Shoulder Joint Dislocation

Traumatic shoulder joint dislocation follows severe pain. Almost all patients following traumatic shoulder joint dislocation visit emergency room. A traumatic shoulder joint dislocation is often seen in elderly patients suffering with severe arthritis and pain is mild to moderate. Pain is often tolerable and elderly patient may think pain is secondary to arthritis. Investigations and treatment in such cases are postponed. Shoulder joint pain should be investigated in elderly patient to rule out dislocation.

Shoulder Joint Dislocation

Symptoms And Signs Of Shoulder Joint Dislocation

Severe Pain-

  • Traumatic shoulder joint dislocation is very painful condition.
  • Pain often comes from soft tissue and cartilage of shoulder joint. Dislocation pulls humerus out of socket and causes injuries to cartilage, rim of the socket, ligaments and tendon, which results in severe pain.
  • Pain is continuous and increased with movements of the arm.

Inability to Move Arm-

  • Patient is unable to move the upper arm around the shoulder joint.
  • Humerus moves within normal ball and socket shoulder joint. Patient is unable to move arms within shoulder joint when humerus is out of socket. The reason is often because of mechanical obstruction to movements.

Abnormal Arm Position-

Anterior Dislocation-

Anterior Dislocation

  • Arm is held in abduction 10 to 20 degrees away from side of the body and externally rotated.
  • Deltoid and acromion prominence is shifted posterior and laterally.
  • Head of humerus is felt anterior to joint.

Posterior Dislocation

  • Following posterior dislocation arm is adducted (lies against side of the body) and internally rotated at shoulder joint.
  • Arm is often flexed at elbow joint.

Inferior Dislocation

Inferior Dislocation

  • Arm is held upward and behind the head until dislocation is corrected.
  • Arm position is known as "Luxatio Erecta".

Tenderness Over The Shoulder Joint

  • Examination of the shoulder joint such as palpation causes severe pain.
  • Pain elicited on slight or blunt touch.

Abnormal Swelling Around Shoulder Joint

Soft Swelling- Caused by hematoma (blood clot.)

Firm To Hard Swelling-

Cause of firm to hard swelling is as follows-

  • Protrusion of Head of Humerus.
  • Fragments of fractured humerus or acromion if shoulder joint dislocation is associated with fracture of one of the shoulder joint bone.

Bruising

Purple discoloration is observed over the shoulder joint because of skin laceration or subcutaneous bleeding

Shoulder Joint Deformity

Causes Of Shoulder Joint Deformity Following Shoulder Joint Dislocation Are As Follows-

  • Protrusion of head of humerus.
  • Hematoma (blood clot)
  • Fragments of fractured humerus or acromion if shoulder joint dislocation is associated with fracture of one of the shoulder joint bone.

Shoulder Joint Stiffness

  • Shoulder joint stiffness is caused by muscle spasm and tendon injury.
  • Muscle spasm is initiated by severe pain and joint inflammation
  • Cartilage tear and/or ligament tear also causes joint stiffness
  • Patient is unable to flex, extend or rotate the arm.

Frozen Shoulder-

Frozen Shoulder Joint Follows-

  • Shoulder joint stiffness
  • Shoulder joint dislocation and
  • Prolonged immobilization of shoulder joint.

Frozen shoulder joint is avoided by immediate correction of dislocation and establishing physical therapy or exercises for earlier joint mobility.

Non-Specific Symptoms

  • Nausea
  • Vomiting
  • Dizziness

Investigations And Diagnostic Tests for Shoulder Joint Dislocation

Investigations And Diagnostic Tests for Shoulder Joint Dislocation

X-RAY of Shoulder Joint

X-Ray is performed in emergency room immediately after admission to rule out shoulder joint dislocation. X-ray will show following joint dislocation with or without fracture-

  • Gleno-Humeral dislocation and
  • Acromio-Clavicular joint dislocation.

MRI

Shoulder joint MRI scanning shows details of soft tissue and bones of the shoulder joint.

  • MRI picture provides multi dimensional views.
  • Magnetic resonance of MRI machine creates images of high resolutions using magnetic resonance.
  • Sophisticated computer analyzes images before displaying on screen.
  • The images are printed or stored on DVD for future reference.

CAT Scan

  • CAT scan takes multiple X-Ray pictures while scanning the soft tissue and bones.
  • The images are analyzed and processed by advanced computers.
  • CAT scan is often used as an alternative diagnostic test instead of MRI.

