Dislocated shoulder

• Significant pain, sometimes felt along the arm past the shoulder.
• Sensation that the shoulder is slipping out of the joint during abduction and external rotation.{{Cite book|title=Essentials of musculoskeletal care|date=2010|publisher=American Academy of Orthopaedic Surgeons|others=Sarwark, John F.|isbn=978-0892035793|location=Rosemont, Ill.|oclc=706805938}}
• Shoulder and arm held in external rotation (anterior dislocation), or adduction and internal rotation (posterior dislocation). Resistance of all movement.
• Numbness of the arm.
• Visibly displaced shoulder. Some dislocations result in the shoulder appearing unusually square.
• No palpable bone on the side of the shoulder.

A diagnosis of shoulder dislocation is often suspected based on the person's history and physical examination. Radiographs are made to confirm the diagnosis. Most dislocations are apparent on radiographs showing incongruence of the glenohumeral joint. Posterior dislocations may be hard to detect on standard AP radiographs, but are more readily detected on other views. After reduction, radiographs are usually repeated to confirm successful reduction and to detect bone damage. After repeated shoulder dislocations, an MRI scan may be used to assess soft tissue damage. In regards to recurrent dislocations, the apprehension test (anterior instability) and sulcus sign (inferior instability) are useful methods for determining predisposition to future dislocation.{{citation needed|date=October 2020}}

There are three main types of dislocations: anterior, posterior, and inferior.{{Cite book| url=https://www.ncbi.nlm.nih.gov/books/NBK459125/ | pmid=29083735 | title=StatPearls | chapter=Shoulder Dislocations Overview | date=2024 | publisher=StatPearls }}

File:Shoulder dislocation with Bankart and Hill-Sachs lesion, before and after reduction.jpg and a Hill-Sachs lesion.]]

In over 95% of shoulder dislocations, the humerus is displaced anteriorly.{{Cite book|title=Current medical diagnosis & treatment 2018|others=Papadakis, Maxine A., McPhee, Stephen J., Rabow, Michael W.|isbn=9781259861482|edition=Fifty-seventh|location=New York|oclc=959649794| vauthors = Rabow MW, McPhee SJ, Papadakis MA |date=2017-09-02}} In most of those, the head of the humerus comes to rest under the coracoid process, referred to as sub-coracoid dislocation. Sub-glenoid, subclavicular, and, very rarely, intrathoracic or retroperitoneal dislocations may also occur.{{EMedicine|orthoped|440|Shoulder Dislocations}}

Anterior dislocations are usually caused by a direct blow to, or fall on, an outstretched arm. The person typically holds his/her arm externally rotated and slightly abducted.{{Cite book| url=https://www.ncbi.nlm.nih.gov/books/NBK459125/ | pmid=29083735 | title=StatPearls | chapter=Shoulder Dislocations Overview | date=2024 | publisher=StatPearls }}

A Hill–Sachs lesion is an impaction of the head of the humerus left by the glenoid rim during dislocation. Hill-Sachs deformities occur in 35–40% of anterior dislocations. They can be seen on a front-facing X-ray when the arm is in internal rotation.{{cite journal | vauthors = Riebel GD, McCabe JB | title = Anterior shoulder dislocation: a review of reduction techniques | journal = The American Journal of Emergency Medicine | volume = 9 | issue = 2 | pages = 180–8 | date = March 1991 | pmid = 1994950 | doi = 10.1016/0735-6757(91)90187-o }} Bankart lesions are disruptions of the glenoid labrum with or without an avulsion of bone fragment.{{Cite book| url=https://www.ncbi.nlm.nih.gov/books/NBK459125/ | pmid=29083735 | title=StatPearls | chapter=Shoulder Dislocations Overview | date=2024 | publisher=StatPearls }}

