neer Award by the American Shoulder and Elbow Surgeons.

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Shoulder Dislocation – Core EM

Shoulder Dislocation Classifications (www. backandbodyclinic.co.uk)

Definition: Separation of the humerus from the scapula at the glenohumeral joint

Epidemiology:

• Most commonly dislocated joint in the body  (17/100,000 people/year)
• Young males most commonly injured

Classification:

• Anterior: 97% (Rowe 1956)
• Posterior: < 3%
• Inferior: < 1% (Also known as: Luxatio Erecta Humeri)
• IMAGE: www.newhealthadvisor.com

Mechanism:

• Anatomy
  • Inherently unstable joint, relies on soft tissues for stabilization
  • Only 25-30% of humeral head articulates with glenoid at any one time
  • Axillary nerve wraps around surgical neck of humerus, most commonly injured nerve in dislocations of any direction
    • Motor: Deltoid muscle
    • Sensory: Anterolateral shoulder
• Anterior:
  • Fall onto outstretched hand
  • Force/blow to abducted and externally rotated +/- extended arm (ie. Blocking basketball shot)
• Posterior:
  • ~50% secondary to trauma (Matsen 2007)
  • 34% associated with seizures (Rouleau 2012)
    • Strongest shoulder muscles (latissimus dorsi, pectoralis major, subscapularis) overpower others and pull shoulder internally, posteriorly
    • Most common dislocation during seizures is anterior due to associated fall
• Inferior:
  • Very high energy injuries. Hyperabduction force levers arm on acromion forcing the humeral head into the infraglenoid region
  • Concomitant injury rate (humerus fracture, rotator cuff tears) as high as 80% (Groh 2010)
  • Concomitant neurologic injury as high as 60% (Groh 2010)

Physical Examination:

• Anterior
  • Arm is held in internally rotated and abducted position
  • Shoulder silhouette flattened with a prominent acromion

Netter’s Concise Orthopaedic Anatomy, Second Edition

• Posterior
  • Arm is fixed, internally rotated, and adducted
  • Posterior shoulder prominence
• Inferior
  • Fixed, abducted position 
  • Arm held above the head

X-Ray Imaging (All Images in Gallery Below):

• For any suspected dislocation, obtain 3 views: AP, Scapula Y, and Axillary (see Approach to Traumatic Shoulder Pain for normal X-ray anatomy)
• Anterior Dislocation
  • AP View: Humeral head dislocated anteriorly and rests under the coracoid process
  • Scapula Y View: Scapula Y view: humeral head displaced medially (to the right) of the scapula
  • Axillary view: Humeral head displaced anteriorly in front of the coracoid process
• Posterior Dislocation
  • AP: “Light bulb on a stick” – often the only sign of a posterior dislocation. The humeral head does not appear displaced from the glenoid BUT it is internally rotated and thus the contour of the humeral head appears rounded – like a light bulb
  • Scapula Y: Humeral head displaced laterally (to the left) of the scapula
  • Axillary: Humeral head displaced posteriorly behind the coracoid process
• Inferior Dislocation
  • Luxatio Erecta: Humeral head displaced inferior to glenoid and arm/humerus fixed above head/superiorly

Shoulder Dislocation X-Rays

Anterior Glenohumeral Dislocation: AP View (www.emrms.com)

Anterior Glenohumeral Dislocation: Scapula Y View (www.emrms.com)

Anterior Glenohumeral Dislocation: Axillary View (www.radiopaedia.org)

Posterior Glenohumeral Dislocation: AP View (Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 35746)

Posterior Glenohumeral Dislocation: Oblique View (Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 35746)

Posterior Glenohumeral Dislocation: Scapula Y View (www. lifeinthefastlane.com)

Posterior Glenohumeral Dislocation: Axillary View (Case courtesy of Dr Sigmund Stuppner, Radiopaedia.org. From the case rID: 44745)

Inferior Glenohumeral Dislocation: Luxatio Erecta (Case courtesy of Dr Andrew Ho, Radiopaedia.org. From the case rID: 22924)

