Treatment of Traumatic Dislocations.
Last updated Thursday, February 10, 2005
Indications for early surgery in shoulders dislocaSoft tissue interposition Tietjen (Tietjen, 1982) reported a case in which surgery was
required to retrieve the avulsed supraspinatus, infraspinatus, and
teres minor from their interposition between the humeral head and the
glenoid.
Bridle and Ferris (Bridle and Ferris, 1990) reported a case of
apparent successful closed reduction of an anterior shoulder
dislocation that appeared to be confirmed on an anteroposterior
radiograph. However, the patient continued to experience severe pain
and a subsequent axillary lateral view demonstrated a persistent
anterior subluxation of the glenohumeral joint. At the time of open
reduction the ruptured muscle belly of the subscapularis was found
interposed between the humeral head and glenoid. Inao and associates
(Inao et al, 1990) reported a case of an acute anterior shoulder
dislocation that was irreducible by closed treatment due to the
interposition of the posteriorly displaced tendon of the long head of
the biceps. Displaced fracture of the greater tuberosity Although fractures of the greater tuberosity are not uncommonly
associated with anterior shoulder dislocation, the tuberosity usually
reduces into an acceptable position when the shoulder is reduced (see
figure 1). Occasionally the greater tuberosity fragment displaces up
under the acromion process or is pulled posteriorly by the cuff
muscles. If the greater tuberosity remains displaced following
reduction of the shoulder joint, consideration should be given to
anatomical reduction and internal fixation of the fragment and repair
of the attendant split in the tendons of the rotator cuff. It is
relatively easy to determine the amount of superior displacement of the
tuberosity fragment on the anteroposterior roentgenogram in the plane
of the scapula. Posterior displacement can be more difficult to
discern. It is important to look for the "vacant tuberosity" sign,
wherein the normal contour of the greater tuberosity is lacking. If
there is concern about the anteroposterior position of the tuberosity
on plain films, a CT scan should be considered. If the tuberosity is
allowed to heal with posterior displacement, it may produce both the
functional equivalent of a rotator cuff tear and a bony block to
external rotation.Glenoid rim fracture Aston and Gregory (Aston and Gregory, 1973) reported three cases in
which a large anterior fracture of the glenoid occurred as a result of
a fall on the lateral aspect of the abducted shoulder. A fracture of
the glenoid lip may require open reduction and internal fixation if it
presents intraarticular incongruity or an inadequate effective glenoid
arc.Special problems Occasionally it may be a consideration to perform an early surgical
reconstruction in a patient who requires absolute and complete shoulder
stability before being able to return to his or her occupation or
sport. Hertz et al (Hertz et al, 1991) reported a 2.4 year followup on
31 patients having an initial dislocation with primary repair of an
arthroscopically demonstrated Bankart lesion: none had recurrent
instability. Arciero (Arciero et al, 1995; Arciero, Wheeler, Ryan et
al, 1994) has initiated a study at West Point in which the Bankart
lesion is repaired arthroscopically after the initial dislocation. His
initial data indicate a decrease in recurrent instability from 80% with
nonoperative management to 14% with early repair. (Arciero, 1996;
Arciero, Taylor, Snyder et al, 1995; Arciero, Wheeler, Ryan et al, 1994)
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