ACUTE SHOULDER
DISLOCATION
-The shoulder is the most
commonly dislocated
major joint.
-Anterior dislocations
account for more than 95%
of dislocations, with
posterior dislocations
making up 4% and inferior
dislocations (luxatio
erecta) about 0.5%.
-Superior and intrathoracic
dislocations are extremely
rare
-A smaller number have an
atraumatic origin and may
be related to congenital,
acquired, or degenerative
conditions.
Sex:
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).
Posterior shoulder
dislocation
1. Arm is held in adduction
and internal rotation.
2. Anterior shoulder is
"squared off" and flat with
prominent coracoid
process.
Shoulders may look
identical in bilateral
dislocation, making it a
commonly missed injury.
3. Posterior shoulder is full
with humeral head
palpable beneath the
acromion process.
4. Patient resists external
rotation and abduction.
-Neurovascular deficits are
infrequent.
Inferior shoulder
dislocation (luxatio
erecta)
-Arm is fully abducted
with elbow commonly
flexed on or behind head.
-Humeral head may be
palpable on the lateral
Age:
-Shoulder dislocation
occurs more frequently in
adolescents than 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.
Older adults also fall more
frequently.
Pathophysiology
-The shoulder dislocates
more than any other joint.
-It moves almost without
restriction, but pays the
price of vulnerability.
-The shoulder's integrity is
maintained by the
glenohumeral joint
capsule, the cartilaginous
glenoid labrum (which
chest wall.
Causes:
Anterior shoulder
dislocations usually result
from abduction, extension,
and external rotation, such
as when preparing for a
volleyball spike.
Falls on an outstretched
hand are a common cause
in older adults.
The humeral head is forced
out of the glenohumeral
joint, rupturing or
detaching the anterior
capsule from its attachment
to the head of the humerus
or from its insertion to the
edge of the glenoid fossa.
This occurs with or without
lateral detachment.
-Posterior dislocations are
caused by severe internal
rotation and adduction.
This type of dislocation
usually occurs during a
seizure, a fall on an
outstretched arm, or
extends the shallow
glenoid fossa), and muscles
of the rotator cuff
Clinical presentations
History
Patients generally
complain of severe
shoulder pain and
decreased range of motion
with a history of trauma.
Physical:
Anterior shoulder
dislocation
1. Arm is held in slight
abduction and external
rotation.
2. Shoulder is "squared
off" (ie, boxlike) with loss
of deltoid contour
compared to contralateral
side.
3. Humeral head is
palpable anteriorly (in the
subcoracoid region,
beneath the clavicle).
4. Patient resists abduction
and internal rotation and is
thus unable to touch the
electrocution.
-Occasionally, a severe
direct blow may cause a
posterior dislocation.
Bilateral posterior
dislocation is rare and
almost always results from
seizure activity.
Rare, but serious, inferior
dislocations (luxatio
erecta) may be due to axial
force applied to an arm
raised overhead, such as
when a motorcycle
collision victim tumbles to
the ground. More
commonly, the shoulder is
dislocated inferiorly by
indirect forces
hyperabducting the arm.
The neck of the humerus is
levered against the
acromion and the inferior
capsule tears as the
humeral head is forced out
inferiorly. This injury
always is accompanied by
fracture and/or serious
opposite shoulder.
NB
-Compare bilateral radial
pulses to help rule out
vascular injury.
-The axillary nerve before
and after reduction by
testing both pinprick
sensation in the
"regimental badge" area of
the deltoid and palpable
contraction of the deltoid
during attempted
abduction.
- Evaluate sensory and
motor function of the
musculocutaneous and
radial nerves.
Anterior dislocation may
be complicated by
(1) Injury to major nerves
arising from the brachial
plexus, most commonly the
axillary nerve;
(2) Fracture of the humeral
head or neck or greater
tuberosity (3) Compression
or avulsion of the anterior
soft-tissue injury.
Differential diagnosis
1. Acromioclavicular
Injury
2. Fractures, Humerus
3. Associated humeral
fractures most commonly
involve the greater
tuberosity, head, and neck
4. Bankart lesion (specific
tear to the anterointerior
glenohumeral ligament
portion of the labrum)
Imaging Studies:
Shoulder trauma series
 Anteroposterior
(AP)
 Axillary or
scapular "Y" views
Anterior dislocation is
characterized by
subcoracoid position of the
humeral head in the AP
view. The dislocation is
often more obvious in a
scapular "Y" view where
the humeral head lies
glenoid; anterior to the "Y."
(4) Tears of the In an axillary view, the
capsulotendinous rotator “golf ball” (ie, humeral
cuff. head) is said to have fallen
-The most common anterior to the “tee” (ie,
sequela is recurrent glenoid).
dislocation.
- Before manipulation,
careful examination is
necessary to determine the
presence or absence of
complicating nerve or
vascular injury.

-In posterior dislocation,

the AP view may show a
normal walking stick
contour of the humeral
head, or it may resemble a
light bulb or ice cream
cone depending upon the
degree of rotation.
-The scapular "Y" view
reveals the humeral head
behind the glenoid (the
center of the "Y"). In an
axillary view, the "golf
ball" falls posteriorly off
the "tee."
-Prereduction films
document the nature of the
dislocation and associated
pathology, such as a Hill-
Sachs lesion (which
consists of a wedge-shaped
defect or groove in the
posterolateral aspect of the
humeral head).or other
humeral fractures.
-Postreduction films
confirm relocation of the
humerus and may reveal
new or previously
obscured pathology.
Immobilization prior to x-
ray is imperative.

Management
The key to a successful
reduction is slow and
steady application of a
maneuver with adequate
analgesia and relaxation.
Successful reduction is
evinced by marked
reduction in pain and
increased range of motion.
A palpable or audible
relocation ("clunk") may
also be noted.
The patient may be asked
to touch the uninjured
shoulder to safely
demonstrate a successful
reduction.
After all reductions, apply
a shoulder immobilizer
with a sling and swathe
and perform a careful
neurovascular examination.
Methods of reduction
Stimson technique:
The patient lies prone on
the bed with the dislocated
arm hanging over the side.
Traction is provided by up
to 10 kg of weight attached
to the wrist or above the
elbow. Apply gentle
internal/external humeral
rotation. Reduction may
take 20-30 minutes.
External rotation
method:
While the patient lies
supine, adduct the arm and
flex it to 90° at the elbow.
Slowly rotate the arm
externally, pausing for
pain.
- Reduce the shoulder
before reaching the coronal
plane. Often successful,
this procedure requires
only one physician and
little force
Traction-countertraction:
While the patient lies
supine, apply axial traction
to the arm with a sheet
wrapped around the
forearm and the elbow bent
90°. An assistant should
apply countertraction using
a sheet wrapped under the
arm and across the chest
while the shoulder is gently
rotated internally and
externally to disengage the
humeral head from the
glenoid.
-Scapular rotation:
This less traumatic
technique has success rates
or more than 90% in
experienced hands, often
without sedation. With the
patient lying prone, apply
manual traction or 5-15 lb
of hanging weight to the
wrist. After relaxation,
rotate the inferior tip of the
scapula medially and the
superior aspect laterally.
Alternatively, the patient
can be seated while an
assistant provides traction-
countertraction by pulling
on the wrist with one hand
and bracing the upper chest
with the other. The same
scapular rotation is then
performed.