Damage to the axillary artery{{cite journal | vauthors = Kelley SP, Hinsche AF, Hossain JF | title = Axillary artery transection following anterior shoulder dislocation: classical presentation and current concepts | journal = Injury | volume = 35 | issue = 11 | pages = 1128–32 | date = November 2004 | pmid = 15488503 | doi = 10.1016/j.injury.2003.08.009 }} and axillary nerve (C5, C6) may result. The axillary nerve is injured in 37% making it the most commonly injured structure with this type of injury.{{cite journal | vauthors = Malik S, Chiampas G, Leonard H | title = Emergent evaluation of injuries to the shoulder, clavicle, and humerus | journal = Emergency Medicine Clinics of North America | volume = 28 | issue = 4 | pages = 739–63 | date = November 2010 | pmid = 20971390 | doi = 10.1016/j.emc.2010.06.006 }} Other common, associated, nerve injuries include injury to the suprascapular nerve (29%) and the radial nerve (22%). Axillary nerve damage results in a weakened or paralyzed deltoid muscle and as the deltoid atrophies unilaterally, the normal rounded contour of the shoulder is lost. A person with injury to the axillary nerve will have difficulty in abducting the arm from approximately 15° away from the body. The supraspinatus muscle initiates abduction from a fully adducted position.{{citation needed|date=October 2020}}

File:Luxation epaule.PNG|An anterior dislocation of the shoulder

File:AnterDisAPMark.png|Anterior dislocation of the right shoulder. AP X ray

File:AnterDisMark.png|Anterior dislocation of the right shoulder. Y view X ray.

File:Lightbulb sign - posterior shoulder dislocation - Roe vor und nach Reposition 001.jpg

Posterior dislocations are uncommon, and are typically due to the muscle contraction from electric shock or seizure. They may be caused by strength imbalance of the rotator cuff muscles. People with dislocated shoulders typically present holding their arm internally rotated and adducted, and exhibiting flattening of the anterior shoulder with a prominent coracoid process.{{citation needed|date=October 2020}}

Posterior dislocations may go unrecognized, especially in an elderly person{{EMedicine|emerg|148|Dislocations, Shoulder}} and in people who are in the state of unconscious trauma.Life in the Fast Lane [http://lifeinthefastlane.com/2009/06/posterior-shoulder-dislocation/ Posterior Shoulder Dislocation] {{webarchive |url=https://web.archive.org/web/20100106011232/http://lifeinthefastlane.com/2009/06/posterior-shoulder-dislocation/ |date=January 6, 2010 }} An average interval of 1 year was noted between injury and diagnosis in a series of 40 people.{{cite journal | vauthors = Hawkins RJ, Neer CS, Pianta RM, Mendoza FX | title = Locked posterior dislocation of the shoulder | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 69 | issue = 1 | pages = 9–18 | date = January 1987 | pmid = 3805075 | doi = 10.2106/00004623-198769010-00003 | url = http://www.medscape.com/medline/abstract/3805075?src=emed_ckb_ref_0 | url-status = live | archive-url = https://web.archive.org/web/20071013084735/http://www.medscape.com/medline/abstract/3805075?src=emed_ckb_ref_0 | archive-date = 2007-10-13 }}

Image:Inferiourdislocation.JPG. Also present is a fracture of the greater tuberosity.]]

Inferior dislocation is the least likely, occurring in less than 1%. This condition is also called luxatio erecta because the arm appears to be permanently held upward or behind the head.{{EMedicine|emerg|148|Dislocations, Shoulder|clinical}} It is caused by a hyper abduction of the arm that forces the humeral head against the acromion.{{cite journal | vauthors = Yamamoto T, Yoshiya S, Kurosaka M, Nagira K, Nabeshima Y | title = Luxatio erecta (inferior dislocation of the shoulder): a report of 5 cases and a review of the literature | journal = American Journal of Orthopedics | volume = 32 | issue = 12 | pages = 601–3 | date = December 2003 | pmid = 14713067 }} Such injuries have a high complication rate as many vascular, neurological, tendon, and ligament injuries are likely to occur from this mechanism of injury.

