eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Dislocation, Shoulder: Follow-up
Updated: Feb 27, 2008
Follow-up
Further Inpatient Care
- After procedural sedation with longer-acting sedating agents (eg, midazolam), the patient should be observed for the necessary period and then discharged in the care of family or friends.
- Patients who require operative reduction and repair should be admitted by the orthopedic surgery service.
Further Outpatient Care
- Arrange orthopedic follow-up in 5-7 days.
- The patient's shoulder should remain in the immobilizer until his or her orthopedic clinic appointment.
- Primary surgical repair of initial acute traumatic shoulder dislocations in young adults engaged in highly demanding physical activities (eg, sports, military) is supported by a Cochrane Database Systematic Reviews of 5 randomized, controlled studies.7 Subsequent shoulder instability was significantly less frequent in the surgical group (relative risk, 0.20; 95% CI, 0.11-0.33), with half of the conservatively treated patients opting for subsequent surgery. Functional assessment measures of the shoulder were also more favorable in those treated surgically. Since this demographic group is at far greater risk of recurrent dislocation, these results cannot be generalized to other groups.
Inpatient & Outpatient Medications
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be taken as needed for pain and inflammation.
- A few days of narcotic analgesia, with an agent such as hydrocodone or oxycodone, is often helpful.
Deterrence/Prevention
- The patient should remain in the immobilizer until under the care of an orthopedic surgeon.
- To prevent recurrent dislocation, patients should avoid immediate participation in contact or sporting activities. Simple activities that involve abduction and external rotation of the arm, such as combing their hair should also be avoided.
Complications
- Recurrent shoulder dislocation (See Prognosis).
- Fractures and soft-tissue injuries (See Other Problems to be Considered.)
- Hill-Sachs lesions occur when the edge of the glenoid causes an impaction fracture in the posterolateral aspect of the humeral head during anterior dislocation and in the anterolateral aspect in posterior dislocation (referred to as a "reverse Hill-Sachs" lesion).
- A Bankart lesion is fracture of the anterior rim of the glenoid labrum associated with joint capsule rupture and inferior glenohumeral ligament injury. Significantly displaced anterior or posterior glenoid rim fractures require operative management. Most initial shoulder dislocations produce a Bankart lesion, particularly in younger patients.
- Fracture of the greater tuberosity, acromion, coracoid, clavicle, and humeral neck also occur.
- Rotator cuff traction injury is most common in elderly patients and in association with inferior dislocations. This is a commonly missed injury, with an average time of 7 months from injury to diagnosis of rotator cuff rupture in patients older than 40 years.
- Nerve injury (See Other Problems to be Considered.)
- Approximately 3% (and higher in some series) of dislocations involve injury to the axillary nerve. Injury may resolve spontaneously or require surgical exploration and possible nerve grafting.
- Patients exhibit numbness in the area of the deltoid muscle and weakness with abduction and external rotation.
- Axillary nerve injury does not change initial treatment, but pre-reduction and post-reduction neurologic examinations are important.
- Radial nerve injury should also be determined. The axillary and radial nerves both arise from the posterior cord. The thumb, wrist, and elbow will be weak on extension, and the dorsal hand will be numb.
- Vascular injury (See Other Problems to be Considered.)
- Axillary artery injuries are rare but have been reported to occur with anterior, inferior, and intra-thoracic dislocations. Especially susceptible are older adults with atherosclerotic axillary arteries. Arterial injury may be associated with decreased radial pulse.
- Lateral chest wall ecchymosis with associated axillary hematoma and bruit may be noted on physical examination.
- Angiography should be considered with any brachial plexus injury.
Prognosis
- Age is a major factor in the likelihood of sustaining a recurrent shoulder dislocation.
- Approximately 80-94% of patients younger than 20 years at the time of the initial dislocation have a recurrence. The major pathology in this age group is thought to be a Bankart lesion with associated inferior glenohumeral ligament injury.
- Of patients younger than 40 years, 26-48% develop recurrent dislocation. The major pathology for this age group is thought to be disruption of the labral attachment of the glenohumeral ligaments.
- Dislocation recurs in only 0-10% of patients older than 40 years. Rotator cuff tear is the major pathology.
- Minor trauma that results in a dislocation is associated with an 86% recurrence rate. Many orthopedic surgeons believe that more than one complete anterior dislocation justifies considering surgical repair.
Patient Education
- For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Shoulder Dislocation.
Miscellaneous
Medicolegal Pitfalls
- Failure to diagnosis posterior dislocations: This type of dislocation can be missed, especially in elderly or cognitively impaired individuals. A careful physical examination, 3 views of the shoulder (ie, a Y-view or an axillary view in addition to the standard AP and lateral views) and proper interpretation of the radiographs are important. One study found an average interval of 1 year between injury and diagnosis of posterior dislocation in a series of 40 patients.8
- Failure to find and document associated fractures or neurovascular injuries
- Complications secondary to the reduction technique such as iatrogenic fracture, nerve injury, or vascular injury
- Complications secondary to use of benzodiazepines, opiates, PSA, or regional anesthesia techniques such as cardiovascular and respiratory depression, or the theoretical risk of joint infection
Special Concerns
- Pregnant patients
- Patients in the third trimester should be placed in the left lateral decubitus position to avoid compression of the inferior vena cava by the uterus.
- The abdomen should be shielded during radiography.
- Relocation techniques that require placement of the patient in a prone position may be problematic.
- Pediatric patients: The epiphyseal plate is prone to fracture, so use a gentle relocation technique.
- Geriatric patients: Because fractures can occur easily with vigorous manipulation, choose a gentle relocation technique that does not require excessive force or traction. The Kocher and external rotation methods, when appropriately performed without traction or leverage, have recently been demonstrated to be safe and relatively painless procedures. Towels or sheets used for traction or counter-traction can cause friction injury to the fragile skin of older adults. This age group is at higher risk for benzodiazepine, opiate, and PSA-related complications.
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Further Reading
Keywords
glenohumeral dislocation, Kocher technique, shoulder pain, anterior shoulder dislocation, posterior shoulder dislocation, inferior shoulder dislocation, luxatio erecta, volleyball spike, fall on an outstretched arm, electrocution, seizure activity, shoulder dislocations, dislocated shoulder
