Disease: Dislocated Shoulder

    Shoulder dislocation facts

    • The shoulder joints are the most commonly dislocated joints in the body.
    • Approximately 25% of shoulder dislocations have associated fractures.
    • Closed reduction, without the need for surgery, is the most common initial treatment. Medications may be required for sedation to help facilitate the reduction.
    • Immobilization with a sling is important to decrease the risk of a repeat dislocation. First dislocations are immobilized in an external rotation position. Recurrent dislocations may be immobilized in a regular sling.
    • Early follow-up is important to decide when to begin allowing shoulder motion.
    • Total time of immobilization varies, and balance needs to exist between shoulder stability and loss of motion and function from prolonged immobilization.
    • Uncomplicated rehabilitation and healing will allow return to normal function in 12-16 weeks.

    What is dislocation of the shoulder? What causes a shoulder dislocation?

    The shoulder joint is the most mobile joint in the body and allows the arm to move in many directions. This ability to move makes the joint inherently unstable and also makes the shoulder the most often dislocated joint in the body.

    In the shoulder joint, the head of the humerus (upper arm bone) sits in the glenoid fossa, an extension of the scapula, or shoulder blade. Because the glenoid fossa (fossa = shallow depression) is so shallow, other structures within and surrounding the shoulder joint are needed to maintain its stability. Within the joint, the labrum (a fibrous ring of cartilage) extends from the glenoid fossa and provides a deeper receptacle for the humeral head. The capsule tissue that surrounds the joint also helps maintain stability. The rotator cuff muscles and the tendons that move the shoulder provide a significant amount of protection for the shoulder joint.

    Dislocations of the shoulder occur when the head of the humerus is forcibly removed from its socket in the glenoid fossa. It's possible to dislocate the shoulder in many different directions, and a dislocated shoulder is described by the location where the humeral head ends up after it has been dislocated. Ninety percent or more of shoulder dislocations are anterior dislocations, meaning that the humeral head has been moved to a position in front of the joint. Posterior dislocations are those in which the humeral head has moved backward toward the shoulder blade. Other rare types of dislocations include luxatio erecta, an inferior dislocation below the joint, and intrathoracic, in which the humeral head gets stuck between the ribs.

    Picture of the shoulder joint

    Dislocations in younger people tend to arise from trauma and are often associated with sports or falls. Older patients are prone to dislocations because of gradual weakening of the ligaments and cartilage that supports the shoulder. Even in these cases, however, there still needs to be some force applied to the shoulder joint to make it dislocate.

    Anterior dislocations often occur when the shoulder is in a vulnerable position. A common example is when the arm is held over the head with the elbow bent, and a force is applied that pushes the elbow backward and levers the humeral head out of the glenoid fossa. This scenario can occur with throwing a ball or hitting a volleyball. Anterior dislocations also occur during falls on an outstretched hand. An anterior dislocation involves external rotation of the shoulder; that is, the shoulder rotates away from the body.

    Posterior dislocations are uncommon and are often associated with specific injuries like lightning strikes, electrical injuries, and seizures. On occasion, this type of dislocation can occur with minimal injury in the elderly, and because X-rays may not easily show a posterior dislocation, the diagnosis is often missed should the patient present for evaluation of shoulder pain.

    What are the symptoms and signs of a dislocated shoulder?

    Dislocations hurt. When the humerus is forcibly pulled out of the socket, cartilage, muscle, and other tissues are stretched and torn. Shoulder dislocations present with significant pain, and the patient will often refuse to move the arm in any direction. The muscles that surround the shoulder joint tend to go into spasm, making any movements very painful. Usually, with anterior dislocations, the arm is held slightly away from the body, and the patient tries to relieve the pain by supporting the weight of the injured arm with the other hand. Often, the shoulder appears squared off since the humeral head has been moved out its normal place in the glenoid fossa. Sometimes, it may be seen or felt as a bulge in front of the shoulder joint.

    As with other bony injuries, the pain may provoke systemic symptoms of nausea and vomiting, sweating, lightheadedness, and weakness. These occur because of the stimulation of the vagus nerve, which blocks the adrenaline response in the body. Occasionally, this may cause the patient to faint or pass out (vasovagal syncope).