Prompt medical treatment should be sought for suspected dislocation.

Usually, the shoulder is kept in its current position by use of a splint or sling. A pillow between the arm and torso may provide support and increase comfort. Strong analgesics are needed to allay the pain of a dislocation and the distress associated with it.{{citation needed|date=October 2020}}

File:Cunningham2017.jpg

{{Main|Shoulder reduction}}

Shoulder reduction may be accomplished with a number of techniques including traction-countertraction, external rotation, scapular manipulation, Stimson technique, Cunningham technique, or Milch technique. Pain can be managed during the procedures either by procedural sedation and analgesia or injected lidocaine into the shoulder joint.{{cite journal | vauthors = Fitch RW, Kuhn JE | title = Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review | journal = Academic Emergency Medicine | volume = 15 | issue = 8 | pages = 703–8 | date = August 2008 | pmid = 18783486 | doi = 10.1111/j.1553-2712.2008.00164.x | doi-access = }} Injecting lidocaine into the joint may be less expensive and faster.{{cite journal | vauthors = Wakai A, O'Sullivan R, McCabe A | title = Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD004919 | date = April 2011 | volume = 2013 | pmid = 21491392 | doi = 10.1002/14651858.CD004919.pub2 | pmc = 8859829 }} If a shoulder cannot be relocated in the emergency room, relocation in the operating room may be required. This situation occurs in about 7% of cases.

{{Cite web|date=2020-09-14|title=Medically Sound: A Bump to a Shoulder – Dislocated, Fractured|url=https://urmedlife.blogspot.com/2020/09/a-bump-to-shoulder-dislocated-fractured.html|access-date=2020-11-01|website=Medically Sound}} Stimson procedure is the least painful, widely used shoulder reduction technique. In this procedure a weight is attached to the wrist while the injured arm is hanging off an examination table for between 20 and 30 minutes. The arm is then slowly rotated until the shoulder is relocated. Sedatives are used in Stimson procedure and first time Stimson reduction for acute shoulder dislocation requires wearing arm slings for between 2 and 4 weeks.

There is no strong evidence of a difference in outcomes when the arm is immobilized in internal versus external rotation following an anterior shoulder dislocation.{{cite journal | vauthors = Whelan DB, Kletke SN, Schemitsch G, Chahal J | title = Immobilization in External Rotation Versus Internal Rotation After Primary Anterior Shoulder Dislocation: A Meta-analysis of Randomized Controlled Trials | journal = The American Journal of Sports Medicine | volume = 44 | issue = 2 | pages = 521–32 | date = February 2016 | pmid = 26116355 | doi = 10.1177/0363546515585119 | s2cid = 26001387 }}{{cite journal | vauthors = Braun C, McRobert CJ | title = Conservative management following closed reduction of traumatic anterior dislocation of the shoulder | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | pages = CD004962 | date = May 2019 | issue = 5 | pmid = 31074847 | pmc = 6510174 | doi = 10.1002/14651858.CD004962.pub4 }} A 2008 study of 300 people for almost six years found that conventional shoulder immobilisation in a sling offered no benefit.{{cite journal | vauthors = Chalidis B, Sachinis N, Dimitriou C, Papadopoulos P, Samoladas E, Pournaras J | title = Has the management of shoulder dislocation changed over time? | journal = International Orthopaedics | volume = 31 | issue = 3 | pages = 385–9 | date = June 2007 | pmid = 16909255 | pmc = 2267594 | doi = 10.1007/s00264-006-0183-y }}