Hill Sachs Lesion (www.wikimedia.org)

Important Additional X-Ray Findings

• Hill Sachs Lesion
  • Impaction fracture of humeral head against glenoid rim
  • Anterior dislocations,
    • Occurs against posterolateral surface
    • Incidence rate 40-90%
    • As high as 100% in recurrent dislocations (Provencher 2012)
  • Posterior dislocations
    • Occurs against anterolateral surface (“reverse Hill Sachs lesion”)
    • Incidence 86%.
  • May require accentuating rotational force (internal vs external) when reducing dislocation to dislodge the lesion off glenoid rim

• Bankart Lesion
  • Detachment of anterior inferior labrum from glenoid
  • “Soft” – Labrum only
  • “Bony” – impaction fracture involving glenoid margin

Bankart Lesion (www. orthop.washington.edu)

Management/Reduction Techniques

• Provide adequate analgesia
  • The more the patient tenses his or her muscles from pain, the more difficult it will be to reduce the joint
  • Consider systemic analgesia vs intraarticular local anesthetics vs both
  • Procedural sedation may be required in select cases
• Complete a full neurologic and vascular assessment prior to the performance of any manipulation technique
• Anterior
  • Cunningham Technique
    • Physician massages the patient’s biceps muscle as the patient holds arm adducted and elbow flexed
    • Patient gradually moves shoulders up and back (shoulder shrug) as tolerated

• Stimson Maneuver

Stimson Maneuver (Netter’s Concise Orthopedic Anatomy 2nd Edition)

• Scapular Manipulation
  • Stimson technique applied
  • Scapula manipulated counterclockwise: stabilized superiorly, medial force applied on inferior angle

Scapular Manipulation with Stimson (aibolita. com)

• Traction-Countertraction
  • Gradual, smooth traction is applied to the affected arm until patient’s muscles relax or tire sufficiently to release the dislocated humeral head
  • An assistant maintains counter traction to maintain patient in place

• Milch

Milch Technique (Netter’s Concise Orthopedic Anatomy 2nd Edition)

• Posterior: requires 2 operators
  • Traction-Countertraction recommended for all posterior dislocations
  • Sitting patient upright and applying forward traction might be useful
• Inferior
  • Arm traction superiorly with gradual shoulder adduction 
  • Sheet wrapped around upper torso to hold patient in place
  • Traction-Countertraction
  • Two-Step (Youm 2014)
    • Arm traction superiorly while pushing humerus laterally
    • This will either reduce the shoulder entirely or convert it to anterior dislocation, which can be reduced as above

Relative Contraindications to ED Reduction:

• Associated fracture of humeral neck
• Associated nerve injury/deficit
• Suspected major vascular injury
• Chronic Dislocation
  • > 48 hours
  • Success rate exceedingly low
  • Refer to orthopedics for surgical evaluation if initial attempts fail

Follow Up

• Immobilize in sling for 3-4 weeks (older patients 1-2 weeks to avoid joint stiffening)
• Rehab should begin with passive range of motion exercises
• Anterior dislocations: no external rotation past neutral and no abduction past 90 degrees for the first 4-6 weeks
• Posterior dislocations: no internal rotation for first 4-6 weeks.

Take Home Points:

• Be vigilant for concomitant neurovascular injuries and always perform a full neurovascular assessment before and after reduction
• Carefully review radiographs for posterior dislocations as they may appear “normal” on first glance
• Be comfortable with multiple reduction techniques. No one approach will reduce all shoulder dislocations.
• Joint injections and systemic analgesia will facilitate reduction. Depending on patient response to initial attempts, procedural sedation may be necessary.

Read More:

LITFL: Posterior Shoulder Dislocation

LITFL: Cunningham’s Shoulder Relocation

EM Sandbox: The Cunningham Technique – Deep Dive Swaminathan

References

Youm T et al. Acute Management of Shoulder Dislocations. J Am Acad Orthop Surg. 2014 Dec;22(12):761-771.PMID: 25425611.