    How do physicians diagnose dislocated shoulders?

    When a patient presents with a shoulder dislocation, pain control and joint relocation are primary considerations. However, it is still important for the health-care professional to take a careful history to understand the mechanism of injury and the circumstances surrounding it. It will also be important to know if this is the first shoulder dislocation or whether the joint has been previously injured. In addition, questions may be asked about medications, allergies, time of the last meal, and past medical history to prepare for a potential anesthetic administration to help relocate, or reduce, the shoulder dislocation.

    Physical examination of the shoulder will begin with inspection to look for "squaring off," or a loss of the normal rounded appearance of the shoulder caused by the deltoid muscle. In thinner patients, the humeral head may be palpated or felt in front of the joint.

    Pain and muscle spasm accompany dislocated joints, and a shoulder dislocation is no different. When the joint is disrupted, the muscles surrounding it are stretched and go into spasm. The patient will experience significant pain and will often resist the smallest movement of any part of the arm. The health-care professional may feel for pulses in the wrist and elbow, as well as test for sensation to assess the blood and nerve supply to the arm. Damage may occur to arteries and nerves when the shoulder is dislocated. The brachial plexus, the axillary artery, and axillary nerve are located in the armpit and are relatively unprotected. Plain X-rays may be taken to confirm the diagnosis of shoulder dislocation and to make certain there are no broken bones associated with the dislocation. Two common fractures are the Hill-Sachs deformity, a compression fracture of the humeral head, and a Bankart lesion, a chip fracture of the glenoid fossa. While these may be present, they do not hinder the relocation of the shoulder. Other fractures of the humerus and scapula may make shoulder reduction more difficult.

    Since the body is 3-D and X-rays are 2-D, at least two X-rays are taken to be able to accurately assess where the humeral head is located -- anteriorly (in front) or posteriorly (behind) in relationship to the glenoid. Extra X-ray views also better assess the bones, looking for fracture.

    In certain circumstances, (often on the athletic field) if a health-care professional is present at the time of injury, an attempt may be made to reduce or relocate the shoulder immediately without X-rays being taken. Using manipulation described below, before the muscles have a chance to go into spasm, it is possible to relocate the shoulder. Imaging of the injured shoulder (X-ray or MRI) would then be considered at a later time.

    What is the treatment for a dislocated shoulder?

    The purpose of the initial treatment of a dislocated shoulder is to reduce the dislocation and return the humeral head to its normal place in the glenoid fossa. There are a variety of methods that may be used to achieve this goal. The decision as to which one to use depends upon the patient, the situation, and the experience of the clinician performing the reduction. Regardless of the technique used, the hope is to be able to efficiently reduce the dislocation with a minimum of anesthesia required. Most attempts at closed reductions are successful; that is, no incision or cut is made into the joint to assist in returning the bones to their normal position. The term "open reduction" refers to performing surgery to repair the dislocation. Methods for reduction of a shoulder dislocation are described below.

    Scapular manipulation

    The patient may be sitting up or lying prone. The health-care professional attempts to rotate the shoulder blade, dislodging the humeral head, and allowing spontaneous relocation. An assistant may be needed to help stabilize the arm.

    External rotation (Hennepin maneuver)

    With the patient lying flat or sitting up, the health-care professional flexes the elbow to 90 degrees and gradually rotates the shoulder outward (external rotation). Muscle spasm may be able to be overcome after five to 10 minutes of gentle pushing, allowing the shoulder to spontaneously relocate. The Milch technique adds gentle lifting of the arm above the head to achieve reduction.

    Traction-counter traction

    With the patient lying flat, a sheet is looped around the armpit. While the health-care professional pulls down on the arm, an assistant, located at the head of the bed, pulls on the sheet to apply counter traction. As the muscles relax, the humeral head is able to return to its normal position.

    Open reduction

    In rare circumstances, the shoulder cannot be reduced using closed reduction techniques because a tendon, ligament, or piece of broken bone gets caught in the joint, preventing return of the humeral head into the glenoid. When closed reduction fails, it may be necessary for an orthopedic surgeon to perform an operation or open reduction.

