View Vol. 1 Iss. 1
Orthopedics Magazine Articles


Twin Cities Shoulder and Elbow Physicians:  

• John T. Anderson, M.D.
• Kurt D. Anderson, M.D.
• Jonathan P. Asp, M.D.
• Thomas N. Connor, M.D.
• Robin C. Crandall, M.D.
• Paul R. Diekmann, M.D.
• Douglas A. Drake, M.D.
• Joseph Flake, M.D.
• Mark E. Friedland, M.D.
• David Gesensway, M.D.
• Benjamin Gulli, M.D.
• Rolf S. Hauck, M.D.
• Peter D. Holmberg, M.D.
• Neil R. Johnson, M.D.
• Cyril (Jay) F. Kruse, M.D.
• Gregory N. Lervick, M.D.
• William R. Lundberg, M.D.
• Jeffrey J. Mair, D.O.
• Christopher P. Meyer, M.D.
• Steven A. Moen, M.D.
• Frank B. Norberg, M.D.
• Randall J. Norgard, M.D.
• Patrick F. O'Keefe, M.D.
• Stephen L. Olmsted, M.D.
• Gavin T. Pittman, M.D.
• Thomas J. Raih, M.D.
• Kayvon S. Riggi, M.D.
• Gary R. Sager, M.D.
• Edward W. Szalapski, M.D.
• Mark A. Urban, M.D.
• Loren N. Vorlicky, M.D.
• Gary E. Wyard, M.D.

Shoulder Dislocations

Dislocated shoulders typically involved in high-speed or collision-type activities such as hockey, rugby, football, wrestling, or snowboarding.

Shouldering The Pain: Reductions and Surgeries Help Patients Manage Shoulder Joint Dislocations

The shoulder, or glenohumeral joint, is the most commonly dislocated joint in the body, accounting for 45 percent of all dislocations.1 Shoulder dislocations occur most commonly in younger people. Typically they happen among those who are involved in high-speed or collision-type activities such as hockey, rugby, football, wrestling, or snowboarding.

The relative risk for glenohumeral instability is explained by the joint’s anatomy. The humeral head is round and articulates with the flat glenoid fossa of the scapula (shoulder blade). Therefore, maintaining normal joint stability requires the interplay of both static restraints (the glenohumeral capsule ligaments, or capsulolabral complex) and dynamic forces (the musculature surrounding the shoulder, including the rotator cuff).

Initial Treatment
Initial management of shoulder dislocations requires recognition of the injury. Medical professionals (certifi ed athletic trainers, emergency medical personnel, or physicians) who are familiar with the injury may be able to perform an initial reduction of the injury with gentle, nonforced maneuvers. When early attempts are unsuccessful, prompt referral to an emergency room is appropriate. In this setting, a reduction can be performed either with conscious sedation or the use of an intra-articular anesthetic agent, such as lidocaine.2 Radiographs should be obtained both before and after the reduction maneuver to confirm anatomic position of the joint, and to rule out associated bone injury, such as a fracture.

Problem Management
Once the joint is reduced, secondary management is initiated. First, the patient should be educated about the natural history and potential complications that might result from the injury. The secondary eff ects are generally age-dependent. In patients younger than 30 years, the primary concern is the development of recurrent joint instability. Recurrent instability may manifest itself as a spectrum of disability, from frank dislocation requiring repeated reduction, to painful “apprehension” or a sense of instability that interferes with daily or athletic activities.3

In patients older than 35, the concern is for associated injuries that occur at the time of dislocation, such as bone fracture, nerve injury, or rotator cuff tears.4 Evaluating for associated injuries and initiating prompt treatment often require secondary imaging studies, including magnetic resonance imaging (MRI) or occasionally computed tomography (CT) scanning. A variety of treatment options might exist. Orthopedic consultation after an initial glenohumeral dislocation is appropriate to help determine the optimal treatment plan, thereby improving recovery and functional outcome.

Surgery or not?
Historically, surgical treatment has been reserved for patients who have developed recurring shoulder dislocation. Advancements with arthroscopic shoulder surgery in the past fi ve to 10 years have led to increased interest in early surgical treatment to correct
the anatomic lesion (tear of the labrum, or Bankart-Perthes lesion) that occurs with shoulder dislocations. For cadets at the United States Military Academy, such treatment has provided improved shoulder stability when compared to rehabilitation alone.5

When managing young inseason athletes, treatment with brief immobilization and early rehabilitation remains a good option. Surgery can be delayed until the off season for those athletes with persistent instability despite appropriate rehabilitation, or those who desire to minimize risk of recurrent instability over time.

References
1. Matsen FA III, Titelman RM, Lippitt SB, Rockwood CA Jr., Wirth MA. In: Rockwood CA Jr., Matsen FA III, Wirth MA, Lippitt SB, eds., The Shoulder, 3rd ed., 2004.
2. Miller SL, Cleeman E, Auerbach J, Flatow EL. Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations: a randomized, prospective study. J Bone Joint Surg Am. 2002;84A:2135-9.
3. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78(11):1677-84.
4. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orth Rel Res. 1993;291:103-6.
5. Bottoni CR, Wilckens JH, DeBerardino TM, D’Alleyrand JC, Rooeny RC, Harpstrite JK, Arciero RA. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, fi rst-time shoulder dislocations. Am J Sports Med. 2002;30(4):576-80.