Dislocated shoulder
Encyclopedia
A dislocated shoulder occurs when the humerus
Humerus
The humerus is a long bone in the arm or forelimb that runs from the shoulder to the elbow....

 separates from the scapula
Scapula
In anatomy, the scapula , omo, or shoulder blade, is the bone that connects the humerus with the clavicle ....

 at the glenohumeral joint
Glenohumeral joint
The glenohumeral joint, or shoulder joint, is a multiaxial synovial ball and socket joint and involves articulation between the glenoid fossa of the scapula and the head of the humerus...

. The shoulder joint has the greatest range of motion of any joint in the body and as a result is particularly susceptible to dislocation and subluxation
Subluxation
A subluxation may have different meanings, depending on the medical specialty involved. It implies the presence of an incomplete or partial dislocation of a joint or organ. The World Health Organization defines both the medical subluxation and the chiropractic subluxation...

. Approximately half of major joint dislocations seen in emergency departments are of the shoulder. Partial dislocation of the shoulder is referred to as subluxation
Subluxation
A subluxation may have different meanings, depending on the medical specialty involved. It implies the presence of an incomplete or partial dislocation of a joint or organ. The World Health Organization defines both the medical subluxation and the chiropractic subluxation...

.

Anterior (forward)

Over 95% of shoulder dislocation cases are anterior. Most anterior dislocations are sub-coracoid. Sub-glenoid; subclavicular
Clavicle
In human anatomy, the clavicle or collar bone is a long bone of short length that serves as a strut between the scapula and the sternum. It is the only long bone in body that lies horizontally...

; and, very rarely, intrathoracic or retroperitoneal dislocations may occur.

It can result in damage to the axillary artery
Axillary artery
In human anatomy, the axillary artery is a large blood vessel that conveys oxygenated blood to the lateral aspect of the thorax, the axilla and the upper limb...

.

Posterior (backward)

Posterior dislocations are occasionally due to electric shock
Electric shock
Electric Shock of a body with any source of electricity that causes a sufficient current through the skin, muscles or hair. Typically, the expression is used to denote an unwanted exposure to electricity, hence the effects are considered undesirable....

 or seizure and may be caused by strength imbalance of the rotator cuff muscles.
Posterior dislocations often go unnoticed, especially in an elderly patient and in the unconscious trauma patient. An average interval of 1 year was discovered between injury and diagnosis of posterior dislocation in a series of 40 patients.

Inferior (downward)

Inferior dislocation is the least likely form, occurring in less than 1% of all shoulder dislocation cases. This condition is also called luxatio erecta because the arm appears to be permanently held upward or behind the head. It is caused by a hyper abduction of the arm that forces the humeral head against the acromion. Inferior dislocations have a high complication rate as many vascular, neurological, tendon, and ligament injuries are likely to occur from this kind of dislocation.

Signs

  • Significant pain
    Pain
    Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...

    , which can sometimes be felt past the shoulder
    Shoulder
    The human shoulder is made up of three bones: the clavicle , the scapula , and the humerus as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The major joint of the shoulder is the glenohumeral joint, which...

    , along the arm.
  • Inability to move the arm from its current position, particularly in positions with the arm reaching away from the body and with the top of the arm
    Arm
    In human anatomy, the arm is the part of the upper limb between the shoulder and the elbow joints. In other animals, the term arm can also be used for analogous structures, such as one of the paired forelimbs of a four-legged animal or the arms of cephalopods...

     twisted toward the back.
  • Numbness of the arm.
  • Visibly displaced shoulder. Some dislocations result in the shoulder appearing unusually square.
  • No bone
    Bone
    Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

     in the side of the shoulder showing shoulder has become dislocated.

Initial

Prompt professional medical treatment should be sought for any suspected dislocation injury.
Usually, a dislocated shoulder is kept in its current position by use of a splint
Splint (medicine)
A splint is a device used for support or immobilization of limbs or of the spine.It can be used:* By the emergency medical services or by volunteer first responders, to immobilize a fractured limb before the transportation; it is then a temporary immobilization;* By allied health professionals such...

 or sling (however, see below). A pillow between the arm
Arm
In human anatomy, the arm is the part of the upper limb between the shoulder and the elbow joints. In other animals, the term arm can also be used for analogous structures, such as one of the paired forelimbs of a four-legged animal or the arms of cephalopods...

 and torso
Torso
Trunk or torso is an anatomical term for the central part of the many animal bodies from which extend the neck and limbs. The trunk includes the thorax and abdomen.-Major organs:...

 may provide support and increase comfort. Strong analgesics are needed to allay the pain of a dislocation and the anxiety associated with it, and hence, conservative measures of pain relief should not be attempted.