    Procedural medications

    Depending upon the amount of pain and spasm present, medication may be needed to sedate and comfort the patient prior to and during the reduction procedure. Medications may also be given to relax the muscles to aid in the joint reduction.

    Patients receiving intravenous medications need to have their vital signs monitored before, during, and after the shoulder relocation just as if they were in the operating room. In some circumstances (for example a patient with underlying lung or heart illnesses), the presence of an anesthesiologist or nurse anesthetist may be appropriate during the relocation. Health-care professionals use intravenous narcotics and muscle relaxants in combination to relieve pain, relax muscles, and help promote amnesia of the events. Common pain medications used include morphine, hydromorphone (Dilaudid), and fentanyl. Physicians may use midazolam (Versed), diazepam (Valium), or lorazepam (Ativan) as a muscle relaxant.

    Learn more about: Dilaudid | Valium | Ativan

    It is common to sedate the patient with anesthetics like ketamine or propofol to allow shoulder reduction. Physicians may use intra-articular (intra = within + articular = joint) injections of lidocaine (Xylocaine) into the shoulder joint as local anesthesia.

    What happens after reduction of a shoulder dislocation?

    Examination

    Once the shoulder has been reduced, the health-care professional will want to reexamine the arm and make certain that no nerve or artery damage occurred during the reduction procedure. Often, the clinician will take another X-ray to reassess the bones.

    Immobilization

    Significant damage occurs to the joint with a shoulder dislocation. The labrum and joint capsule have to tear, and there may be associated injuries to the rotator cuff. These are the structures that lend stability to the shoulder joint, and since they are injured, the shoulder is at great risk to dislocate again.

    A sling or shoulder immobilizer may be used as a reminder not to use the arm and allow the muscles that surround the joint to relax and not have to support the bones against gravity.

    For a patient who sustains their first shoulder dislocation, the clinician will often immobilize the shoulder in mild external rotation, meaning that the arm is placed in a special sling that supports the arm away from the body.

    The physician may place repeated dislocations in a regular sling or immobilizer for comfort and support.

    The length of time a sling is worn depends upon the individual patient. A balance must be reached between immobilizing the shoulder to prevent recurrent dislocation and losing range of motion if the shoulder has been kept still for too long.

    Pain control

    Once a clinician reduces a shoulder dislocation, much of the pain is resolved. Physicians may recommend ibuprofen (Advil) as an anti-inflammatory medication and prescribe narcotic pain medications like codeine or hydrocodone for the short term.

    Ice is an important component of pain control, helping to decrease the swelling associated with the injury.

    Special situations/recurrent dislocations

    In certain situations, it's possible to reduce dislocations immediately. This is especially true in the sports medicine arena, where a health-care professional may reduce the dislocation on the field of play. This is a reasonable treatment alternative because the care provider was able to see the injury occur, examine the patient and come to the diagnosis, and then reduce the injury before muscles spasm sets in.

    Many patients experience shoulder subluxation or partial dislocation. These are patients who have had previous dislocations and are aware that their shoulder has dislocated again and then spontaneously reduced. They may choose not to seek urgent or emergent care, but this situation should not be ignored. Once a shoulder dislocates, it becomes unstable and more prone to future dislocation and injury.

    What are the symptoms and signs of a dislocated shoulder?

    Dislocations hurt. When the humerus is forcibly pulled out of the socket, cartilage, muscle, and other tissues are stretched and torn. Shoulder dislocations present with significant pain, and the patient will often refuse to move the arm in any direction. The muscles that surround the shoulder joint tend to go into spasm, making any movements very painful. Usually, with anterior dislocations, the arm is held slightly away from the body, and the patient tries to relieve the pain by supporting the weight of the injured arm with the other hand. Often, the shoulder appears squared off since the humeral head has been moved out its normal place in the glenoid fossa. Sometimes, it may be seen or felt as a bulge in front of the shoulder joint.

