Shoulder Dislocation Surgery Treatment & Management
- Author: Scott Welsh, MD; Chief Editor: S Ashfaq Hasan, MD more...
Many methods can be used to successfully reduce a shoulder dislocation, but the most important factor for a successful reduction is time to reduction. As time passes, the muscles become more spastic, and the reduction becomes significantly more difficult. Methods of reduction include the following:
The Hippocratic method involves longitudinal traction on the arm and a counterforce to the axilla, usually with the heel of the foot.
The Kocher method involves traction to the elbow with external rotation of the humerus and adducting the elbow toward the chest. This method is not currently recommended because of its association with neurovascular complications and proximal humerus fractures.
The external rotation method, which is a modification of the Kocher maneuver, involves flexing the elbow to 90° and slowly adducting the arm to the patient's side. The arm is then carefully externally rotated stopping every few degrees to wait for the muscle spasms to subside.
The Stimson technique requires the patient to be positioned prone. The patient's arm is allowed to hang over the edge of the bed with about 10 pounds of weight hanging from the wrist.
The Milch technique is very successful and relatively atraumatic. It involves the surgeon abducting the patient's arm with one hand while applying pressure to the humeral head with the other hand. When the patient's arm is fully abducted, external rotation and traction are applied. The success rate of this technique is 72-89%. Only about one third of patients require sedation or analgesia. Lacey and associates modified this technique by performing the Milch maneuver with the patient in the prone position.
Scapular manipulation is also relatively atraumatic and incorporates internal rotation of the scapula to disengage the humeral head. The patient is placed prone and 5-15 pounds of traction are applied to the forearm. The inferior angle of the scapula is then rotated medially, and the superior aspect is rotated laterally. The success rate is 92-96%.
The Spaso technique involves the use of vertical traction while the surgeon grasps the wrist or forearm with the patient supine. [13, 14] Traction is maintained as the shoulder is externally rotated. The opposite hand may be used to push posteriorly on the head. Continual traction for several minutes will often overcome the spastic rotator cuff muscles, which are more relaxed with the arm in a forward-flexed position (roughly 90°). The success rate is 87.5%.
Traction/countertraction is the method preferred by many authors. This method involves the application of longitudinal traction in the direction of the deformity and countertraction by using a sheet wrapped around the patient's chest. The shoulder is gently rotated internally and externally to disengage the head from the glenoid.
Sedation and analgesia
Many options are available to achieve the patient's maximum comfort and to increase the ease of the reduction. If a dislocation is identified early, reduction may be achieved without the use of narcotics, sedatives, or muscle relaxants, particularly when the scapular manipulation technique is used.
More commonly, however, some type of analgesic is combined with a sedative or muscle relaxant. Morphine or fentanyl is generally administered on the patient's arrival in the emergency department. A sedative such as Versed or etomidate is subsequently used to achieve reduction. Recently, etomidate has become a popular choice because of its rapid onset (< 30 s) and short duration of effects (< 5 min). It also provides excellent muscle relaxation and is more predictable than Versed. Typically, a narcotic analgesic is administered prior to administering etomidate, as etomidate does not contain any analgesic properties.
Another alternative is the intra-articular administration of lidocaine. Usually, about 20 mL of 1% lidocaine without epinephrine is injected with a 1.5-inch 20-gauge needle about 2 cm lateral and inferior (or posterolateral) to the acromion. The needle is directed toward the glenoid in a slightly caudal direction. This method has been compared to intravenous sedation and found to be as effective for pain control and ease of reduction. Intraarticular lidocaine has been shown to be as successful or slightly less effective in achieving reduction, primarily in cases of delayed (ie, >5.5 h) presentation.
Conservative treatment of shoulder dislocations remains a controversial topic in orthopedics. Traditionally, patients have been placed in a sling with or without an immobilizer strap for a period of 1-6 weeks. Internal rotation and adduction is the classic position of immobilization, and external rotation and abduction are avoided.
Two studies, however, shed new light on this topic. An MRI study showed the best coaptation of the anteroinferior glenoid labrum to the glenoid rim, with the arm in about 35° of external rotation and held at the patient's side. Another study in cadavers revealed that a range from full internal rotation to about 30° of external rotation exists in which the labrum is coapted to the glenoid when the arm is in slight adduction. Flexion or abduction tends to displace the labrum. Despite these findings, the position of mobilization remains in slight internal rotation to prevent recurrent dislocations.
The duration of immobilization is also a source of debate. Most authors recommend 3-4 weeks of immobilization in patients younger than 30 years and 7-10 days of immobilization in patients older than 30-40 years. However, one study revealed a significant reduction in the recurrence rate from 78% to 44% at 1 year and from 85% to 69% at 2 years if the arm was immobilized for 4-7 weeks instead of 0-3 weeks. The recurrence-free period was also extended from 4 to 14 months with longer treatment. On the contrary, Hovelius et al performed a prospective, randomized trial with 10-year follow-up and found that the duration of immobilization had no effect on the long-term recurrence rate.
