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Dislocations of the glenohumeral joint

SHANMUGANATHAN RAJASEKARAN, RISHI MUGESH KANNA, JAYARAMARAJU DHEENADHAYALAN

Introduction 297 Recurrent shoulder instability: TUBS and AMBRI 300


Pathoanatomy of the shoulder dislocation 297 Posterior dislocation of the shoulder 300
Mechanism of injury 298 Inferior glenohumeral dislocation (luxatio erecta) 301
Clinical evaluation 298 Superior glenohumeral dislocation 301
Radiographic evaluation 298 Summary 301
Treatment 299 References 302
Complications 299

NATIONAL BOARD STANDARDS

Understand the anatomy of the shoulder joint Know the types of dislocations
To know the important shoulder stabilizers Be able to conduct closed reductions
Pathoanatomy of shoulder dislocations Know the indications and principles of surgical treatment

INTRODUCTION and the long head of biceps are the important muscular
stabilizers. The neurovascular bundle lies close to the low-
Dislocations of the shoulder joint are very common er body of the glenohumeral joint and can be injured in
injuries, accounting for up to 45% of all dislocations.1 anteroinferior dislocations.
Anterior dislocations occur more frequently than posteri-
or dislocations while inferior and superior dislocations are
rare. The high incidence of shoulder dislocation is related PATHOANATOMY OF THE SHOULDER
to the fact that the shoulder joint is a totally DISLOCATION
unconstrained joint and thus allows the greatest range of
motion of any articulation in the body. The glenoid fossa Shoulder dislocations are usually traumatic events and are
articulates with only 25% of the articular surface of the always associated with stretching and tearing of the cap-
humeral head and, although it is augmented by the sule. See fig. 25.2 for the anatomy. In younger patients, the
labrum, it contributes lit- tle to the stability of the joint. anterior capsule and labrum are avulsed from the glenoid
The labrum, joint capsule, glenohumeral ligaments (Bankarts lesion) and this may also occasionally include a
(superior, middle and inferior) and adhesivecohesive small fragment of the bone (bony Bankarts lesion). The
forces owing to the presence of syn- ovial fluid provide soft-tissue avulsion is usually off the glenoid, but occa-
passive stability while the deltoid, long head of biceps and sionally it can be off the humerus with avulsion of gleno-
the rotator cuff provide active stability to the shoulder humeral ligaments (HAGL lesion). When the humeral
joint. So the ligaments serve as static restraints and head dislocates anterior to the glenoid fossa, a compres-
the muscles serve as dynamic stabilizers (Fig. 25.1). sion fracture can occur on the posterolateral part of the
The rotator cuff muscles (supraspinatous, humeral head owing to the force of impaction of the head
infraspinatous and teres minor) with the subscapularis
Complications 299

on the anterior edge of the glenoid (HillSachs lesion). MECHANISM OF INJURY


This is seen in 27% of acute anterior dislocations and
74% of recurrent anterior dislocations. In more elderly Anterior glenohumeral dislocation may occur as a result
patients beyond the age of 40, associated rotator cuff of either direct or indirect trauma.2 Indirect trauma to the
tears can occur. There is considerable discussion on the upper extremity with the shoulder in abduction, extension
pathology that predisposes to recurrent dislocation. It is and external rotation is the most common mechanism.
usually a combination of factors, as studies have shown Direct, anteriorly directed impact to the posterior shoul-
that sec- tioning of the anterior capsule alone does not der may produce an anterior dislocation. Recurrent dislo-
lead to insta- bility. cations with minimal trauma may occur in patients with
Dislocations are commonly classified by direction congenital or acquired ligamentous laxity.
(ante- rior, inferior, posterior or multidirectional), onset
(acute, recurrent or chronic) and aetiology (traumatic,
minimally traumatic, atraumatic or microanterior
CLINICAL EVALUATION
instability). Anterior dislocation of the shoulder is the
most common, accounting for about 90% of shoulder
The patient typically presents with the dislocated shoulder
dislocations.
held in slight abduction and external rotation with the arm
supported with the opposite hand. Any attempt at move-
ments produces severe pain. There is flattening of the
Posterior Anterior roundness of the shoulder owing to a relative prominence
of the acromion, a hollow beneath the acromion laterally
Supraspinatus and a palpable mass anteriorly.
A careful neurovascular examination is important to
Coracoacromian assess the integrity of the axillary nerve (sensation over the
arch deltoid) and the musculocutaneous nerve (sensation on
Coracohumeral
Infraspinatus ligament the anterolateral forearm). Sometimes patients may pres-
Superior
ent after spontaneous reduction. Here, a typical history
glenohumeral and apprehension of the patient to abduct or extensively
ligament rotate the shoulder must raise suspicion of a dislocation.
Teres minor
Middle
glenohumeral
ligament RADIOGRAPHIC EVALUATION
Inferior
glenohumeral Anteroposterior and trans-scapular lateral (Y) views are
ligament adequate to confirm the diagnosis (Fig. 25.3). Only if the
direction of the dislocation is not clearly evident should an
axillary view be obtained as this may produce pain and
Figure 25.1 Anatomy of the shoulder joint as viewed from the severe spasm to the patient. Radiographs must be exam-
humeral articular surface. The static and dynamic stabilizers of ined for associated tuberosity fractures and other bony
the shoulder joint are shown. injuries. Special views of the shoulder such as the