    As with other bony injuries, the pain may provoke systemic symptoms of nausea and vomiting, sweating, lightheadedness, and weakness. These occur because of the stimulation of the vagus nerve, which blocks the adrenaline response in the body. Occasionally, this may cause the patient to faint or pass out (vasovagal syncope).

    How do physicians diagnose dislocated shoulders?

    When a patient presents with a shoulder dislocation, pain control and joint relocation are primary considerations. However, it is still important for the health-care professional to take a careful history to understand the mechanism of injury and the circumstances surrounding it. It will also be important to know if this is the first shoulder dislocation or whether the joint has been previously injured. In addition, questions may be asked about medications, allergies, time of the last meal, and past medical history to prepare for a potential anesthetic administration to help relocate, or reduce, the shoulder dislocation.

    Physical examination of the shoulder will begin with inspection to look for "squaring off," or a loss of the normal rounded appearance of the shoulder caused by the deltoid muscle. In thinner patients, the humeral head may be palpated or felt in front of the joint.

    Pain and muscle spasm accompany dislocated joints, and a shoulder dislocation is no different. When the joint is disrupted, the muscles surrounding it are stretched and go into spasm. The patient will experience significant pain and will often resist the smallest movement of any part of the arm. The health-care professional may feel for pulses in the wrist and elbow, as well as test for sensation to assess the blood and nerve supply to the arm. Damage may occur to arteries and nerves when the shoulder is dislocated. The brachial plexus, the axillary artery, and axillary nerve are located in the armpit and are relatively unprotected. Plain X-rays may be taken to confirm the diagnosis of shoulder dislocation and to make certain there are no broken bones associated with the dislocation. Two common fractures are the Hill-Sachs deformity, a compression fracture of the humeral head, and a Bankart lesion, a chip fracture of the glenoid fossa. While these may be present, they do not hinder the relocation of the shoulder. Other fractures of the humerus and scapula may make shoulder reduction more difficult.

    Since the body is 3-D and X-rays are 2-D, at least two X-rays are taken to be able to accurately assess where the humeral head is located -- anteriorly (in front) or posteriorly (behind) in relationship to the glenoid. Extra X-ray views also better assess the bones, looking for fracture.

    In certain circumstances, (often on the athletic field) if a health-care professional is present at the time of injury, an attempt may be made to reduce or relocate the shoulder immediately without X-rays being taken. Using manipulation described below, before the muscles have a chance to go into spasm, it is possible to relocate the shoulder. Imaging of the injured shoulder (X-ray or MRI) would then be considered at a later time.

    What is the treatment for a dislocated shoulder?

    The purpose of the initial treatment of a dislocated shoulder is to reduce the dislocation and return the humeral head to its normal place in the glenoid fossa. There are a variety of methods that may be used to achieve this goal. The decision as to which one to use depends upon the patient, the situation, and the experience of the clinician performing the reduction. Regardless of the technique used, the hope is to be able to efficiently reduce the dislocation with a minimum of anesthesia required. Most attempts at closed reductions are successful; that is, no incision or cut is made into the joint to assist in returning the bones to their normal position. The term "open reduction" refers to performing surgery to repair the dislocation. Methods for reduction of a shoulder dislocation are described below.

    Scapular manipulation

    The patient may be sitting up or lying prone. The health-care professional attempts to rotate the shoulder blade, dislodging the humeral head, and allowing spontaneous relocation. An assistant may be needed to help stabilize the arm.

    External rotation (Hennepin maneuver)

    With the patient lying flat or sitting up, the health-care professional flexes the elbow to 90 degrees and gradually rotates the shoulder outward (external rotation). Muscle spasm may be able to be overcome after five to 10 minutes of gentle pushing, allowing the shoulder to spontaneously relocate. The Milch technique adds gentle lifting of the arm above the head to achieve reduction.

    Traction-counter traction

    With the patient lying flat, a sheet is looped around the armpit. While the health-care professional pulls down on the arm, an assistant, located at the head of the bed, pulls on the sheet to apply counter traction. As the muscles relax, the humeral head is able to return to its normal position.

