Shoulder Dislocation Surgery
- Author: Scott Welsh, MD; Chief Editor: S Ashfaq Hasan, MD more...
Shoulder dislocations account for almost 50% of all joint dislocations. Most commonly, these dislocations are anterior (90-98%) and occur because of trauma. Most anterior dislocations are subcoracoid in location. Subglenoid, subclavicular, and, very rarely, intrathoracic or retroperitoneal dislocations may occur.
Shoulder dislocations account for almost 50% of all joint dislocations.
The usual mechanism of injury is extreme abduction, external rotation, extension, and a posterior directed force against the humerus. Forceful abduction or external rotation alone can also lead to dislocation (about 30% of cases), as can a direct blow to the posterior humerus (29%), forced elevation and external rotation (24%), and a fall onto an outstretched hand (17%).[1, 2, 3]
Posterior dislocations are less common (2-10%) and are the result of an axial load applied to the adducted and internally rotated arm. Classic posterior dislocations also occur as a result of electrocution or seizures because of the strength imbalance between the internal rotators (subscapularis, latissimus dorsi, pectoralis major muscles), which overpower the external rotators (teres minor and infraspinatus muscles).
Inferior dislocations are rare and result from a hyperabduction force that causes the humeral neck to lever against the acromion. Diagnosing inferior dislocations is critical because of the high incidence of complications. Neurologic injuries (particularly axillary nerve lesions) are associated with inferior dislocations in as many as 60% of cases, vascular injuries occur in about 3.3% of cases, rotator cuff tears in occur in 80-100% of cases, and greater tuberosity fractures and pectoralis major avulsions are also associated with inferior dislocations.
Superior dislocations are extremely rare and result from an extreme force in a cephalic direction to the adducted arm. Acromioclavicular injuries and fractures of the acromion, clavicle, and tuberosities may occur with superior dislocations.
Atraumatic instability is usually multidirectional and commonly occurs in individuals with generalized hyperlaxity due to connective tissue disorders, such as Ehlers-Danlos syndrome and Marfan syndrome. A small or flat glenoid fossa, excessive anteversion or retroversion of the glenoid, weak rotator cuff muscles, neuromuscular disorders, or a redundant capsule may also jeopardize the concavity-compression, adhesion-cohesion, or the glenoid suction-cup phenomena that aid in stability of the shoulder.
Multidirectional instability most commonly occurs in younger populations, usually in patients younger than 30 years, and is often familial and bilateral. The first dislocation often occurs after a minor injury or after a period of disuse. Patients may experience subluxations that progress over time to actual dislocations, which spontaneously reduce. These dislocations may be voluntary or involuntary. Voluntary dislocations have been associated with psychiatric illnesses and may be used in attention seeking behavior. Surgery should be avoided in this population because the instability is likely to recur.
Patients with anterior dislocations usually present with the arm in slight abduction and externally rotated. The humeral head can often be palpated in the front of the shoulder. Internal rotation and adduction are limited. Movement is usually very painful as a result of muscle spasms.
Patients with posterior dislocations present with the arm internally rotated and adducted. External rotation is severely limited. A posterior prominence is usually palpable, the anterior shoulder is flattened, and the coracoid process is more prominent. Historically, these dislocations have been missed or misdiagnosed as a frozen shoulder.
Inferior dislocations lead to a condition known as luxatio erecta, which describes a classic presentation of the arm abducted 110-160° with the forearm resting on or behind the patient's head.[5, 6]
Surgery may be indicated if patients are unable or unwilling to change their occupation or avoid participating in high-risk sports and if they have recurrent dislocations or subluxations.
See Surgical therapy.
Surgery should be avoided in patients with voluntary shoulder dislocations associated with psychiatric illnesses because the instability is likely to recur.
Pettrone FA. Athletic Injuries of the Shoulder. New York:. McGraw-Hill. 1995.
Rockwood CA, Matsen FA, Wirth MA, et al. The Shoulder. 2nd ed. Philadelphia:. WB Saunders Co. 1998.
Rowe CR. The Shoulder. New York:. Churchill Livingstone. 1988.
Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009 Jun. 91(6):1405-13. [Medline]. [Full Text].