Figure 25.2 (ae) The normal shoulder anatomy


and the various pathological lesions in an anterior
shoulder dislocation. (a) Normal anatomy of the
shoulder. (b) Anterior capsular tear. (c) Capsular
Bankart's lesion (avulsion of the capsule from the
anterior glenoid). (d) Bony Bankart's lesion.
(e) HillSachs lesion (fracture of the posterolateral
(a) (b) (c) surface of the humeral head).

(d) (e)
In the more commonly performed method of reduc-
tion by traction, the patient lies supine with analgesia
obtained either by intravenous sedation or, preferably,
by a subclavian perivascular block regional anaesthesia.
An assistant applies countertraction by holding the two
ends of a sheet passed around the thorax near the axilla
and the forearm is gently pulled in a line of 30 of
abduc- tion, 20 of forward flexion and gradually
(a) (b)
externally rotated. The traction must be gentle and
sustained, avoiding sudden and forceful attempts as this
may lead to a fracture, especially in the elderly. Once
Figure 25.3 (a,b) Anterior glenohumeral dislocation. (a) The sustained gentle traction has been given, as the shoulder
anteroposterior radiograph of the shoulder shows the muscles fatigue, the shoulder is adducted and gently
dislocated humeral head lying anteroinferiorly under the internally rotated to reduce the joint.
coracoid process. (b) The axillary view shows the humeral head In the rare event of inability to reduce an acute anteri-
lying anterior or dislocation, soft-tissue interposition must be suspected.
to the glenoid fossa. Note the empty glenoid fossa in both the This may require open reduction. Other indications for
views (arrows). operative intervention are a grossly displaced greater
tuberosity fracture that does not fall into position or a gle-
noid fracture that is greater than 5 mm in size.
HillSachs view (tangential view of the anteroinferior
glenoid rim), West Point axillary view and Stryker notch
view (to visualize a posterolateral humeral head defect) are Post-reduction treatment
not mandatory in the acute setting.
CT may be useful in defining humeral head or glenoid The shoulder is usually immobilized for a brief period in a
impression fractures, and anterior labral bony injuries. sling until pain relief is achieved, but the length of
MRI may be used to identify rotator cuff, capsular and immo- bilization has no effect on the susceptibility for
glenoid labral lesions. Both CT and MRI are usually not further recurrent dislocations. A range of motion and
required in the evaluation of acute dislocations. rotator cuff strengthening exercises should be initiated at
the earliest but abduction and external rotation should be
avoided.
TREATMENT

Treatment of the first episode of dislocation COMPLICATIONS

Reduction of the dislocation must be performed at the ear- Early complications


liest as it provides prompt relief of pain. This can usually
be achieved even without full anaesthesia, provided the These include nerve injuries involving the axillary and/or
reduction is done gently with good muscle relaxation. musculocutaneous nerves in approximately 514% of
Numerous techniques of reduction have been dislo- cations. These are usually neurapraxia and almost
described. Hippocrates proposed a method of reduction in always recover spontaneously. Both neural and vascular
which one foot is placed across the axillary fold and onto injuries can occur in young adults involved in high-velocity
the chest wall to provide countertraction, with traction injuries. The greater tuberosity may shear off during the
and gentle internal rotation of the affected upper extremity. dislocation; however, it usually falls into place during
Later Kocher proposed a technique using traction and reduction. If it remains displaced, internal fixation is
external rotation and gently levering the humeral head on required. Vascular injuries involve the axillary artery and
the anterior glenoid to effect reduction. These methods are typically can occur in elderly patients with atherosclerosis.
rarely followed now as they are associated with increased They can also occur at the time of an open or closed
risk of humeral fracture. The two commonly performed reduction.
methods are either the Stimson prone reduction technique
or the reduction by traction with abduction and external
rotation (Milch technique). In the Stimson technique, after Late complications
injection of 1020 mL of 1% lidocaine into the gleno-
humeral joint, the patient is placed prone on an examina- Recurrent anterior dislocation is the most common com-
tion table with the involved arm hanging in a dependent plication after dislocation and the incidence is related to
position from the edge of the table. Eventually, with suffi- the age at the time of initial dislocation the lower the
cient fatigue in the shoulder musculature, the joint can be age, the higher the incidence of recurrence.
easily reduced into normal position. Susceptibility for redislocation is unrelated to the type or
length of post- reduction immobilization. Recurrent
dislocation is related
to ligament and capsular changes and occasionally to large
bony lesions such as the HillSachs or the bony Bankart
lesion. Patients may also have pain as a result of recurrent
subluxation or instability without an actual dislocation.
Shoulder stiffness can also occur because of prolonged
immobilization and is more common in patients over the
age of 40 years.