    Open reduction

    In rare circumstances, the shoulder cannot be reduced using closed reduction techniques because a tendon, ligament, or piece of broken bone gets caught in the joint, preventing return of the humeral head into the glenoid. When closed reduction fails, it may be necessary for an orthopedic surgeon to perform an operation or open reduction.

    Procedural medications

    Depending upon the amount of pain and spasm present, medication may be needed to sedate and comfort the patient prior to and during the reduction procedure. Medications may also be given to relax the muscles to aid in the joint reduction.

    Patients receiving intravenous medications need to have their vital signs monitored before, during, and after the shoulder relocation just as if they were in the operating room. In some circumstances (for example a patient with underlying lung or heart illnesses), the presence of an anesthesiologist or nurse anesthetist may be appropriate during the relocation. Health-care professionals use intravenous narcotics and muscle relaxants in combination to relieve pain, relax muscles, and help promote amnesia of the events. Common pain medications used include morphine, hydromorphone (Dilaudid), and fentanyl. Physicians may use midazolam (Versed), diazepam (Valium), or lorazepam (Ativan) as a muscle relaxant.

    Learn more about: Dilaudid | Valium | Ativan

    It is common to sedate the patient with anesthetics like ketamine or propofol to allow shoulder reduction. Physicians may use intra-articular (intra = within + articular = joint) injections of lidocaine (Xylocaine) into the shoulder joint as local anesthesia.

    What happens after reduction of a shoulder dislocation?

    Examination

    Once the shoulder has been reduced, the health-care professional will want to reexamine the arm and make certain that no nerve or artery damage occurred during the reduction procedure. Often, the clinician will take another X-ray to reassess the bones.

    Immobilization

    Significant damage occurs to the joint with a shoulder dislocation. The labrum and joint capsule have to tear, and there may be associated injuries to the rotator cuff. These are the structures that lend stability to the shoulder joint, and since they are injured, the shoulder is at great risk to dislocate again.

    A sling or shoulder immobilizer may be used as a reminder not to use the arm and allow the muscles that surround the joint to relax and not have to support the bones against gravity.

    For a patient who sustains their first shoulder dislocation, the clinician will often immobilize the shoulder in mild external rotation, meaning that the arm is placed in a special sling that supports the arm away from the body.

    The physician may place repeated dislocations in a regular sling or immobilizer for comfort and support.

    The length of time a sling is worn depends upon the individual patient. A balance must be reached between immobilizing the shoulder to prevent recurrent dislocation and losing range of motion if the shoulder has been kept still for too long.

    Pain control

    Once a clinician reduces a shoulder dislocation, much of the pain is resolved. Physicians may recommend ibuprofen (Advil) as an anti-inflammatory medication and prescribe narcotic pain medications like codeine or hydrocodone for the short term.

    Ice is an important component of pain control, helping to decrease the swelling associated with the injury.

    Special situations/recurrent dislocations

    In certain situations, it's possible to reduce dislocations immediately. This is especially true in the sports medicine arena, where a health-care professional may reduce the dislocation on the field of play. This is a reasonable treatment alternative because the care provider was able to see the injury occur, examine the patient and come to the diagnosis, and then reduce the injury before muscles spasm sets in.

    Many patients experience shoulder subluxation or partial dislocation. These are patients who have had previous dislocations and are aware that their shoulder has dislocated again and then spontaneously reduced. They may choose not to seek urgent or emergent care, but this situation should not be ignored. Once a shoulder dislocates, it becomes unstable and more prone to future dislocation and injury.

    Source: http://www.rxlist.com

    The purpose of the initial treatment of a dislocated shoulder is to reduce the dislocation and return the humeral head to its normal place in the glenoid fossa. There are a variety of methods that may be used to achieve this goal. The decision as to which one to use depends upon the patient, the situation, and the experience of the clinician performing the reduction. Regardless of the technique used, the hope is to be able to efficiently reduce the dislocation with a minimum of anesthesia required. Most attempts at closed reductions are successful; that is, no incision or cut is made into the joint to assist in returning the bones to their normal position. The term "open reduction" refers to performing surgery to repair the dislocation. Methods for reduction of a shoulder dislocation are described below.

    Source: http://www.rxlist.com

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