Ultrasound

  • Ultrasound study is performed to diagnose soft tissue swelling, fracture and dislocation
  • Probe of ultrasound is placed over shoulder joint. A computer resulting in image analyzes the rebound information.
  • The study is beneficial to diagnose fluid collection (hematoma- blood clot) in the joint and abnormal alignment of the joint (dislocation).

Electical Study: Electromyogram (EMG)

EMG is performed to evaluate following injuries-

Arthroscopy Of Shoulder Joint

Arthroscopy Of Shoulder Joint

Arthroscopy is performed to rule out following injuries associated with shoulder joint dislocation.

  • Shoulder Joint Fracture
  • Joint Hematoma
  • Subcutaneous Hematoma
  • Tendon injury and tear
  • Ligament tear and injury

Treatment Of Shoulder Joint Dislocation

1. Emergency Room Treatment Of Shoulder Joint Dislocation-

Patient following shoulder joint dislocation are often brought to emergency room. Shoulder joint dislocation is either repeat or first time dislocation. Emergency room treatment is as follows.

Pain Medications (Analgesics)-

  • Severe intractable pain is treated with oral or intravenous opioids.
  • Repeat shoulder joint dislocation is often reduced under opioid analgesia.

Muscle Relaxants

Indications For Muscle Relaxants-

  • Muscle Pain
  • Muscle Spasm.
  • Assist close reduction of repeat or habitual shoulder joint dislocation.
  • Post surgery muscle spasm.

Close Reduction

Indications For Close Reduction-

  • Repeat shoulder joint dislocation- may or may not need sedation.
  • First time shoulder joint dislocation- always needs sedation or general anesthesia.
Methods of Close Reduction To Treat Anterior Shoulder Joint Dislocation-

Hennepin Maneuver: Close Reduction By External Rotation

  • Procedure is performed while patient is lying flat on hard surface or sitting on comfortable chair.
  • Procedure is performed under light sedation or general anesthesia.
  • Physician will hold the arm at wrist and arm is flexed at elbow to 90 degrees.
  • Arm is slowly twisted outward (external rotation) with traction toward floor.
  • Procedure is repeated if arm rotation is resisted by muscle spasm.
  • Joint is reduced when flex forearm is positioned at 90 degree to shoulder joint.
  • The outcome of the procedure is checked with X-Ray.

Rockwood Technique-

  • Rockwood Technique Procedure involves traction and counter traction.
  • Patient is advised to lie flat on firm bed
  • Bed sheet is looped around the armpit.
  • Assistant gently pulls down the dislocated arm (traction).
  • Orthopedic surgeon pulls on the bed sheet to apply counter traction
  • Procedure may be performed under sedation.

Stimson's Technique-

  • Patient lies on hard table in prone position (face down on table) with dislocated arm hanging on the side of the table.
  • 5 pounds of weight is taped around the wrist of dislocated arm.
  • Elbow joint is bent 90 degree.
  • Downward traction is created by weight and pull of the elbow flex dislocated arm by an orthopedic surgeon.
  • Procedure may take 20 to 30 mins to reduce the dislocation.

2. Elective Treatment Of Shoulder Joint Dislocation

Moist Heat

Moist Heat For Shoulder Joint Dislocation

  • Treatment is suggested for 3 to 4 times a day for 2 to 3 weeks.
  • Moist heat is indicated for chronic pain and muscle spasm.

Cold or Ice Therapy

Cold or Ice Therapy For Shoulder Joint Dislocation

  • Treatment is suggested for 3 to 4 times a day for 20 to 30 minutes for 2 to 3 weeks.
  • Ice therapy is indicated for chronic pain, joint swelling and muscle spasm.

Immobilized Shoulder Joint

Immobilization of shoulder joint is done by using Figure of 8 slings.

Immobilized Shoulder Joint

Indications For Immobilization-

  • Dislocated Shoulder joint
  • Following close reduction
  • Following open surgical reduction
  • Prevent repeat dislocation

3. Elective Physical Therapy (PT) For Shoulder Joint

Physical therapy (PT) is advised following close or open reduction of the shoulder joint.

Physical Therapy: First 8 weeks

  • Supervised physical therapy of wrist and elbow joint is advised following close or open reduction of shoulder joint.
  • Exercise is prescribed to prevent joint stiffness and muscle spasm
  • Exercise is performed for 8 to 10 weeks following dislocation.