RECURRENT SHOULDER INSTABILITY:


TUBS AND AMBRI (a) (b)

There are two different types of recurrent shoulder insta- Figure 25.4 Anteroposterior (a) and axillary lateral
bility, one that follows a previous traumatic shoulder dis- (b) radiographs of a neglected posterior dislocation of the
location and the other that presents without any history shoulder. The anterolateral aspect of the humeral head has a
of previous trauma.3 The aetiology, presenting features, defect (reverse HillSachs lesion; white arrow) that would prevent
pathology and management principles are different for a stable reduction of the dislocation. The empty glenoid fossa is
both these conditions. shown by the black arrow.
After an acute traumatic dislocation, the type of recur-
rent instability observed is termed TUBS (traumatic, uni-
directional, Bankart lesion; surgery is often necessary).
Mechanism of injury
These patients have no problems of generalized ligament
laxity and the dislocation is purely secondary to the distur- A fall onto an adducted and forward flexed arm may result
bances caused by the previous trauma. They are usually in a posterior dislocation. But, more often, posterior dislo-
young patients and have excellent results following sur-
cations occur as a result of indirect injury that produces
gery. Different types of surgical repair have been
marked internal rotation and adduction, such as during a
described. At present both open and arthroscopic Bankart
convulsion or an electrocution. A direct trauma applied to
repairs are in vogue.4 Arthroscopic repair is technically the anterior shoulder may also result in a posterior trans-
difficult but the redislocation rates are comparable to lation of the humeral head.
open Bankart repairs. We prefer the inferior capsular shift
reconstruc- tion, which addresses the Bankarts lesion and
also the lax- ity of the capsule and has a very high success Clinical evaluation
rate.
The other type of recurrent instability presents without A posterior glenohumeral dislocation does not present with
any previous history of trauma and is termed AMBRI striking deformity and the symptoms can be minimal,
(atraumatic, multidirectional, bilateral, rehabilitation is the lead- ing to frequently missed diagnosis. The shoulder
primary mode of treatment; inferior capsular shift is per- typically is in the position of adduction, flexion and
formed only rarely).5 Often the shoulder may show insta- internal rotation. Limited forward elevation (often
bility in two or more directions, and patients demonstrate <90) with restricted external rotation should raise
signs of general systemic laxity. The typical patient is a suspicion of the diagnosis. In thinner individuals, a
double-jointed adolescent demonstrating a sulcus sign palpable mass posterior to the shoul- der and flattening of
and apprehension when stress is applied in both the the anterior shoulder may be obvious.
anteri- or and posterior directions. By strengthening the
dynamic stabilizers, it should be possible to overcome the
inherent glenohumeral joint laxity. Non-operative Radiographic evaluation
treatment is the treatment of choice because operative
management is asso- ciated with a high failure rate. If The findings in the standard anteroposterior views may
physical rehabilitation fails to provide adequate often appear normal unless carefully examined. The
improvement, however, these patients often require humeral head, because it is medially rotated, loses its nor-
surgical tightening of the entire shoulder cap- sule with the mal contour and is shaped like an electric light bulb. The
inferior capsular shift procedure.6 glenoid appears partially vacant (space between anterior
rim and humeral head >6 mm) vacant glenoid sign.
There is absence of the normal elliptic overlap of the
POSTERIOR DISLOCATION OF THE SHOULDER humeral head on the glenoid. The trough sign is an
impaction fracture of the anterior humeral head caused by
Posterior dislocation (Fig. 25.4) accounts for less than the posterior rim of glenoid, which is more visible on the
10% of all shoulder dislocations.7 A high degree of suspi- lateral view. Posterior dislocations are most readily recog-
cion is necessary as up to 60% of posterior dislocations nized on the axillary view. CT scans will also show clearly
are missed on initial examination.
Summary 301