Emergency department
Emergency department
An emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...

 care is focused on returning the shoulder to its normal position via processes known as reduction
Reduction (orthopedic surgery)
Reduction is a medical procedure to restore a fracture or dislocation to the correct alignment. When a bone fractures, the fragments lose their alignment in the form of displacement or angulation. For the fractured bone to heal without any deformity the bony fragments must be re-aligned to their...

. Normally, closed reduction, in which several methods are used to manipulate the bone and joint
Joint
A joint is the location at which two or more bones make contact. They are constructed to allow movement and provide mechanical support, and are classified structurally and functionally.-Classification:...

 from the outside, is used. A variety of techniques exist, but some are preferred due to fewer complication
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...

s or easier execution. In cases where closed reduction is not successful, surgical open reduction may be needed. Following reduction, X-Ray
X-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...

 imaging is often used to ensure that the reduction was successful and there are no fracture
Fracture
A fracture is the separation of an object or material into two, or more, pieces under the action of stress.The word fracture is often applied to bones of living creatures , or to crystals or crystalline materials, such as gemstones or metal...

s. The arm should be kept in a sling or immobilizer for several days, preferably until orthopedic consultation.
Hippocrates
Hippocrates
Hippocrates of Cos or Hippokrates of Kos was an ancient Greek physician of the Age of Pericles , and is considered one of the most outstanding figures in the history of medicine...

' and Kocher
Kocher manoeuvre
Kocher manoeuvre is a surgical manoeuvre to expose structures in the retroperitoneum behind the duodenum and pancreas; for example to control hemorrhage from the inferior vena cava or aorta, or to facilitate removal of a pancreatic tumour. It is named for the Nobel prize-winning surgeon Dr...

's method are rarely used anymore. Hippocrates used to place the heel
Heel
In human anatomy, the heel is the prominence at the posterior end of the foot. It is based on the projection of one bone, the calcaneus or heel bone, behind the articulation of the bones of the lower leg.- Human anatomy :...

 in the axilla and reduce shoulder dislocations.
Kocher's method, if performed patiently and slowly, can be performed without anesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...

 and if done correctly does not cause pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...

. Traction
Traction (orthopedics)
In orthopedic medicine, traction refers to the set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system.There are two types of traction: skin traction and skeletal traction....

 is applied on the arm and it is abducted. Then, it is externally rotated, and the arm is adducted following which it is internally rotated and maintained in the position with the help of a sling. A chest x-ray
Chest X-ray
In medicine, a chest radiograph, commonly called a chest X-ray , is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures...

 should be taken to confirm whether the head of humerus has reduced back into the glenoid cavity
Glenoid cavity
The glenoid cavity is a shallow pyriform, articular surface, which is located on the lateral angle of the scapula. It is directed laterally and forward and articulates with the head of the humerus; it is broader below than above and its vertical diameter is the longest.This cavity forms the...

. This methodology is performed with external rotation of shoulder, and adduction of the elbow. Some do not recommend it because of possible neurovascular complications and proximal humerus fractures.

If no medical help is available, fairly simple methods can be attempted, such as Milch's method, or Stimson's Method (anterior dislocations).

In Australia, an anterior dislocation reduction method that is commonly used is the Spaso technique. This technique was first used by Spaso Miljesic a plaster technician at Western Health, Melbourne, Australia. The technique is reliable and simple. Holding the patient's wrist, gently flex the arm at the shoulder joint with an extended elbow until 90 degrees is achieved. Then apply gentle traction and external rotation. Listen for a clunk indicating relocation. If the patient experiences pain and muscle spasm, wait until it subsides and gently continue. Procedural sedation may be useful. A recent study found the Spaso technique useful in 87.5% of cases of anterior dislocation with no complications.

Post-reduction: immobilisation in external versus internal rotation

For thousands of years, treatment of anterior shoulder dislocation has included immobilisation of the patient's arm in a sling, with the arm placed in internal rotation (across the body). However, three studies, one in cadavers and two in patients, suggest that the detachment of the structures in the front of the shoulder is made worse when the shoulder is placed in internal rotation to be seen. By contrast, the structures are realigned when the arm is placed in external rotation. New data suggest that if the shoulder is managed non-operatively and immobilised, it should be immobilised in a position of external rotation.

Another study found that conventional shoulder immobilisation in a sling offered no benefit.

