Treatment of Traumatic Dislocations.
Last updated Thursday, February 10, 2005
Figure 2 - Cummerbund "handshake" cast Acute traumatic anterior dislocations
Acute dislocations of the glenohumeral joint should be reduced as
gently and expeditiously as possible, ideally after a complete set of
radiographs is obtained to rule out associated bony injuries.Timing of reduction and analgesia Early relocation promptly eliminates the stretch and compression of
neurovascular structures, minimizes the amount of muscle spasm that
must be overcome to effect reduction, and prevents progressive
enlargement of the humeral head defect in locked dislocations. The
extent of anesthesia required to accomplish a gentle reduction depends
on many factors, including the amount of trauma that produced the
dislocation, the duration of the dislocation, the number of previous
dislocations, whether the dislocation is locked, and to what extent the
patient can voluntarily relax the shoulder musculature. When seen
acutely, some dislocations can be reduced without the use of
medication. At the other extreme, reduction of a long-standing, locked
dislocation may require a brachial plexus block or general anesthetic
with muscle relaxation. Many practitioners use narcotics and muscle
relaxants to aid in the reduction of shoulder dislocations. A potential
trap exists: the dosages required to produce muscle relaxation while
the shoulder is dislocated may be sufficient to produce respiratory
depression once the shoulder is reduced. Our recommendation is that if
these medications are to be used, they should be administered through
an established intravenous line. This produces a more rapid onset, a
short duration of action, and the opportunity to adjust the required
dose more appropriately. Furthermore, resuscitation (if necessary) is
facilitated by the prospective presence of such a route of access.
Airway management tools should be readily available.
Lippitt et al (Lippitt et al, 1991; Lippitt et al, 1992) compared
two methods of analgesia for the reduction of anterior dislocations:
(1) intravenous analgesia and muscle relaxation and (2) intraarticular
lidocaine. With respect to the first, they found a 75% success rate and
a 37% complication rate in a retrospective series of 52 reductions in
which intravenous narcotics (morphine (3-24 mg) or meperidine (12.5 -
100 mg) with or without diazepam (1.5 - 15 mg) or midazolam (1 - 10
mg)) were used for analgesia. They remarked on the difficulty of
determining the appropriate intravenous dose of narcotics. Level of
pain, age, smoking history, alcohol consumption, cardiac disease and
regional perfusion are just a few of the factors which may influence
the narcotic requirement (Bailey and Stanley, 1986). Older patients and
intoxicated patients are more sensitive to the respiratory depressant
effects of narcotics. Because pain counteracts the respiratory
depressant effects, patients sedated by narcotics are at increased risk
of respiratory depression after removal of the painful stimulus when
the shoulder is reduced. Complications from intravenous analgesia
included respiratory depression, hypotension, hyperemesis, and
oversedation. With respect to the second method using 20 cc of 1% plain
intraarticular lidocaine, Lippitt et al found a 100% success rate in
the reduction of 40 dislocations with no complications. One patient
inadvertently received 400 mg instead of 200 mg of lidocaine and
developed transient tinnitus, perioral numbness, and mild dysarthria. A
survey revealed that both the patients and the physicians were
satisfied with this method. The authors speculated that the success of
the intraarticular injection may be due to a combination of pain relief
allowing reduction, relief from muscle spasm and venting of the joint. Method of reduction Once the shoulder is relaxed, a variety of gentle methods can be
used to achieve reduction. Gentle traction on the arm is common to
most. One such method is known as the Stimson technique. Although named
for Lewis A. Stimson (Stimson, 1900; Stimson, 1912) of New York City,
Stimson credited a Dr. Cole, a house-staff physician of the Chambers
Street Hospital. In the Stimson method, the patient is placed prone on
the edge of the examining table while downward traction is gently
applied. (Stimson, 1900) The traction force may be applied by the
weight of the arm, by weights taped to the wrist, or by the surgeon. It
may take several minutes for the traction to produce muscle relaxation.
It is important that patients not be left unattended in this position,
particularly if narcotics and muscle relaxants have been administered.