Rowe CR: Prognosis in dislocations of the shoulder. J Bone Joint Surg Am 1956; 38(5):957-977 PMID 13367074

Matsen FA et al.  Principles for the evaluation and management of shoulder instability. Instr Course Lect 2007; 56:23-34. PMID: 17472289

Rouleau DM et al. Incident of associated injury in posterior shoulder dislocation: Systematic review of the literature. J Orthop Trauma 2012 ;26(4):246-251. PMID: 22183196

Robinson CM, Aderinto J. Posterior shoulder dislocations and fracture- dislocations. J Bone Joint Surg Am 2005; 87 (3):639-650. PMID: 15741636

Patel DN et al. Luxatio erecta: Case series with review of diagnostic and management principles. Am J Orthop 2011;40(11): 566-570. PMID: 22263209

Groh GI et al. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg 2010;19(3):423-426. PMID: 19836975

Provencher MT et al. The Hill-Sachs lesion: Diagnosis, classification, and management. J Am Acad Orthop Surg 2012;20(4):242-252. PMID: 22474094

Schwartz D. Emergency Radiology Case Studies. Upper Extremity: Patient 6. 271-279. McGraw-Hill Education / Medical; 1 edition (November 26, 2007)

Thompson J, Netter F, Machado C. Netter’s Concise Orthopaedic Anatomy. Second edition. Saunders Elsevier 2010.

Allon Mordel, MD

Treatment. Shoulder joint. Dislocations company blog

Description of the disease, symptoms and causes, methods of treatment.

Shoulder joint is a mobile anatomical formation represented by a spherical joint. From the point of view of biomechanics, such a structure provides a wide variety of movements in the joint, allowing it to perform its physiological functions, but on the other hand, it is prone to shoulder dislocations, especially when the ligamentous apparatus of the joint is incompetent. Dislocation of the shoulder is accompanied by a complete disengagement of the head of the humerus and the articular cavity of the scapula, which entails the complete shutdown of the joint from the musculoskeletal skeleton.

Causes

The functional state of the shoulder joint is provided by the ligaments of the shoulder, which hold the two articulating bones and allow free movement. As already mentioned, with their failure, for example, with tendonitis (inflammation of the ligament), dislocation or subluxation is observed. However, dislocation of the shoulder joint does not always mean a possible pathology in the ligamentous apparatus. A strong traumatic effect on the joint leads to displacement of the articular surface of the bone and, as a result, dislocation. Dislocation of the shoulder joint can occur when falling on an outstretched arm, hitting from the lateral side. If the dislocation of the shoulder is already habitual, i.e., it is not the first time, the treatment of dislocation of the shoulder joint is carried out in most cases surgically and only in a hospital. Patients need to understand the full nature of their state of health when there is a real possibility of losing shoulder functionality.

Symptoms

Shoulder dislocation symptoms are visually noticeable and beyond doubt. In some cases, to confirm the diagnosis, it is necessary to conduct additional diagnostic methods, especially relevant for subluxations. Radiography for dislocation is shown to absolutely all victims to confirm the diagnosis, determine the location of the articular surfaces of the bones and visualize possible bone fragments, which should not be normal. Clinically, patients complain of pain, a complete lack of movement in the shoulder joint. Often, the victim goes to the trauma center with such a hand tied on a scarf. He cannot remove it on his own; I have to support it with my other good hand.

First aid

In case of dislocation of the shoulder, it consists in immobilizing the damaged joint with a Deso bandage or a ladder splint. Traumatic dislocation of the shoulder is accompanied by severe pain, to reduce which the patient is given non-narcotic (analgin) or narcotic (promedol) analgesics.

There are two methods of treatment of shoulder joint dislocation: conservative and surgical.

Conservative treatment

This treatment method includes:

• shoulder reduction;
• drug treatment;
• subsequent course of physiotherapy;
• exercise therapy.

