Step-by-step evaluation and treatment of shoulder dislocation

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doi:doi: 0.12788/jfp.0279

Applied Evidence

Step-by-step evaluation and treatment of shoulder dislocation

J Fam Pract. 2021 October;70(8):367-375,402 | doi: 0.12788/jfp.0279

By

Nata Parnes, MD

Jeff Perrine, FNP-C

Kenneth J. Fish, DO, FAAFP

Tailor management decisions by taking into account the patient’s age, the direction of instability, functional demands, risk of recurrence, and associated injuries.

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PRACTICE RECOMMENDATIONS

› Refer first-time dislocation in patients younger than 20 years or who have a displaced fracture to an orthopedic surgeon. A

› Order magnetic resonance imaging (MRI) for all patients with a suspected rotator cuff tear. A

› Send patients with weakness of the rotator cuff—but no tear on MRI—for evaluation by electromyography and nerve-conduction studies. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Valencia Mora M, Ruiz Ibán MA, Heredia JD, et al. Physical exam and evaluation of the unstable shoulder. Open Orthop J. 2017;11(suppl 6, M12):946-956. doi: 10.2174/1874325001711010946

2. Khiami F, Gérometta A, Loriaut P. Management of recent first-time anterior shoulder dislocation. Orthop Traumatol Surg Res. 2015;101(1 suppl):S51-S57. doi: 10.1016/j.otsr.2014.06.027

3. Antonio GE, Griffith JF, Yu AB, et al. First-time shoulder dislocation: high prevalence of labral injury and age-related differences revealed by MR arthrography. J Magn Reson Imaging. 2007;26:983-991. doi: 10.1002/jmri.21092

4. Carrazzone OL, Tamaoki MJS, Ambra LFM, et al. Prevalence of lesions associated with traumatic recurrent shoulder dislocation. Rev Bras Ortop. 2015;46:281-287. doi: 10.1016/S2255-4971(15)30196-8

5. Mahaffey BL, Smith PA. Shoulder instability in young athletes. Am Fam Physician. 1999;59:2773-2787.

6. Amar E, Maman E, Khashan M, et al. Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success. J Shoulder Elbow Surg. 2012;21:1443-1449. doi: 10.1016/j.jse.2012.01.004

7. Jain NB, Wilcox RB 3rd, Katz JN, et al. Clinical examination of the rotator cuff. PM R. 2013;5:45-56. doi: 10.1016/j.pmrj.2012.08.019

8. Lizzio VA, Meta F, Fidai M, et al. Clinical evaluation and physical exam findings in patients with anterior shoulder instability. Curr Rev Musculoskelet Med. 2017;10:434-441. doi: 10.1007/s12178-017-9434-3

9. Farber AJ, Castillo R, Clough M, et al. Clinical assessment of three common tests for traumatic anterior shoulder instability. J Bone Joint Surg Am. 2006;88:1467-1474. doi: 10.2106/JBJS.E.00594

10. Robinson CM, Shur N, Sharpe T, et al. Injuries associated with traumatic anterior glenohumeral dislocations. J Bone Joint Surg Am. 2012;94:18-26. doi: 10.2106/JBJS.J.01795

11. de Laat EA, Visser CP, Coene LN, et al. Nerve lesions in primary shoulder dislocations and humeral neck fractures. A prospective clinical and EMG study. J Bone Joint Surg Br. 1994;76:381-383.

12. Avis D, Power D. Axillary nerve injury associated with glenohumeral dislocation: a review and algorithm for management. EFORT Open Rev. 2018;3:70-77. doi: 10.1302/2058-5241.3.170003

13. Drury JK, Scullion JE. Vascular complications of anterior dislocation of the shoulder. Br J Surg. 1980;67:579-581. doi: 10.1002/bjs.1800670817

14. Lafuente JLA, Marco SM, Pequerul JMG. Controversies in the management of the first time shoulder dislocation. Open Orthop J. 2017;11:1001-1010. doi: 10.2174/1874325001711011001

15. te Slaa RL, Brand R, Marti RK. A prospective arthroscopic study of acute first-time anterior shoulder dislocation in the young: a five-year follow-up study. J Shoulder Elbow Surg. 2003;12:529-534. doi: 10.1016/s1058-2746(03)00218-0

16. Kavaja L, Lähdeoja T, Malmivaara A, et al. Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis. Br J Sports Med. 2018;52:1498-1506. doi: 10.1136/bjsports-2017-098539

17. Krych AJ, Sousa PL, King AH, et al. The effect of cartilage injury after arthroscopic stabilization for shoulder instability. Orthopedics. 2015;38:e965-e969. doi: 10.3928/01477447-20151020-03

18. Polyzois I, Dattani R, Gupta R, et al. Traumatic first time shoulder dislocation: surgery vs non-operative treatment. Arch Bone Jt Surg. 2016;4:104-108.

19. Maman E, Harris C, White L, et al. Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging. J Bone Joint Surg Am. 2009;91:1898-1906. doi: 10.2106/JBJS.G.01335

20. Safran O, Schroeder J, Bloom R, et al. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med. 2011;39:710-714. doi: 10.1177/0363546510393944

21. Parnes N, Bartoszewski NR, Defranco MJ. Arthroscopic repair of full-thickness rotator cuff tears in active patients younger than 40 years: 2- to 5-year clinical outcomes. Orthopedics 2018;41:e52-e57. doi: 10.3928/01477447-20171114-02

22. Sofu H, Gürsu S, Koçkara N, et al. Recurrent anterior shoulder instability: review of the literature and current concepts. World J Clin Cases. 2014;2:676-682. doi: 10.12998/wjcc.v2.i11.676

23. Emond M, Le Sage N, Lavoie A, et al. Clinical factors predicting fractures associated with an anterior shoulder dislocation. Acad Emerg Med. 2004;11:853-858. doi: 10.1111/j.1553-2712.2004.tb00768.x

24. Parnes N, Jupiter JB. Fixed-angle locking plating of displaced proximal humerus fractures. Instr Course Lect. 2010;59:539-552.

The architecture of the glenohumeral joint makes it the most common large joint to become dislocated, accounting for approximately 45% of all dislocations. Anterior dislocation constitutes more than 95% of glenohumeral joint dislocations; posterior dislocation, only 2% to 5%.^1,2

For the family physician, determining appropriate follow-up after emergent reduction depends on several distinct variables, which we review here; subsequent treatment might involve, as we outline, physical therapy, immobilization, surgical intervention, or a combination of several modalities. Treatment decisions can make the difference between successful rehabilitation and potential disability, particularly in typically young and active patients.

Numerous mechanisms of injury

Anterior shoulder dislocations typically occur with the affected shoulder in a position of abduction and external rotation; 90% of patients are 21 to 30 years of age, and men are affected 3 times more often than women.² Unsurprisingly, athletes are affected most frequently, with the common sports-related mechanism of injury being either sudden pressure exerted on the abducted and externally rotated arm or a fall onto an outstretched hand with the arm elevated. Repetitive microtrauma from such sports as swimming, baseball, and volleyball can also lead to instability.

Bankart lesion. This tear of the anterior or inferior section of the labrum is the most characteristic lesion noted in anterior dislocations, found in 73% of first-time dislocations and 100% of recurrent dislocations.^3,4

Hills-Sachs lesion is often associated with a Bankart lesion. The Hills-Sachs lesion is an impaction fracture of the posterolateral aspect of the humeral head resulting from its displacement over the anterior lip of the glenoid. Hill-Sachs lesions are seen in 71% of first-time and recurrent dislocations.³

Less common concomitant injuries during anterior shoulder dislocation include rupture of the rotator-cuff tendons (particularly in patients older than 40 years), glenoid and proximal humerus fractures, a tear of the superior labrum (known as a “SLAP lesion”), cartilage injury, and neurovascular injury.

Posterior instability typically occurs as a result of a strong muscle contraction, as seen in electrocution or seizure; however, it can be caused by athletic trauma, particularly in football.⁵ Repetitive forces exerted on the forward-flexed and internally rotated shoulder position during blocking puts football players at increased risk of posterior instability.⁵

Continue to: Multidirectional instability