Analgesia While analgesia may not be necessary to achieve reduction, we are
impressed with the safety and effectiveness of intraarticular lidocaine
as described by Lippitt et al. (Lippitt, Kennedy and Thompson, 1991;
Lippitt, Kennedy and Thompson, 1992) In this method a maximum 20 cc of
1% plain lidocaine is injected using an 18 gauge needle placed two
centimeters below the lateral edge of the acromion just posterior to
the dislocated humeral head and directed towards the glenoid fossa. The
amount of lidocaine is limited to 200 mg. (Savarsee and Covino, 1986)
Placement of the needle in the joint is confirmed by a combination of
(1) feeling the needle penetrate the glenohumeral capsule, (2)
aspirating joint fluid/hemarthrosis and assuring that the injection is
not intravascular, (3) gently palpating the glenoid fossa with the
needle, and (4) verifying easy flow on injection and return of the
injected lidocaine solution. Fifteen minutes are allowed to maximize
the analgesic effect of the lidocaine prior to manipulation.
Maneuver Reduction of either anterior or posterior glenohumeral dislocations
usually can be effected by traction on the abducted and flexed arm with
counter traction on the body. The patient is placed supine with a sheet
around the thorax, with the loose ends on the side opposite the
shoulder dislocation where they are held by an assistant. The surgeon
stands on the side of the dislocated shoulder near the waist of the
patient. The elbow of the dislocated shoulder is flexed to 90 degrees
(to relax the neurovascular structures) and traction applied through a
sheet looped over the patient's forearm or traction can be applied
directly. Steady traction along the axis of the arm will usually effect
reduction. To this basic maneuver, one may add gentle rocking of the
humerus from internal to external rotation or outward pressure on the
proximal humerus from the axilla. These additions are particularly
useful if prereduction axillary roentgenograms show the humeral head to
be impaled on the glenoid rim. Postreduction roentgenograms are used to
confirm reduction and to detect fractures. A postreduction
neurovascular check is routine.
A glenohumeral joint that has been dislocated for several days is a chronic dislocation.
Reduction and analgesia The principles and methods for reducing a chronic dislocation are
similar to those relating to an acute dislocation except for the fact
that the patient and the shoulder are usually more fragile and the
relocation is more difficult. As the chronicity of the dislocation
increases, so do the difficulties and complications of reduction. When
one encounters an elderly patient with pain in the shoulder whose
x-rays reveal an anterior dislocation, a very careful history is needed
to determine whether the initial injury occurred recently or quite a
while earlier.
Chronic dislocations are seen most commonly in elderly people and in
those whose general health or mental status may prevent them from
seeking help for the injury. The event causing injury itself may be
relatively trivial. (Bennett, 1936; Mirick, Clinton and Ruiz, 1979) Old
age, chronicity of dislocation, and soft bone make closed reduction
difficult and dangerous. (McLaughlin, 1949) If a closed reduction is to
be performed, it should be done with minimal traction, without
leverage, and with total muscle relaxation under controlled general
anesthesia. If the dislocation is over a week old, the humeral head is
likely to be firmly impaled on the anterior glenoid with such soft
tissue contraction that gentle closed reduction is impossible. Open reduction If a gentle attempt at closed reduction fails, open procedure
reduction is considered. This can be a complex procedure because of the
altered position of the axillary artery and branches of the brachial
plexus and because the structures are tight and scarred. When the risks
of attempting reduction appear to outweigh the advantages, the
dislocated position may be accepted. Sometimes the symptoms of chronic
dislocation are surprisingly minimal. (Ganel et al, 1980)
In performing an open reduction, the subscapularis and anterior
capsule are incised near their insertion to the lesser tuberosity
allowing substantial external rotation of the dislocated shoulder.
External rotation and lateral traction will usually disimpact the
humerus from the glenoid. While lateral traction is maintained, the
humerus is gently internally rotated under direct vision to assure that
the articular surface of the humerus passes safely by the anterior
glenoid lip and into the glenoid fossa. Leverage is avoided because the
head is usually very soft. If the posterolateral head defect is greater
than 40 per cent or if the head collapses during reduction, a humeral
head prosthesis may be necessary to restore a functional joint surface.
The subscapularis and capsule are then repaired. The shoulder is
carefully inspected for evidence of cuff tear or vascular damage. Results of treatment of chronic dislocations Schulz and associates (Schulz et al, 1969) reported a series of 17
posterior and 44 anterior chronic dislocations. These dislocations
occurred primarily among elderly people; more than half of the
dislocations were associated with fracture of the tuberosities, humeral
head, humeral neck, glenoid, or coracoid process. More than one third
involved neurological deficits. Closed reduction was attempted in 40
shoulders and was successful in twenty. Of the twenty shoulders
successfully reduced (3 posterior and 17 anterior), the duration of
dislocation exceeded four weeks in only one instance. Open reduction
was performed in 20 and humeral head excision in 6. Eight patients were
not treated, and five shoulders were irreducible.