the posterior dislocation and the percentage of the humeral forward elevation. Pain is usually severe; the humeral head
head impacted during the dislocation. is palpable on the lateral chest wall and
axilla.
Injury to the axillary artery or brachial plexus is com-
Treatment mon and must be looked for. Associated rotator cuff tears,
pectoralis injury and proximal humeral fracture are also
Closed reduction is best done under general anaesthesia. common. Anteroposterior and axillary views are typically
With the patient supine, traction should be applied to the diagnostic, with inferior dislocation of the humeral head
adducted arm in the line of the deformity with gentle and superior direction of the humeral shaft along the gle-
lifting of the humeral head into the glenoid fossa. The noid margin.
shoulder should never be forced into external rotation, as Closed reduction may be accomplished by the use of
this may result in a humeral head fracture if an impaction tractioncountertraction manoeuvres. Axial traction in
fracture is locked on the posterior glenoid rim. If the head line with the humeral shaft, with a gradual decrease in
is locked, axial traction should be accompanied by lateral shoulder abduction and countertraction applied with a
traction on the upper arm to unlock the humeral head from sheet around the patients thorax, usually achieves reduc-
the glenoid. tion. Failure of closed reduction is due to the humeral
Post reduction, a radiograph should be done to confirm head buttonholing through the inferior capsule and soft-
reduction. If the shoulder is stable, a sling immobilization tissue envelope. Open reduction is then indicated.
is adequate. However if the shoulder subluxates or
redislo- cates, the shoulder is immobilized in a shoulder
spica in mild abduction and lateral rotation for a period of SUPERIOR GLENOHUMERAL DISLOCATION
3 weeks.
External rotation and deltoid isometric exercises may be This very rare injury occurs with extreme anterior and
performed during the period of immobilization. After dis- supe- rior directed force applied to the adducted upper
continuation of immobilization, an aggressive internal and extremity, such as a fall from a height onto the upper
external rotator strengthening programme is instituted. extremity. The humeral head is forced superiorly from the
Open reduction is indicated if dislocation is irreducible glenoid fossa. Typically it is accompanied by fractures of
(impaction fracture on the posterior glenoid preventing the acromion, clavicle, coracoid and humeral
reduction). Major displacement of an associated lesser tuberosities, as well as by soft-tissue injury to the rotator
tuberosity fracture or a fractured large posterior glenoid cuff, glenohumeral capsule, biceps tendon and surrounding
fragment will require fixation. If the shoulder is unstable musculature.
secondary to a large humeral impaction fracture, a transfer The patient typically presents with a foreshortened upper
of the lesser tuberosity with attached subscapularis into extremity held in adduction and a palpable humeral head
the defect (modified McLaughlin procedure) or a above the level of the acromion. The anteroposterior
hemiarthro- plasty (>40% involvement) is indicated. radiograph is typically diagnostic, with dislocation of the
humeral head superior to the acromion process. Closed
reduction with axial traction applied in an inferior direction
Complications and lateral traction applied to the upper arm achieves reduc-
tion. Irreducible dislocations may require open reduction.
Missed posterior dislocations are quite common and the
management has to be individualized depending on the
age of the patient, the duration since dislocation and the SUMMARY
pres- ence of any fracture. They will invariably require
surgery and good results can be obtained even when the The wide range of motion allowed by the shoulder joint
interven- tion is done as late as 6 months. enables us to keep the upper limb at various positions in
Recurrent dislocation may occur with large anterome- space. However, in order to achieve such mobility, the
dial humeral head defects and large posterior glenoid rim bony stability of the joint is reduced and depends mainly
fractures. They may require surgical stabilization to pre- on various static and dynamic soft-tissue stabilizers. As
vent recurrence. such, the shoulder is one of the most commonly dislocated
joints in the human body. Most traumatic dislocations are
anterior and are treated efficiently by closed methods of
INFERIOR GLENOHUMERAL DISLOCATION reduction. Late instability is a potential complication that
(LUXATIO ERECTA) may require surgical stabilization procedures, either open
or arthroscopic. With the increasing interest in recre-
This very rare injury results from a hyperabduction force ational and sporting activities, the incidence of gleno-
causing impingement of the neck of the humerus on the humeral instability may be increasing. Effective shoulder
acromion, which levers the humeral head out inferiorly. rehabilitation techniques are available for these multidi-
The patient typically presents in a characteristic salute rectional instabilities and surgery is reserved for select
fashion, with the humerus locked in abduction and patients only.