When repositioning, a local anesthetic is injected into the shoulder joint. Under local anesthesia, a closed removal of the dislocation of the shoulder joint is performed. The method of Janelidze, Kocher, Hippocrates, Mukhin-Cat is used. This treatment of shoulder dislocation provides for good anesthesia, in some cases, anesthesia. The most famous leverage method is the Kocher method. The method is quite traumatic, and can only be used in young people. One hand of the doctor is superimposed on the elbow bend of the injured arm, the second is held by the wrist joint. The limb is bent at the elbow at a right angle. And then smooth, very careful manipulations:

• limb traction and shoulder adduction;
• turning the shoulder outward by deflecting the forearm;
• moving the elbow joint forward and inward;
• turning the shoulder by the forearm inward with moving the hand to a healthy shoulder girdle.

After the dislocation of the shoulder is reduced, a Dezo bandage is applied for a period of 3-4 weeks. As soon as the head of the shoulder takes its place, the pain decreases sharply and may disappear in a few days. After the shoulder capsule has healed, the bandage is removed, physiotherapy and therapeutic exercises are prescribed to develop the joint. Treatment of dislocation of the shoulder joint in a conservative way and manual reduction is the most favorable of the outcomes that therapy provides.

Surgical treatment

If the joint cannot be adjusted without surgery, an open reduction is performed, followed by fixation with a pin or lavsan sutures. Traumatologists perform an open operation according to the canons of general surgery. The treatment of shoulder dislocation in this case is delayed for a long time, the patient is hospitalized, and accompanying drug therapy is prescribed. As already mentioned, it is impossible and does not make sense to refuse the operation. The joint is immobilized, and delay in order to discuss the outcomes and forecasts threatens with stretching of the ligamentous apparatus of the joint and the occurrence of already habitual dislocations, which will be difficult to get rid of.

Shoulder Dislocation Recovery Company Blog

Description. Methods and terms of rehabilitation.

Dislocation of the shoulder joint – pathological divergence of the articular articulating surfaces in relation to each other. Often, patients mistakenly assume that the injury is exclusively acquired, which, on the one hand, is extremely obvious. However, in addition to dislocations resulting from falls from a height, road accidents and other accidents, shoulder dislocation can also be congenital in infants. Injuries, despite the common localization of the lesion, differ in treatment principles, but always require rehabilitation.

Make an appointment with a traumatologist-orthopedist Ondar Temir Evgenyevich and get an effective rehabilitation program :

Learn more about shoulder dislocation recovery

When diagnosing a dislocation, it is always necessary for the patient to provide first aid in the form of creating conditions for fixing the injured limb, and also to send the patient to a medical institution. It is very important to correct the shoulder dislocation as soon as possible in order for the sprained shoulder ligaments to converge quickly and retain their former elasticity. In this case, the rehabilitation of a dislocated shoulder joint will require no more than a few days of maintenance courses. Much more insidious than injuries that were not provided with specialized assistance in a timely manner, for example, habitual dislocation of the shoulder or congenital malformations, as mentioned earlier. Their treatment requires specific approaches, it is often necessary to surgically perform ligament plastic surgery, further strengthen them, etc. Of course, the rehabilitation of congenital dislocations of the shoulder, even with successful treatment, consists in long-term physiotherapy, massages and physiotherapy exercises.

Terms of rehabilitation

A simple dislocation without complications – as a rule, a weekly course allows the patient to return to his previous labor activity, even if his work is associated with hard physical labor.

Rehabilitation of a dislocated shoulder joint is also not always a simple process from a clinical point of view, given that dislocations can be problematic. However, according to statistics, in case of timely admission to the hospital of the patient, i.e., prevention of muscle and ligament sprain, rehabilitation does not cause difficulties.

Rehabilitation of chronic dislocations of the elbow joint is carried out by long courses aimed at restoring, first of all, the former elasticity of the structures that fix the joints and can take up to 1.5 months.

Rehabilitation methods

Physiotherapy, dosed therapeutic sessions in the gym and in the pool, and massage have an adequate clinical effect.

Often, against the background of such severe injuries, inflammatory processes occur, where the body’s own microflora comes first. That is, in fact, arthritis and bursitis form at the site of the dislocation of the shoulder, which similarly aggravates rehabilitation, causing inconvenience to both the patient and the doctor.