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Shoulder Dislocation in Emergency Medicine

  • Author: Sharon R Wilson, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Sep 15, 2015
 

Background

Shoulder dislocation is documented in Egyptian tomb murals as early as 3000 BC, with depiction of a manipulation for glenohumeral dislocation resembling the Kocher technique. Hippocrates detailed the oldest known reduction method still in use today and advocated treating chronic shoulder instability with cauterization of the deep tissues of the anterior shoulder.

Historical techniques to reduce dislocated glenohumeral joints have been shown to be safe when applied correctly. Kocher's method as originally described in 1870 did not involve traction and fell into disfavor when complications occurred with the application of large forces. Most dislocations are anterior, but less frequently, posterior, inferior (luxatio erecta), superior, and intrathoracic dislocations are also possible.

Recent data indicate that arthroscopic stabilization is performed in nearly 90% of shoulder stabilization surgeries in the United States. The percentage of arthroscopic stabilizations increased from 71% of stabilization procedures in 2004 to 89% in 2009, whereas the percentage of open stabilizations decreased from 29% in 2004 to 11% in 2009 (P < .0001).[1]

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Pathophysiology

The shoulder is the most frequently dislocated joint. It moves almost without restriction but pays the price of stability. The shoulder's integrity is maintained by the glenohumeral joint capsule, the cartilaginous glenoid labrum (which extends the shallow glenoid fossa), and muscles of the rotator cuff.

Anterior dislocations occur in as many as 98% of cases. Anterior displacement of the humeral head is the most common dislocation seen by emergency physicians and is depicted in the image below.

Y-view radiograph of the right shoulder shows ante Y-view radiograph of the right shoulder shows anterior dislocation of the humeral head relative to the glenoid fossa.

Posterior displacement is the next most frequently occurring dislocation. Inferior (luxatio erecta), superior, and intrathoracic dislocations are rare and are usually associated with complications.

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Epidemiology

Frequency

United States

Shoulder dislocations affect approximately 1.7% of the population and are most frequently secondary to trauma. The incidence of all traumatic shoulder dislocations has been estimated at 11.2 cases per 100,000 person-years, with a cumulative incidence rate of 0.7% for men and 0.3% for women up to age 70 years.

International

A Danish study estimated the incidence of shoulder dislocation at 17 cases per 100,000.[2] In a random sample of people in Sweden, 1.7% reported a history of shoulder dislocation.[3]

A more recent Greek study examined the demographic data and recurrence rates of shoulder dislocations of 308 patients (170 men and 138 women).[4] Subjects were observed for approximately 6 years. The most frequent mechanism of injury was falling, and 92% of reductions were in the ED. The overall recurrence rate in all ages was 50%, but rose to almost 89% in the 14-20 year age group.

Sex

Gender distribution is bimodal, with peak incidence in men aged 20-30 years (with a male-to-female ratio of 9:1) and in women aged 61-80 years (with a female-to-male ratio of 3:1).

Age

Shoulder dislocation occurs more frequently in adolescents than in younger children because the weaker epiphyseal growth plates in children tend to fracture before dislocation occurs.

In older adults, collagen fibers have fewer cross-links, making the joint capsule and supporting tendons and ligaments weaker and dislocation more likely.

Anterior dislocation is most commonly seen in those aged 18-25 years due to sporting injury. The second most common age group to sustain anterior dislocation is in elderly persons due to their susceptibility to falls.

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Contributor Information and Disclosures
Author

Sharon R Wilson, MD Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of California at Davis Medical Center

Sharon R Wilson, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, American Association of University Women

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel D Price, MD Director of International Ultrasound, Department of Emergency Medicine, Alameda County Medical Center, Highland Hospital and Trauma Center

Daniel D Price, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

James E Keany, MD, FACEP Associate Medical Director, Emergency Services, Mission Hospital Regional Medical Center, Children's Hospital of Orange County at Mission

James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, California Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Tom Scaletta, MD President, Smart-ER (http://smart-er.net); Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

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Y-view radiograph of the right shoulder shows anterior dislocation of the humeral head relative to the glenoid fossa.
 
 
 
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