Shoulder Dislocation in Emergency Medicine Clinical Presentation
- Author: Sharon R Wilson, MD; Chief Editor: Trevor John Mills, MD, MPH more...
Patients with shoulder dislocation generally complain of severe shoulder pain and an associated decreased range of motion of the affected extremity.
Mechanisms of injury are usually traumatic but may vary. Mechanisms may include sports, assaults, falls, seizures, throwing an object, reaching to catch an object, forceful pulling on the arm, reaching for an object, turning over in bed, or combing hair.
Patients may have a history of recurrent ED visits for the same complaint.
Specific mechanisms or historical facts may be suggestive of certain types of dislocations, such as lightning injuries, electrical injuries, and seizure with posterior dislocations; throwing a ball or a punch or forceful pulling of the arm with an anterior dislocation; and axial loading of an extremely abducted arm with inferior dislocation.
Anterior shoulder dislocation (95-98% of ED dislocations):
Arm is held in slight abduction and external rotation.
Shoulder is "squared off" (ie, boxlike) with loss of deltoid contour compared with contralateral side.
Humeral head is palpable anteriorly (subcoracoid region, beneath the clavicle).
Patient resists abduction and internal rotation and is unable to touch the opposite shoulder.
Compare bilateral radial pulses to help rule out vascular injury.
In all cases, evaluate the axillary nerve before and after reduction by testing both pinprick sensation in the "regimental badge" area of the deltoid and palpable contraction of the deltoid during attempted abduction. Evaluate sensory and motor function of the musculocutaneous and radial nerves.
Posterior shoulder dislocation (3% of ED shoulder dislocations):
Arm is held in adduction and internal rotation.
Anterior shoulder is "squared off" and flat with prominent coracoid process. Shoulders may look identical in bilateral dislocation, making it a commonly missed injury.
Posterior shoulder is full with humeral head palpable beneath the acromion process.
Patient resists external rotation and abduction.
Neurovascular deficits are infrequent.
Inferior (luxatio erecta) shoulder dislocation (0.5% of ED dislocations) :
Arm is fully abducted with elbow commonly flexed on or behind head.
Humeral head may be palpable on the lateral chest wall.
Anterior shoulder dislocations usually result from abduction, extension, and external rotation, such as when preparing for a volleyball spike. Falls on an outstretched hand are a common cause in older adults. The humeral head is forced out of the glenohumeral joint, rupturing or detaching the anterior capsule from its attachment to the head of the humerus or from its insertion to the edge of the glenoid fossa. This occurs with or without lateral detachment.
Posterior dislocations are caused by severe internal rotation and adduction. This type of dislocation usually occurs during a seizure, a fall on an outstretched arm, or electrocution. Occasionally, a severe direct blow may cause a posterior dislocation. Bilateral posterior dislocation is rare and almost always results from seizure activity. Misinterpretation of the radiograph appearance of a posterior dislocation may result in misdiagnosis as a soft tissue injury in up to 79% of cases.
Rare, but serious, inferior dislocations (luxatio erecta) may be due to axial force applied to an arm raised overhead, such as when a motorcycle collision victim tumbles to the ground. More commonly, the shoulder is dislocated inferiorly by indirect forces hyperabducting the arm. The neck of the humerus is levered against the acromion and the inferior capsule tears as the humeral head is forced out inferiorly. Luxatio erecta almost always has an associated fracture or soft-tissue injury. One series found 80% of patients to have fracture of the greater tuberosity or tear of the rotator cuff. Neurologic compromise was found in 60% of patients, with the axillary nerve the most commonly injured nerve. Inferior dislocations have the highest incidence (3.3%) of vascular compromise.
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