A prospective study by Finestone et al in patients who had experienced primary traumatic anterior shoulder dislocation found no difference in outcome with shoulder immobilization in external versus internal rotation. Of the 51 study patients, 24 received a traditional brace with the shoulder in internal rotation and 27 were immobilized with the shoulder in external rotation of 15-20º. After a mean of 33.4 months, 37% of patients in the external-rotation group and 41.7% of those in the internal-rotation group had sustained a further dislocation, a statistically insignificant difference. Finestone et al concluded that external-rotation bracing may not be as effective as previously reported in prevention of recurrent anterior shoulder dislocation.
Rehabilitation usually begins after 3 weeks of immobilization, starting with active assisted range of motion (ROM) with external rotation limited to 20°, pendulum exercises, and scapular retractions beginning 4-6 weeks after injury. Beginning 7-8 weeks after injury, active ROM are prescribed, with external rotation limited to 45°, isometric cuff strengthening, and scapular exercises and retraining. Active ROM with terminal stretch, isotonics, and scapular strengthening are performed 9-12 weeks after injury. Patients may return to noncontact sports with no overhead requirements after 3 months. Athletes may return to contact and overhead sports after 4 months. The success of this regimen largely depends on the patient's age at the time of the initial dislocation.
Greater tuberosity fractures associated with dislocation and advanced age are good prognostic indicators for successful nonoperative treatment. Activity modification, such as avoiding overhead work, heavy manual labor, and high-risk sports can minimize the risk of future dislocations.
Recurrence rates for nonoperative treatment
Nonathletes have a 30% recurrence risk with nonoperative treatment, and athletes have an 82% recurrence risk with nonoperative treatment.
If the dislocation was the patient's first, recurrence rates with nonoperative treatment depend on age, as follows:
Patients aged 1-10 years have a 100% recurrence rate.
Patients aged 11-20 years have a 27-95% recurrence rate.
Patients aged 21-30 years have a 40-79% recurrence rate.
Patients aged 31-40 years have a 40-72% recurrence rate.
Patients aged 41-50 years have a 0-24% recurrence rate.
Using the Western Ontario Shoulder Instability Index (WOSI) and the limb-specific Disabilities of the Arm, Shoulder and Hand score (DASH), a retrospective review study assessed the functional outcome of patients during the 2 years after a posterior glenohumeral dislocation. The study noted that while the prevalence of posterior dislocation is low, the most common complication is recurrent instability. Factors putting these patients at highest risk for recurrent instability were age younger than 40 years, dislocation during a seizure, and a large humeral head defect. Most patients who sustain the injury from a traumatic accident, those who are older, and those with a small anterior humeral head defect realize a lower risk of recurrent instability.
Surgery may be indicated if patients are unable or unwilling to change their occupation or avoid participating high-risk sports and they have recurrent dislocations or subluxations.
The question of timing of surgery remains unclear. Several studies have advocated arthroscopic or open stabilization procedures after the initial dislocation in lieu of the traditional method of surgical intervention after a trial of nonoperative treatment in patients with a history of multiple dislocations or subluxations. In military recruits and in young athletes aged 17-27 years, studies have shown far superior results with surgery after the initial dislocation in these patients, as opposed to the results after a trial of nonoperative treatment.[26, 27, 28]
In a prospective trial, the repeat dislocation rate was 4% after arthroscopic stabilization of acute dislocations and 94.5% after nonoperative treatment. In another study, patients were randomly assigned to immobilization and early surgical intervention. In these patients, the repeat dislocation rate was 15.9% at 2 years, and the recurrence rate was 47% in patients treated nonoperatively. Studies by Arciero et al, Hintermann et al, and Patel and Leith should also be reviewed.
Historically, open stabilization procedures have had a rate of repeat dislocation rate slightly lower than that of arthroscopic procedures, but the discrepancy is significantly less today, as technical skills and anchoring devices have improved. In a study in Sweden, the arthroscopic failure rate was 15%, compared with an open stabilization rate of 10%. External rotation was better maintained in the arthroscopic group, in whom it was 90°, compared with the group that underwent open procedures, in whom it was 80°.
Another study of arthroscopic and open reconstruction revealed failure rates of 33% and 8%, respectively. However, many authors believe that their arthroscopic results are the same, if not better, than their results with open procedures for both athletes in contact sports and athletes in noncontact sports. The trend is toward minimally invasive surgery, and the results of arthroscopic instability repairs will continue to improve. A key element in a successful instability procedure is addressing any capsular laxity, whether by means of an open capsular shift, an arthroscopic capsular plication, thermal capsulorrhaphy, or rotator interval closure.
A study 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.
The sequence for one technique is illustrated in the drawings below.
Shoulder dislocations result in various associated arthroscopic findings and various vascular and neurologic complications. One must be astute when examining patients for neurovascular compromise, both prior to and after reduction attempts. Most patients with a first-time dislocation also have a Bankart lesion (ie, an avulsion of the anterior capsulolabral complex from the glenoid rim with disruption of the medial scapular periosteum).
Variations of this injury include a bony Bankart lesion, in which the labrum remains intact but a fracture occurs through the anterior glenoid rim. A Perthes lesion is similar to a Bankart lesion, except the medial scapular periosteum remains intact; thus, the labrum may appear normal on MRI and arthroscopy unless the arm is abducted and externally rotated away from the neutral position.
An anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion differs from the Bankart lesion in that the anterior labrum is medially displaced. It heals in an abnormal position, leading to an incompetent anterior inferior glenohumeral ligament. Hill-Sachs lesions commonly occur and are compression fractures that result from impaction of the posterolateral humeral head against the anterior/inferior glenoid rim, which can occasionally result in a loose body. One study examined whether failures of arthroscopic Bankart repairs related to Hill-Sachs lesions can be treated by “remplissage” (filling in) of the defect with rotator cuff tendon. The data noted no significant statistical difference in the range of motion between patients treated with arthroscopic Bankart repair alone versus Bankart and remplissage. An identical rate of recurrence was found in both groups, and one third of patients experienced posterosuperior pain.
Rotator cuff tears are rare in young individuals but common in older patients. Approximately 30% of patients older than 40 years have a cuff tear, as do about 80% of patients older than 60 years. Greater tuberosity fractures also occur with dislocations in older patients, and these have been associated with a lower incidence of recurrent dislocations. Older patients are less likely to have a Bankart lesion and more likely to have a cuff tear, a greater tuberosity fracture, or an avulsion of the capsule and subscapularis from the lesser tuberosity. Younger patients more commonly have labral tears. Coracoid fractures may also occur as a result of an anterior dislocation or a difficult reduction attempt.
Vascular injuries are rare, but they may occur with anterior or inferior dislocations, especially in older patients with atherosclerosis of the axillary artery. The humeral head displaces the artery anteriorly over the head, and the pectoralis muscle acts as a fulcrum against the artery, leading to rupture. Arteriography should be performed if a vascular injury is possible. Because of the proximity of the 2 structures, arteriography should be strongly considered any time a brachial plexus injury is observed. Most commonly, patients present with delayed vascular compromise secondary to an intimal injury and resultant occlusion. Acute obstruction or rupture occurs in about 3.3% of cases of luxatio erecta. Pseudoaneurysm may also occur, especially after recurrent dislocations. Subclavian vein thrombosis may result from a venous injury and present with unilateral swelling and pain.
Neurologic injuries are more common than vascular injuries, particularly axillary neurapraxias, which are found in about 8-10% of patients with anterior dislocations. Patients have weakness in abduction and external rotation, as well as numbness over the lateral aspect of the upper arm. Among possible neurologic complications, these lesions have the poorest prognosis. Radial nerve injuries must also be considered in cases of axillary nerve damage because both arise from the posterior cord. These injuries may result in weak thumb, wrist, and elbow extension, as well as numbness on the dorsal aspect of the hand.
Long thoracic nerve palsies may also result from traction on the nerve, leading to scapular winging due to paralysis of the serratus anterior. Suprascapular nerve palsies cause weakness in abduction and external rotation. Dorsal scapular nerve injuries cause weakness in abduction. Musculocutaneous injuries lead to weak elbow flexion and supination, as well as lateral forearm numbness.
Arthroscopic findings after shoulder dislocation include the following:
Bankart lesions in 80-89% of patients
Anterior capsular insufficiency in 74% of patients
Hill-Sachs lesions in 67% of patients
Inferior glenoid labral tears in 51% of patients
Glenohumeral ligament insufficiency in 50% of patients
Partial or complete rotator cuff tears in 13% of patients
Dysplastic glenoid in 13% of patients
Biceps tendon lesions in 12% of patients
Brachial plexus injuries in 11% of patients
Posterior glenoid labral tear in 11% of patients
Axillary nerve injuries in 8-10% of patients
SLAP lesions in 8% of patients
Partial subscapularis tear in 8% of patients
Loose bodies in 5% of patients
Outcome and Prognosis
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.
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.
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.
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.
Abdelhady et al conducted a prospective study to assess the efficacy of the Latarjet procedure in patients with recurrent anterior shoulder dislocation and generalized hyperlaxity. Mean Rowe score was 47.5 points preoperatively and increased to 91.07 postoperatively; the increase was statistically highly significant. Mean range of postoperative external rotation was 69.29°. The investigators concluded that in these patients, the Latarjet procedure has a higher success rate than capsulolabral repair procedures.
Longo et al conducted a systematic review of the literature to evaluate clinical outcome, rate of recurrence, complications, and rate of postoperative osteoarthritis in patients with anterior shoulder instability managed with Latarjet, Bristow, or Eden-Hybinette procedures. The review included 46 studies, in which 3211 shoulders were evaluated. The mean value of the Coleman Methodology Score (CMS) was 65 points. Preoperatively, the most commonly detected injuries were glenoid bone loss and Bankart lesions.
The investigators concluded that the open Bristow-Latarjet procedure was a valid surgical option for treating anterior shoulder instability. Clinical outcomes associated with the Eden-Hybinette procedure were very similar to those of the Bristow-Latarjet technique, but the former was associated with a higher rate of postoperative osteoarthritis and recurrence. An arthroscopic Bristow-Latarjet procedure appeared to be better in terms of prevention of recurrence and rehabilitation, but further studies are needed to confirm this difference.
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