File:Post Dislocated shoulder MRI 01.png

In young adults engaged in highly demanding activities shoulder surgery may be considered.{{cite journal | vauthors = Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V | title = Management of primary acute anterior shoulder dislocation: systematic review and quantitative synthesis of the literature | journal = Arthroscopy | volume = 30 | issue = 4 | pages = 506–22 | date = April 2014 | pmid = 24680311 | doi = 10.1016/j.arthro.2014.01.003 }} Arthroscopic surgery techniques may be used to repair the glenoidal labrum, capsular ligaments, biceps long head anchor or SLAP lesion or to tighten the shoulder capsule.{{cite web|title=Shoulder Scope|url=http://www.orthop.washington.edu/?q=patient-care/articles/sports/shoulder-scope.html|website=UW Orthopaedics and Sports Medicine, Seattle|access-date=14 October 2017|language=en|date=3 August 2012|url-status=live|archive-url=https://web.archive.org/web/20171013225042/http://www.orthop.washington.edu/?q=patient-care/articles/sports/shoulder-scope.html|archive-date=13 October 2017}}

Arthroscopic stabilization surgery has evolved from the Bankart repair, a time-honored surgical treatment for recurrent anterior instability of the shoulder.{{cite web | url=http://www.orthop.washington.edu/openbankart | title=Bankart repair for unstable dislocating shoulders | publisher=University of Washington: Orthopaedics and Sports Medicine | url-status=live | archive-url=https://web.archive.org/web/20080115171413/http://www.orthop.washington.edu/openbankart | archive-date=2008-01-15 }} However, the failure rate following Bankart repair has been shown to increase markedly in people with significant bone loss from the glenoid (socket).{{cite journal | vauthors = Burkhart SS, De Beer JF | title = Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion | journal = Arthroscopy | volume = 16 | issue = 7 | pages = 677–94 | date = October 2000 | pmid = 11027751 | doi = 10.1053/jars.2000.17715 }} In such cases, improved results have been reported with some form of bone augmentation of the glenoid such as the Latarjet operation.{{cite journal | vauthors = Burkhart SS, De Beer JF, Barth JR, Cresswell T, Criswell T, Roberts C, Richards DP | title = Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss | journal = Arthroscopy | volume = 23 | issue = 10 | pages = 1033–41 | date = October 2007 | pmid = 17916467 | doi = 10.1016/j.arthro.2007.08.009 }}{{cite journal | vauthors = Noonan B, Hollister SJ, Sekiya JK, Bedi A | title = Comparison of reconstructive procedures for glenoid bone loss associated with recurrent anterior shoulder instability | journal = Journal of Shoulder and Elbow Surgery | volume = 23 | issue = 8 | pages = 1113–9 | date = August 2014 | pmid = 24561175 | doi = 10.1016/j.jse.2013.11.011 }}{{cite journal | vauthors = Chen D, Goldberg J, Herald J, Critchley I, Barmare A | title = Effects of surgical management on multidirectional instability of the shoulder: a meta-analysis | journal = Knee Surgery, Sports Traumatology, Arthroscopy | volume = 24 | issue = 2 | pages = 630–9 | date = February 2016 | pmid = 26658564 | doi = 10.1007/s00167-015-3901-4 | s2cid = 35624937 }}

Although posterior dislocation is much less common, instability following it is no less challenging and, again, some form of bone augmentation may be required to control instability.{{cite journal | vauthors = Millett PJ, Schoenahl JY, Register B, Gaskill TR, van Deurzen DF, Martetschläger F | title = Reconstruction of posterior glenoid deficiency using distal tibial osteoarticular allograft | journal = Knee Surgery, Sports Traumatology, Arthroscopy | volume = 21 | issue = 2 | pages = 445–9 | date = February 2013 | pmid = 23114865 | doi = 10.1007/s00167-012-2254-5 | s2cid = 8237748 }} Damaged ligaments, including labral tears, occurring as a result of posterior dislocations may be treated arthroscopically.{{citation needed|date=October 2020}}