Perniceni and coworkers (Perniceni and Augereau, 1983) described the
reinforcement of the anterior shoulder complex in three patients after
reduction of neglected anterior dislocations of the shoulder. They used
the Gosset (Gosset, 1960) technique, which places a rib graft between
the coracoid and the glenoid rim. Rowe and Zarins (Rowe and Zarins,
1982) reported on 24 patients with unreduced dislocations of the
shoulder and operated on 14 of them. Evaluation After reducing the dislocation, anteroposterior and lateral x-ray
views are obtained in the plane of the scapula to verify the adequacy
of the reduction and to provide an additional opportunity to detect
fractures of the glenoid and proximal humerus. The patient's
neurological status is again checked, including the sensory and motor
functions of all five major nerves in the upper extremity. The strength
of the pulse is verified and evidence of bruits or an expanding
hematoma is sought. (Gugenheim and Sanders, 1984) The integrity of the
rotator cuff is initially evaluated by observing the strength of
isometric external rotation and abduction.
Trimmings (Trimmings, 1985) demonstrated that aspiration of the
hemarthrosis from the shoulder can be an effective means of reducing
discomfort after the shoulder is reduced. Protection Since recurrent glenohumeral instability is the most common
complication of a glenohumeral dislocation, postreduction treatment
focuses on optimizing shoulder stability. Thus, two potentially
important elements in postreduction treatment are protection and muscle
rehabilitation. Reeves demonstrated that after repair of the
subscapularis in primates, three months were necessary before normal
capsular patterns of collagen bundles were observed, five months before
the tendon was histologically normal, and four to five months before
tensile strength was regained. (Reeves, 1968b) It is unknown whether
labral tears or ligamentous avulsions from the glenoid heal or how long
this might take. In any event, it is apparent that the shoulder cannot
be immobilized for the full length of time required for complete
healing. (The reader is referred to the previous section "Recurrence of
instability after anterior dislocations, effect of post dislocation
treatment" for a review of some of the literature on the effectiveness
of different post-reduction management programs.)
The authors treat first time dislocations in a manner similar to the
post operative management for dislocation repairs. Thus younger
patients are placed on the "90-0 program" in which flexion is limited
to 90 degrees and external rotation is limited to zero degrees for the
first three weeks while strength is maintained with cuff and deltoid
isometrics. The elbow is fully extended at least several times a day to
prevent "sling soreness." Because persons over 30 are more likely to
develop stiffness of the shoulder, elbow, and hand, the duration of
immobilization is progressively reduced for individuals of increasing
age. (Kiviluoto, Pasila, Jaroma et al, 1980; McLaughlin and Cavallaro,
1950; McLaughlin and MacLellan, 1967; Rowe, 1956; Yoneda, Welsh and
MacIntosh, 1982) Patients are checked at three weeks after relocation
and examined for stiffness; if external rotation to zero degrees is
difficult, formal stretching exercises are started. Otherwise, the
patient is allowed to increase the use of the shoulder as comfort
permits. Strengthening At three weeks, the patient institutes more vigorous rotator cuff
strengthening exercises using rubber tubing or weights. The patient is
informed that strong subscapularis and infraspinatus muscles are
ideally situated to increase glenohumeral stability. (Saha, 1971)
Burkhead and Rockwood, (Burkhead and Rockwood, 1992) Glousman and
coworkers, (Glousman, Jobe and Tibone, 1988) and Tibone and Bradley
(Tibone and Bradley, 1993) have emphasized the importance of
strengthening not only the rotator cuff but also the scapular
stabilizing muscles because of their vital importance in providing a
stable platform for shoulder function. Even in the case of recurrent
instability, Rockwood and Burkhead (Burkhead and Rockwood, 1992) found
that a complete exercise program was effective in the management of 12%
of patients with traumatic subluxation, 80% with anterior atraumatic
subluxation, and 90% with posterior instability.
Swimming is recommended at six weeks to enhance endurance and
coordination. By three months after the dislocation, most patients
should have almost full flexion and rotation of the shoulder. The
patient is not allowed to use the injured arm in sports or for
over-the-head labor until they have achieved (1) normal rotator
strength, (2) comfortable and nearly full forward elevation, and (3)
confidence in their shoulder with it in the necessary positions. Any
deviation from the expected course of recovery requires careful
re-evaluation for occult fractures, loose bodies, rotator cuff tears,
peripheral nerve injuries, and glenohumeral arthritis.
