Shoulder Disclocations

Dislocations

Dislocated shoulders are a uncommon presentation in the A/E following a sports type of injury in the younger age group. These are more common in the elderly.

The amount of force required to dislocate a shoulder decreases with age in a linear fashion, hence a young snowboarder would require to 'bash' themselves pretty hard to dislocate the shoulder, if no previous injuries have been thrust upon the joint.

Classification

Chronological:

• ACUTE: injury within the last 3 weeks
• CHRONIC: dislocation more than 3 weeks
• RECURRENT: multiple episodes of dislocations

Anatomical:

• ANTERIOR: most common type of dislocation, where the head of the humerus is in front of the shoulder joint.
• POSTERIOR: uncommon, and the most easily missed type dislocation, where the head is situated behind the shoulder joint.

Following a traumatic dislocation, the chances of re-dislocating the shoulder is greatest in the younger age group.

percentage chance of redislocation = 100 - age;

ie a 15 year old will have a 85% of dislocating the shoulder again,

Clinical Features

• Pain. The pain is severe and is located in the region of the affected shoulder following a traumatic first dislocation. This is mainly true of anterior dislocations.
• Deformity. Anterior dislocations reveal themselves with the obvious lengthening of the arm, and the elongated look of the shoulder. The affected individual will support the afflicted arm.
• Posterior dislocations do not reveal themselves to well, and one can be lead to think all is well, hence they are are most often upto 80% of times missed until a later date.
• Bruising. There is a variable amount of bruising but a large bruising should be suspicious of an underlying fracture as well as a dislocation (fracture-dislocation)
• Numbness/Weakness. There may a weakness of lifting the shoulder and a numbness over the shoulder, for as the shoulder dislocates, it stretches the 'Axillary Nerve', and causes the nerve to disfunction. This usually recovers over the following days to months.

MANAGEMENT

• REDUCE. A dislocated shoulder will require it to be reduced.

• In a young strapping muscular person with a first dislocation, the muscular spasm can be so great as to prevent an easy reduction back into the socket under sedation. An attempt might be made in the Emergency Room, with analgesia, Enotnox(laughing-gas),sedatives, or even infiltration of the joint with local anaesthetic. This may not achieve the desired effect and hence a General Anaesthetic may be required.

Methods of reduction aim to work opposite to the dislocating force, they are:

• Hippocratic:traditional
• Hanging
• Sock-in-Arm
  

  Hippocratic Method: Apply traction
  		Alternative Method of reduction: Hanging Method

Following reduction an X-ray is ALWAYS taken! This is to check the whilst reducing the shoulder, the force used has not caused a fracture around the shoulder.

HOLD. The arm is held in a sling, and the sling is worn under the clothes for 3 weeks and outside for a further 3 weeks. This all varies with the experience of the treating surgeon, but in a young individual it is IMPERITIVE to follow the course, the longer you hold it there, the longer you give the healing process to repair the ruptured tissues to heal and tighten! Remember, you had to tear a lot of tissues to get the thing out in the first place, and basically you have created a weakness in front of the shoulder, hence makes it easier for theshoulder to re-dislocated. So for your own sake keep it in the sling.

• MOVE. While the arm is in the sling, remember to excercise those fingers, wrists an elbows. Then follow the regime set by your physiotherapist, to get the shoulder moving again.

• REMEMBER: in an Anterior Dislocation the best way to redislocate it is you put your arm back and outwards, ie when serving at tennis, or when you reach backwards and upwards to get something from your shelf!

RECURRENT

So you are one of the unfortunate characters who after the initial dislocation now redislocateds when you literally sneeze.

Well you are not the only one agonising ove the situation, so is the surgeon who has to decide what to do.

Usually it means an operative measure, now remember all the surgery is to TIGHTEN the tissues in front of the shoulder, if you have an anterior dislocation. So you have to look after yourself, if you disrupt those tissues by putting some force through it again, ie. Landing on your outstretched hand when wiped out trying that new Air, well, tough! It was the risk you took and lost.

The operation is successful majority of the time, but it is a major procedure, and requires all your effort to recover from the procedure with a functional shoulder.

• CHRONIC DISLOCATION

If you have had a dislocation for more than three weeks, and not seen a doctor for whatever reasons, by this time the tissues around the joint have a chance to tighten, and reducing the shoulder without opening the shoulder is not only very difficult but dangerous.

So expect the shoulder to be opened, and then held in place with a variety of metal-work.

Following that the gruesome physiotherapy starts. To get the shoulder moving again, and attempt to regain that initial range of movements.

Mail: H Dashti