Fung DA, Menkowitz M, Chern K. Asymmetric bilateral shoulder dislocation involving a luxatio erecta dislocation. Am J Orthop. 2008 May. 37(5):E97-8. [Medline].
Groh GI, Wirth MA, Rockwood CA Jr. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg. 2009 Oct 15. [Medline].
Saupe N, White LM, Bleakney R, Schweitzer ME, Recht MP, Jost B, et al. Acute traumatic posterior shoulder dislocation: MR findings. Radiology. 2008 Jul. 248(1):185-93. [Medline].
Braunstein V, Kirchhoff C, Ockert B, Sprecher CM, Korner M, Mutschler W, et al. Use of the fulcrum axis improves the accuracy of true anteroposterior radiographs of the shoulder. J Bone Joint Surg Br. 2009 Aug. 91(8):1049-53. [Medline].
Sanders TG, Morrison WB, Miller MD. Imaging techniques for the evaluation of glenohumeral instability. Am J Sports Med. 2000 May-Jun. 28(3):414-34. [Medline].
Itoi E, Sashi R, Minagawa H, et al. Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging. J Bone Joint Surg Am. 2001 May. 83-A(5):661-7. [Medline].
Wen DY. Current concepts in the treatment of anterior shoulder dislocations. Am J Emerg Med. 1999 Jul. 17(4):401-7. [Medline].
Kirkley A, Griffin S, Richards C, et al. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder. Arthroscopy. 1999 Jul-Aug. 15(5):507-14. [Medline].
Yuen MC, Yap PG, Chan YT, Tung WK. An easy method to reduce anterior shoulder dislocation: the Spaso technique. Emerg Med J. 2001 Sep. 18(5):370-2. [Medline].
Fernández-Valencia JA, Cuñe J, Casulleres JM, Carreño A, Prat S. The Spaso technique: a prospective study of 34 dislocations. Am J Emerg Med. 2009 May. 27(4):466-9. [Medline].
Kosnik J, Shamsa F, Raphael E, et al. Anesthetic methods for reduction of acute shoulder dislocations: a prospective randomized study comparing intraarticular lidocaine with intravenous analgesia and sedation. Am J Emerg Med. 1999 Oct. 17(6):566-70. [Medline].
Moharari RS, Khademhosseini P, Espandar R, Soleymani HA, Talebian MT, Khashayar P, et al. Intra-articular lidocaine versus intravenous meperidine/diazepam in anterior shoulder dislocation: a randomised clinical trial. Emerg Med J. 2008 May. 25(5):262-4. [Medline].
Yuen CK, To DB. Is operative repair better than conservative treatment after primary anterior shoulder dislocation?. Arthroscopy. 2008 Aug. 24(8):971; author reply 971. [Medline].
Itoi E, Hatakeyama Y, Urayama M, et al. Position of immobilization after dislocation of the shoulder. A cadaveric study. J Bone Joint Surg Am. 1999 Mar. 81(3):385-90. [Medline].
Hovelius L, Olofsson A, Sandström B, Augustini BG, Krantz L, Fredin H, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up. J Bone Joint Surg Am. 2008 May. 90(5):945-52. [Medline].
Maeda A, Yoneda M, Horibe S, et al. Longer immobilization extends the "symptom-free" period following primary shoulder dislocation in young rugby players. J Orthop Sci. 2002. 7(1):43-7. [Medline].
Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients. A ten- year prospective study. J Bone Joint Surg Am. 1996 Nov. 78(11):1677-84. [Medline].
Finestone A, Milgrom C, Radeva-Petrova DR, Rath E, Barchilon V, Beyth S, et al. Bracing in external rotation for traumatic anterior dislocation of the shoulder. J Bone Joint Surg Br. 2009 Jul. 91(7):918-21. [Medline].
Kralinger FS, Golser K, Wischatta R, et al. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med. 2002 Jan-Feb. 30(1):116-20. [Medline].
Robinson CM, Seah M, Akhtar MA. The epidemiology, risk of recurrence, and functional outcome after an acute traumatic posterior dislocation of the shoulder. J Bone Joint Surg Am. 2011 Sep 7. 93(17):1605-13. [Medline].
Gerber C, Costouros JG, Sukthankar A, Fucentese SF. Static posterior humeral head subluxation and total shoulder arthroplasty. J Shoulder Elbow Surg. 2009 Jul-Aug. 18(4):505-10. [Medline].
DeBerardino TM, Arciero RA, Taylor DC, Uhorchak JM. Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Two- to five-year follow-up. Am J Sports Med. 2001 Sep-Oct. 29(5):586-92. [Medline].
Patel RV, Leith J. Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. J Bone Joint Surg Am. 2008 Aug. 90(8):1786; author reply 1786-7. [Medline].
Robinson CM, Jenkins PJ. Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder. J Bone Joint Surg Am. 2008 Aug. 90-A(8):1786-1787. [Medline].
Larrain MV, Botto GJ, Montenegro HJ, et al. Arthroscopic repair of acute traumatic anterior shoulder dislocation in young athletes. Arthroscopy. 2001 Apr. 17(4):373-7. [Medline].
Arciero RA, Taylor DC, Snyder RJ, Uhorchak JM. Arthroscopic bioabsorbable tack stabilization of initial anterior shoulder dislocations: a preliminary report. Arthroscopy. 1995 Aug. 11(4):410-7. [Medline].
Hintermann B, Gachter A. Arthroscopic findings after shoulder dislocation. Am J Sports Med. 1995 Sep-Oct. 23(5):545-51. [Medline].
Karlsson J, Magnusson L, Ejerhed L, et al. Comparison of open and arthroscopic stabilization for recurrent shoulder dislocation in patients with a Bankart lesion. Am J Sports Med. 2001 Sep-Oct. 29(5):538-42. [Medline].
Owens BD, Harrast JJ, Hurwitz SR, Thompson TL, Wolf JM. Surgical trends in bankart repair: an analysis of data from the american board of orthopaedic surgery certification examination. Am J Sports Med. 2011 Sep. 39(9):1865-9. [Medline].
Beeson MS. Complications of shoulder dislocation. Am J Emerg Med. 1999 May. 17(3):288-95. [Medline].
Guanche CA, Quick DC, Sodergren KM, et al. Arthroscopic versus open reconstruction of the shoulder in patients with isolated Bankart lesions. Am J Sports Med. 1996 Mar-Apr. 24(2):144-8. [Medline].
Sekiya JK, Wickwire AC, Stehle JH, Debski RE. Hill-Sachs Defects and Repair Using Osteoarticular Allograft Transplantation: Biomechanical Analysis Using a Joint Compression Model. Am J Sports Med. 2009 Sep 2. [Medline].
Nourissat G, Kilinc AS, Werther JR, Doursounian L. A prospective, comparative, radiological, and clinical study of the influence of the "remplissage" procedure on shoulder range of motion after stabilization by arthroscopic bankart repair. Am J Sports Med. 2011 Oct. 39(10):2147-52. [Medline].
Scheibel M, Kuke A, Nikulka C, Magosch P, Ziesler O, Schroeder RJ. How long should acute anterior dislocations of the shoulder be immobilized in external rotation?. Am J Sports Med. 2009 Jul. 37(7):1309-16. [Medline].
Owens BD, DeBerardino TM, Nelson BJ, Thurman J, Cameron KL, Taylor DC, et al. Long-term follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocations in young athletes. Am J Sports Med. 2009 Apr. 37(4):669-73. [Medline].
Maier M, Geiger EV, Ilius C, Frank J, Marzi I. Midterm results after operatively stabilised shoulder dislocations in elderly patients. Int Orthop. 2009 Jun. 33(3):719-23. [Medline].
Cordischi K, Li X, Busconi B. Intermediate outcomes after primary traumatic anterior shoulder dislocation in skeletally immature patients aged 10 to 13 years. Orthopedics. 2009 Sep. 32(9):[Medline].
Abdelhady A, Abouelsoud M, Eid M. Latarjet procedure in patients with multiple recurrent anterior shoulder dislocation and generalized ligamentous laxity. Eur J Orthop Surg Traumatol. 2014 Oct 24. [Medline].
Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V. Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy. 2014 Sep. 30(9):1184-211. [Medline].