Soft 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)Reduction The reduction of acute, traumatic posterior dislocations may be much
more difficult than the reduction of acute, traumatic anterior
dislocations. Hawkins and coworkers (Hawkins, Neer, Pianta et al, 1987)
reviewed 41 cases of locked posterior shoulder dislocations. The
average interval between injury and diagnosis was one year! In seven
shoulders the deformity was accepted. Closed reduction was successful
in only 6 of the 12 cases in which it was attempted.
Intravenous narcotics combined with muscle relaxants or
tranquilizers may provide insufficient analgesia and muscle relaxation;
general anesthesia with muscle paralysis may be required. Atraumatic
closed reduction can usually be accomplished once the muscle spasm has
been eliminated. With the patient in the supine position, longitudinal
and lateral traction is applied to the arm while it is gently rocked in
internal and external rotation. Once the head is disimpacted it is
lifted anteriorly back into the glenoid fossa. In locked posterior
dislocations, it may be necessary to gently stretch out the posterior
cuff and capsule by maximally internally rotating the humerus before
reduction is attempted. Care should be taken not to force the arm into
external rotation before reduction is achieved; if the head is locked
posteriorly on the glenoid rim, forced external rotation could produce
a fracture of the head or shaft of the humerus.
If gentle closed reduction of a locked posterior glenohumeral
dislocation is not possible, open reduction may be accomplished through
an anterior deltopectoral approach. (See references:
Doege, 1929; Hawkins, Neer, Pianta et al, 1987; Johnson, 1931; Kuhnen
and Groves, 1979; Lam, 1966; McLaughlin, 1963b; Romanes, 1972; Saxena
and Stavas, 1983) Because local anatomy is significantly distorted, the
tendon of the long head of the biceps is used as a guide to the lesser
tuberosity. The subscapularis is released either by lesser tuberosity
osteotomy or by direct incision. With the glenoid thus exposed, open
reduction is carried out by gently pulling the humeral head laterally
and then lifting its articular surface up on the face of the glenoid. Postreduction care If, after closed reduction, the shoulder is stable in the sling
position, this type of post reduction management is most convenient for
the patient. However, if there is concern about recurrent instability,
the shoulder is immobilized in a shoulder spica or brace with the
amount of external rotation necessary to provide stability. (Cautilli
et al, 1978a; Cautilli et al, 1978b) Scougall (Scougall, 1957) has
shown experimentally in monkeys that a surgically detached posterior
glenoid labrum and capsule heal soundly without repair. He concluded
that the best position of immobilization, to allow healing for all of
the posterior structures, was in abduction, external rotation, and
extension and that the position should be maintained for four weeks.
While some have recommended pin fixation for three weeks after
reduction (Wilson and McKeever, 1949), this method carries risk of pin
breakage and infection. Early surgery in acute traumatic posterior dislocation Indications for surgery include a displaced lesser tuberosity
fracture, a significant posterior glenoid fracture, an irreducible
dislocation, an open dislocation, or an unstable reduction.
A major cause of recurrent instability after reduction of a
posterior dislocation is the presence of a large anteromedial humeral
head defect. If at the time of reduction, stability cannot be obtained
because of such a defect, it may be rendered extra-articular by filling
it with the subscapularis tendon as described by McLaughlin (Lev-EI and
Rubinstein, 1981; McLaughlin, 1951; McLaughlin, 1952; McLaughlin, 1959;
McLaughlin, 1963b) or the lesser tuberosity as described by Neer.
(Nicola, 1953, Rockwood, 1984) If the humeral head defect involves over
30 per cent of the articular surface, prosthetic replacement may be
indicated, otherwise instability may recur with internal rotation.
Hawkins et al demonstrated the use of each of these techniques in a
series of locked posterior dislocations. (Hawkins, Neer, Pianta et al,
1987).
After surgery the arm may be immobilized in a sling and swathe for
two weeks as recommended by McLaughlin, positioning the arm at the side
posterior to the coronal plane using a strip of tape or canvas
restraint as recommended by Rowe and Zarins (Rowe and Zarins, 1982), or
a modified spica in neutral rotation for six weeks followed by an
additional 3 to 6 months of rehabilitative exercises as recommended by
Rockwood. (Rockwood, 1984)
Keppler et al have suggested using rotational osteotomy of the
humerus in the post reduction management of locked posterior
dislocations. (Keppler et al, 1994). