Knee and Shoulder Surgeon
Professor of Mashhad University of Medical Sciences
حرم مطهر امام رضا حرم مطهر امام رضا

Acute Shoulder Dislocations

Acute Shoulder Dislocations

First Time Dislocators
Evidence based outcome from a first time dislocation of the shoulder:

Prevalence

  • Population study
  • Random sample of 2092 people
  • 18-70 years
  •  35 reported a dislocation (1.7%)
  • M:F 3:1
  • M:F 9:1 21-30 yrs age group
  • Prevalence Simonet 1984 Clinical Orthopaedics
  • Cumulative incidence up to 70 years
  • Male 0.7%
  • Female 0.3%

Recurrence

The reported rate of redislocation is 17% to 96% with a mean of 67%
Increased rate of recurrence in younger age groups

Primary anterior dislocation of the shoulder in young patients. A 10 year prospective study – Hovelius 1996 JBJS(A)

  • Multi centre study
  • 10 year follow up
  • 245 patients
  • Age 12-40 years
  • 57% sporting injury
  • Non-operative management
  • 52% no additional dislocation
  • 8 shoulders considered unstable but no dislocation
  • 23% operative treatment
  • In 12 to 22 year age group operation in 34%
  • Hill -Sachs lesion associated with a worse prognosis
  • Greater tuberosity fracture associated with a better prognosis
  • Immobilisation method not relevant

The prognosis following acute primary glenohumeral dislocation – Slaa et al JBJS(B) 2004

  • 105 patients
  • Mean follow up 5 years
  • Recurrence of 26% within 4 years overall
  • Age most significant prognostic factor
  • Under 20 years recurrence in 64%
  • Over 40 years recurrence in 6%

Surgical versus non-surgical treatment for acute shoulder dislocations
A prospective, randomised evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations – Bottoni et al AM J Sports Med 2002

  • 24 patients randomised
  • Non-operative treatment with sling for 4 weeks
  • Operative arthroscopic  repair within 10 days using Suretac
  • Failure due to redislocation or instability symptoms preventing return to full duty
  • Average follow up 36 months
  • 3 patients lost to follow up
  • Non-operative failed in 9/12 (75%)
  • Operative failed in 1/9 (11%)

Prospective randomised clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder – Kirkley et al 1999 Arthroscopy

  • Prospective randomised single blind study
  • 40 patients under 30 years of age
  • Traumatic first time dislocation
  • Non-operative treatment with shoulder immobilization for 3 weeks
  • Operative treatment within 4 weeks using arthroscopic transglenoid sutures
  • Mean age 24 years
  • All patients except 1 had Bankart lesion
  • Minimum follow up 24 months
  • Non-operative 9/19 (47%) redislocation
  • Operative 3/19 (16%) redislocation
  • WOSI 16% better in operative group
  • 1 post operative infection treated with antibiotics

Arthroscopic lavage compared with nonoperative treatment for traumatic anterior shoulder dislocation: A two year follow- up of a prospective randomised study. Wintzell JSES 1999

  • 30 consecutive patients
  • Traumatic primary dislocation
  • Randomised
  • Mean age 24 years
  • Non-operative with immobilization up to 1 week
  • Operative with arthroscopic lavage within 10 days
  • 2 year follow up
  • Redislocation in 3/15 (20%) of lavage group
  • Redislocation in 9/15 (60%) of non-operative group

Primary repair after traumatic anterior dislocation of the shoulder joint Jackobsen 1997 Orthop transactions

  • Randomised
  • 76 patients
  • Median age 22 years
  • Operative open repair within 1 week
  • Non-operative treatment with sling for 1 week2 year follow up

Primary repair after traumatic anterior dislocation of the shoulder joint Jackobsen 1997 Orthop transactions

  • Redislocation in 1/37 patients treated operatively
  • Redislocation in 20/39 treated operatively

Cochrane review Surgical versus non-surgical treatment for acute anterior shoulder dislocation Handoll et al 2004

  • 5 studies included
  • 239 patients
  • Typically male aged 22 years
  • Primary traumatic anterior shoulder dislocation
  • Primary outcomes
    • Pooled results show subsequent instability, either dislocation or subluxation, was highly statistically significantly less in the surgical group RR 0.2
  • Secondary outcomes
    • Objective instability ( positive ant app test) was significantly less common in the surgical group
  • Only complication was 1 septic joint
  • No data pertaining to stiffness or muscle strength
  • Evidence appears reliable but with reservations
  • Long term prognosis relating to arthritis remains uncertain

Conclusions

“The limited evidence available from randomised controlled trials supports primary surgery in young adults (usually male( engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation.
There is no evidence available to determine  whether surgical or non-surgical treatment is better for other categories of patient or injury.
In particular there is no evidence available to determine whether non-surgical treatment  should not remain the prime treatment option after primary dislocation in those patients who are at a much lower risk of redislocation.”

 External Rotation Brace Evidence

For several thousand years, even before Hippocrates used his hot poker, dislocated shoulders have been treated in a sling with the arm internally rotated. In spite of, and perhaps because of, using the same treatment for so long, there is little information that it does any good.

The labrum acts as a Chuck Block, increasing the concavity of the glenoid and preventing translation of the Humeral Head. Thus it stops the head sliding or rolling off the glenoid.

Itoi felt that following an anterior dislocation of the shoulder the labrum would lie medially in internal rotation and reduce on external rotation. This theory was based on previous studies already in the literature.

 Rehabilitation of the Shoulder Following Shoulder Dislocation

Physiotherapy

  • Explanation of injury and the splint – Need to look at compliance with wearing the sling and advice.
  • Surrounding joints eg wrist, elbow, fingers and hand. Not forgetting the cervical spine.
  • Scapula setting as preparation for active rehab and ensuring that the arm is actually resting on the splint.
  • Even with the sling in situ the arm will be subject to the effects of gravity pulling the shoulder girdle into a position of protraction add this to the bodies natural reaction to injury which is to curl up and protect promotion of scapula position and posture will help to maintain postural muscles such as lower traps etc

Proprioception

Shoulder depends on the intact feedback system due to the inherent unstable nature of the joint. Proprioception transmitted to the brain via the mechanoreceptors within the capsuloligamentous structures. The rotator cuff shares an intimate link with the capsule and therefore disruption in proprioception will have a knock on affect in the recruitment of the cuff muscles therefore further reducing the stability of the joint.
Proprioception disrupted  with  injury to the shoulder.
Tension created within the muscles will have a direct effect on the proprioceptive information. Muscles that are kept in one position for a period of time the sensitivity to joint position reduces.
Weight bearing through joint will result in the co –contraction of the muscles thereby having a facilitatory effect on the neuro-receptors.
Aim too bring an approximation of the surfaces together to increase the joint awareness.

Examples of Exercises
1. Isometric contractions
2. Weight bearing through the limb. For example: pushing hand/ fist against wall
3. Scapula setting
4. Balance exercises.

Looking to produce approximation of joint facilitation of proprioception.

Preparation for final rehab.

Depends on patients treating level of expectations  etc. Can incorporate gym ball balance work, standing on  one leg and encourage facilitation of entire neural system.
The neural system is linked throughout the body and due to the nature of its transmission of its messages influence one part of the system and you will cause a resultant effect somewhere else in the system.

Mobilisation of the shoulder after splint removal

Aims of Rehab
1. Regain ROM – ROM at GH joint with good humeral scapula rhythm
2. Start progressive strengthening
3. Facilitate specific muscle groups
4. Practice activity related movements.
Move between lying/ sitting and standing. Looking for control and pain free success
Incorporating proprioceptive rehab
For example sitting on a ball, standing on one leg, four point kneeling.
Infraspinatus during flexion/ abduction. Serratus anterior in four point kneeling.
Altering the speed / repetition / resistance according to point in rehab.

Range Of Motion Exercises

Active assisted / active
Specific mobilisation techniques
Normal movement patterns
Related patterns to job / sport
Progressive Resisted exercises
Starting position
Speed and control of exercises
Increase resistance

Facilitation of Specific Muscles groups
– Infraspinatus
– Lower traps, middle traps
– Trans abds

Activity related Activities

Manual workers
Sports person
Sedentary workers

Physiotherapy should allow full return to work and try not to encourage an avoidance culture.

Bonutti, J Comput Assist Tomogr. 1993

  • the tense subscapularis kept the capsule in contact with the underlying bone structures in external rotation, whereas in internal rotation the subscapularis became redundant and the labrum and the capsule folded into the joint
  • Full Abstract Here

Perugia et al, JSES, 1996

  • 112 shoulders
  • First time anterior dislocations
  • Two groups
    • Grp 1 – Desault bandage for three weeks
    • Grp 2 – shoulder spica 600 abduction.
  • At 4.2 years, the recurrence rate was:
    • Grp 1 – 74%
    • Grp 2 – 21%

Itoi et al. JBJS(Am) 1999 – Cadaveric study.

  • Ten thawed fresh-frozen cadaveric shoulders with all of the muscles removed.
  • A simulated Bankart lesion was created.
  • Linear transducers attached to the anteroinferior and inferior portions of the Bankart lesion
  • The opening and closing of the lesion were recorded with the arm in:
    0, 30, 45, and 60 degrees of elevation in the coronal and sagittal planes
    as well as with the arm in rotation from full internal to full external rotation in 10-degree increments.
  • The best coapted positions were:
    • Adduction + full internal rotation to 30 degrees of external rotation.
    • 30 degrees of flexion or abduction, neutral and internal rotation

Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I Sato K (2001) – Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging – Journal of Bone & Joint Surgery 83A: 661-7

  • 19 patients with shoulder dislocations.
  • MRI
  • Arm held at the side of the trunk and positioned
    • internal rotation (mean, 29 degrees)
    • external rotation (mean, 35 degrees)
    • The effect of an external rotation position (Itoi et al 2001)

Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I, Kobayashi M (2003) – A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. – Journal of Shoulder & Elbow Surgery 12: 413-5 2003

  • 40 patients with initial shoulder dislocations.
  • Randomised into:
    • internal rotation (IR) sling
    • external rotation (ER) splint (10 degrees)
  • 5 month Follow-up
  • Recurrence rate:
    • 30% in the IR group
    • 0% in the ER group

Latest Unpublished Results form Itoi – October 2004

  • Prospective multicenter randomised study from January 2000
  • 110 patients
  • Age range 17-80 (mean 40 yrs )
  • Anterior dislocation of the shoulder without fractures
  • 83 initial dislocations + 27 recurrent dislocations
  • Randomised to immobilization in either internal rotation (IR group, 51 shoulders) or external rotation (ER group, 59 shoulders) for 3 weeks.
  • Mean  follow-up = 20 months.
  • Average immobilization period = 15.9 ± 8.1 days in the IR group and 16.9 ± 7.1 days in the ER group.
  • Recurrence rate = 18/51 (35%) in the IR group and 11/59 (19%) in the ER group.
  • For those less than 29 years of age, recurrence rate was 48% in the IR group and 24% in the ER group.
  • In the IR group no significant difference between those immobilized for 3 weeks and those immobilized for less than 3 weeks (29% vs 45%, p=0.24)
  • In the ER group, there was a significant difference (8.7% vs 54%, p=0.0002).
  • For all patients splinted for at least 3 weeks, there was a significant difference in the recurrence rate between the IR and ER groups (p=0.0196).
  • Conclusion: Immobilization in external rotation after shoulder dislocation is better than the conventional immobilization in internal rotation in terms of reducing recurrent dislocations.

 

 

 

 

 

 

 

 

 

  • Dr. Mohammad Hosein Ebrahimzadeh
  • Knee and Shoulder Surgeon
  • Professor of Mashhad University of Medical Sciences
  • Office Address :Floor 3, Nikan Building,
  • Koohsangi 6, Koohsangi Street, Mashhad, Iran.
  • 38541812-051
  • E-mail :
Dr. Mohammad Hosein Ebrahimzadeh انجمن جراحان ارتوپدی