Surgery

Some cases require non-emergency surgery to repair damage to the tissue
Tissue (biology)
Tissue is a cellular organizational level intermediate between cells and a complete organism. A tissue is an ensemble of cells, not necessarily identical, but from the same origin, that together carry out a specific function. These are called tissues because of their identical functioning...

s surrounding in the shoulder joint and restore shoulder stability. Arthroscopic surgery techniques may be used to repair the glenoidal labrum
Glenoidal labrum
The glenoid labrum is a fibrocartilaginous rim attached around the margin of the glenoid cavity in the shoulder blade. The shoulder joint is considered a 'ball and socket' joint. However, in bony terms the 'socket' is quite shallow and small, covering at most only a third of the 'ball'...

, capsular ligaments, biceps
Biceps brachii muscle
In human anatomy, the biceps brachii, or simply biceps in common parlance, is, as the name implies, a two-headed muscle located on the upper arm. Both heads arise on the scapula and join to form a single muscle belly which is attached to the upper forearm...

 long head anchor or SLAP lesion
SLAP tear
A SLAP tear or SLAP lesion is an injury to the Glenoid labrum . SLAP is an acronym that stands for "superior labral tear from anterior to posterior".-Overview:...

 and/or to tighten the shoulder capsule.

The time-proven surgical treatment for recurrent anterior instability of the shoulder is a Bankart repair. Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy
Arthroscopy
Arthroscopy is a minimally invasive surgical procedure in which an examination and sometimes treatment of damage of the interior of a joint is performed using an arthroscope, a type of endoscope that is inserted into the joint through a small incision...

 can lessen pain and improve function for active individuals. When the front of the shoulder socket has been broken or worn, a bone graft may be required to restore stability.
When the shoulder dislocates posteriorly (out the back), a surgery to reshape the socket may be necessary. Surgery to build up the back of the glenoid socket using an osteotomy
Osteotomy
An osteotomy is a surgical operation whereby a bone is cut to shorten, lengthen, or change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum...

 and graft
Medical grafting
Grafting refers to a surgical procedure to move tissue from one site to another on the body, or from another person, without bringing its own blood supply with it. Instead, a new blood supply grows in after it is placed. A similar technique where tissue is transferred with the blood supply intact...

 can restore shoulder anatomy
Anatomy
Anatomy is a branch of biology and medicine that is the consideration of the structure of living things. It is a general term that includes human anatomy, animal anatomy , and plant anatomy...

 and lessen pain and improve function. Conversely, there are new procedures that should be investigated as a possible alternative to open surgery.

Non-operative

Rotator cuff
Rotator cuff
In anatomy, the rotator cuff is the group of muscles and their tendons that act to stabilize the shoulder. The four muscles of the rotator cuff, along with the teres major muscle, the coracobrachialis muscle and the deltoid, make up the seven scapulohumeral muscles of the human body.-Function:The...

 and deltoid strengthening has long been the focus of conservative treatment for the unstable shoulder and in many cases is advocated as a substitute for surgical stabilization. In multidirectional instability patients who have experienced atraumatic subluxation
Subluxation
A subluxation may have different meanings, depending on the medical specialty involved. It implies the presence of an incomplete or partial dislocation of a joint or organ. The World Health Organization defines both the medical subluxation and the chiropractic subluxation...

 or dislocation events, cohort studies demonstrate good responses to long-term progressive resistance exercises if judged according to function, pain, stability, and motion scores. However, in those experiencing a discrete traumatic dislocation event, responses to non-operative treatment are less than satisfactory, a pattern that inspired the Matsen and Harryman classification of shoulder instability, TUBS (traumatic, unidirectional, Bankart, and usually requiring surgery) and AMBRI (atraumatic, multidirectional, bilateral, rehabilitation, and occasionally requiring an inferior capsular shift). It is thought that traumatic dislocations, as opposed to atraumatic dislocations and instability events, result in a higher incidence of capsuloligamentous injuries that disturb normal anatomy and leave shoulders too structurally compromised to respond to conservative treatment. Pathoanatomic studies of first-time traumatic anterior dislocators reveal a high rate of labral lesions including Bankart lesions
Bankart lesion
In orthopaedics, a Bankart lesion is an injury of the anterior glenoid labrum due to repeated shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it...

.

See also

  • Shoulder problems
  • Shoulder surgery
    Shoulder surgery
    As the shoulder is the most complex and unstable joint in the body, it can get injured easily. Many surgeries have been developed to repair the muscles, connective tissue or damaged joints that can arise from traumatic or overuse injuries to the shoulder....

  • Reduction (orthopedic surgery)
    Reduction (orthopedic surgery)
    Reduction is a medical procedure to restore a fracture or dislocation to the correct alignment. When a bone fractures, the fragments lose their alignment in the form of displacement or angulation. For the fractured bone to heal without any deformity the bony fragments must be re-aligned to their...


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