Background
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.
Recent studies
According to Scheibel et al, immobilization of the shoulder in 30º of external rotation seems to allow a similar coaptation of the glenoid labrum regardless of whether immobilization is for 3 weeks or 5 weeks. The authors divided 22 patients into 2 groups: 11 patients immobilized for 3 weeks and 11 patients immobilized for 5 weeks in 30º of external rotation. No statistically significant differences were found after acute, 3-week, and 5-week magnetic resonance imaging examinations.[1]
In a study by Owens et al, acute arthroscopic Bankart repair in young, active patients with first-time traumatic anterior glenohumeral dislocations resulted in excellent subjective function and return to athletics, with an acceptable rate of recurrence and reoperation. Of 39 patients followed (40 shoulders), 6 patients sustained recurrent dislocations, 9 patients had subluxation events, and 6 patients underwent revision stabilization surgery.[2]
Another study, also by Owens et al, reviewed data from the American Board of Orthopaedic Surgery (ABOS) and noted that the use of open repair has declined in recent years, with a trend toward arthroscopic Bankart repair. The study found the most commonly reported complications were nerve palsy/injury and dislocation; rate of nerve injury was 2.2% in the open group, compared with 0.3% in the arthroscopic group. The dislocation rate was 1.2% with open stabilization, compared with 0.4% arthroscopically.[3]
Maier et al compared the clinical benefit of operative stabilization in younger patients (49 patients < 40 y) and older patients (23 patients > 40 y) after anterior shoulder dislocation and found that there was significant reduction in recurrence in both groups. However, the clinical functional results measured by the Constant score, Rowe score, and disabilities of the arm, shoulder, and hand (DASH) score revealed significantly better outcomes in the younger group.[4]
In a study of Cordischi et al of skeletally immature patients (14 patients aged 10.9-13.1 y) who sustained a primary traumatic unidirectional anterior shoulder dislocation, those patients who were treated nonoperatively fared better than those treated by surgery (average Western Ontario Shoulder Instability index [WOSI] score of 9.1 vs 151.7, respectively). According to the authors, in the pediatric skeletally immature patient, nonoperative treatment results in low shoulder instability recurrence risk and sound functional outcome.[5]
For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Shoulder Dislocation.
Problem
See Complications for a discussion of associated injuries.
Epidemiology
Frequency
Shoulder dislocations account for almost 50% of all joint dislocations.
Etiology
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%).[6, 7, 8]
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,[9] 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.
Presentation
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.[10, 11]
Indications
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.
Relevant Anatomy
See Surgical therapy.
Contraindications
Surgery should be avoided in patients with voluntary shoulder dislocations associated with psychiatric illnesses because the instability is likely to recur.
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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. Apr 2009;37(4):669-73. [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. Sep 2011;39(9):1865-9. [Medline].
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