There remains those situations characterized by multidirectional instability, which have failed to respond satisfactorily to rehabilitation, falling under the AMBRI classification previously noted. This is usually due to an overstretched and redundant capsule which no longer offers stability or support. Traditionally, this has responded well to a 'reefing' procedure known as an open inferior capsular shift.{{cite journal | vauthors = Fleega BA, El Shewy MT | title = Arthroscopic inferior capsular shift: long-term follow-up | journal = The American Journal of Sports Medicine | volume = 40 | issue = 5 | pages = 1126–32 | date = May 2012 | pmid = 22437281 | doi = 10.1177/0363546512438509 | s2cid = 11329565 }} More recently, the procedure has been carried out as an arthroscopic procedure, rather than open surgery, again with comparable results. Most recently, the procedure has been carried out using radio frequency technology to shrink the redundant shoulder capsule (thermal capsular shrinkage);{{cite journal | vauthors = Mohtadi NG, Kirkley A, Hollinshead RM, McCormack R, MacDonald PB, Chan DS, Sasyniuk TM, Fick GH, Paolucci EO | display-authors = 6 | title = Electrothermal arthroscopic capsulorrhaphy: old technology, new evidence. A multicenter randomized clinical trial | journal = Journal of Shoulder and Elbow Surgery | volume = 23 | issue = 8 | pages = 1171–80 | date = August 2014 | pmid = 24939380 | doi = 10.1016/j.jse.2014.02.022 }} while long-term results of this development are currently unproven, recent studies show thermal capsular shrinkage have higher failure rates with the highest number of cases of instability recurrence and re-operation.

Following shoulder reduction, most people are given self-management advice on recovery, such as home exercises, but some receive additional physiotherapy. A randomised controlled trial showed similar shoulder function after 6 months between those who received self-management advice only and those who had extra physiotherapy. Both groups also had a similar number of complications.{{Cite journal |last1=Kearney |first1=Rebecca S. |last2=Ellard |first2=David R. |last3=Parsons |first3=Helen |last4=Haque |first4=Aminul |last5=Mason |first5=James |last6=Nwankwo |first6=Henry |last7=Bradley |first7=Helen |last8=Drew |first8=Stephen |last9=Modi |first9=Chetan |last10=Bush |first10=Howard |last11=Torgerson |first11=David |last12=Underwood |first12=Martin |date=2024-01-17 |title=Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomised controlled trial |url=https://www.bmj.com/content/384/bmj-2023-076925 |journal=BMJ |language=en |volume=384 |pages=e076925 |doi=10.1136/bmj-2023-076925 |issn=1756-1833 |pmc=10792684 |pmid=38233068}}{{Cite journal |date=24 April 2024 |title=Shoulder dislocation: a single physiotherapy session is usually sufficient |url=https://evidence.nihr.ac.uk/alert/shoulder-dislocation-extra-physiotherapy-is-no-better-than-self-management/ |journal=NIHR Evidence|doi=10.3310/nihrevidence_62848 }}

After an anterior shoulder dislocation, the risk of a future dislocation is about 20%. This risk is greater in males than females.{{cite journal | vauthors = Wasserstein DN, Sheth U, Colbenson K, Henry PD, Chahal J, Dwyer T, Kuhn JE | title = The True Recurrence Rate and Factors Predicting Recurrent Instability After Nonsurgical Management of Traumatic Primary Anterior Shoulder Dislocation: A Systematic Review | journal = Arthroscopy | volume = 32 | issue = 12 | pages = 2616–2625 | date = December 2016 | pmid = 27487737 | doi = 10.1016/j.arthro.2016.05.039 }}

• Shoulder problems

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{{Medical resources

| DiseasesDB = 31231

| ICD10 = {{ICD10|S|43|0|s|40}}

| ICD9 = {{ICD9|831}}

| OMIM =

| MedlinePlus =

| ICDO =

| eMedicineSubj = orthoped

| eMedicineTopic = 440

| eMedicine_mult = {{eMedicine2|radio|630}} {{eMedicine2|sports|152}}

| MeshID = D012783

}}

{{Dislocations, sprains and strains}}

Category:Injuries of shoulder and upper arm

Category:Shoulder

shoulder Dislocated

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