Physical Therapy: After 8 weeks

  • Muscle Exercises- Hand and forearm muscle exercises are performed under supervision. Muscle exercise prevents muscle atrophy and weakness
  • Strengthening of shoulder muscles
  • Improve flexibility of the shoulder
  • Improve shoulder joint movement
  • Prevent joint stiffness

4. Medications Prescribed Following Reduction Of Dislocation

NSAIDs For Shoulder Joint Dislocation

Indications for NSAIDS Are as Follows-

  • Inflammation
  • Mild to moderate pain
  • Most common NSAIDs prescribed are Motrin, Naproxen, Daypro, and Celebrex.

Opioids For Shoulder Joint Dislocation

Indications for Opioids are as follows-

  • Chronic severe pain.
  • May cause addiction and dependence.
  • Side effects such as nausea, vomiting or constipation are resistant to treatment.
  • Most common opioids prescribed are either short acting or long acting.
    1. Short acting opioids are hydrocodone, percocet and morphine.
    2. Long acting opioids are Oxycontin, MS Contin and Methadone.

Muscle Relaxants For Shoulder Joint Dislocation

Indications for muscle relaxants are as follows-

  • Muscle spasm
  • Frozen shoulder and
  • Muscle pain

5. Interventional Therapy For Shoulder Joint Dislocation

Interventional Therapy For Shoulder Joint Dislocation

Cortisone Injection For Shoulder Joint Dislocation

Indications for shoulder joint corticosteroids is as follows-

  • Shoulder joint inflammation
  • Chronic pain
  • Improve mobility and joint stiffness

Nerve Block For Shoulder Joint Dislocation

Indication for shoulder joint block is as follows-

  • Chronic pain
  • Muscle spasm
  • Improve joint movement
  • Assist physical therapy by reducing pain

6. Surgery For Shoulder Joint Dislocation

Close Reduction For Shoulder Joint Dislocation

Indications for close reduction are as follows-

  • Repeat shoulder joint dislocation
  • First time anterior shoulder joint dislocation
First Time Anterior Shoulder Joint Dislocation
  • Emergency room- Most of the close reduction is performed while patient is admitted at emergency room.
  • Out patient Surgery- Procedure is performed at outpatient surgery
  • Discharged following procedure-Patient discharged home following reduction
  • Arthroscopy- Patient is scheduled for arthroscopy immediately following shoulder joint reduction.

Arthroscopy For Shoulder Joint Dislocation

Arthroscopy is a procedure performed under general or local anesthesia. Arthroscope is a thin tubular instrument with camera at one end and eyepiece at other end. Camera end of the arthroscope is inserted into shoulder joint following tiny skin incision. The camera image is digitized, magnified and transferred to television screen.

Arthroscopy is performed following reduction of dislocation to diagnose associated injury.

Following surgical repairs are done using arthroscope-

  • Repair Glenoid Labrum
  • Repair capsular ligament
  • Tighten shoulder capsule

Open Reduction For Shoulder Joint Dislocation

  • Incision is done in front of shoulder joint (deltopectoral interval). Muscle and tendon separated from joint. Dislocated joint is reduced by lateral (outward traction) and internal rotation. Would is closed.
  • In cases with history of repeated dislocation using special sutures tightens capsule.
  • Bone graft is also used to reinforce capsule and rotator cuff.
  • Tendon and ligament tear is repaired with sutures.

Treatment of Shoulder Joint Fracture Associated With Dislocation

Open Reduction-

Shoulder joint replacement- build glenoid cavity and replace head of humerus.

Also Read: Causes and Types of Shoulder Joint Dislocation.

References

1. Labral injuries: accuracy of detection with unenhanced MR imaging of the shoulder.

Gusmer PB, Potter HG, Scatz JA, Wickiewica TL, Altchek DW, O'Brien SJ, et al. Radiology. 1996;200:519–24.

2. The pathology and treatment of recurrent dislocations of the shoulder joint.

Bankart ASB. Br J Surg. 1938;26:23–9.

3. Arthroscopic findings after shoulder dislocation.

Hintermann B, Gachter A. J Sports Med. 1995;23:545–51.

4. Position of immobilisation after dislocation of glenohumeral joint. A study using magnetic resonance imaging.

Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I, Sato K. J Bone Joint Surg Am. 2001;83:661–7.

5. Treating the initial anterior shoulder dislocation an evidence based medicine approach.

Kuhn JE. Sports Med Arthrosc. 2006;14:192–8. [PubMed]

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: May 2, 2016

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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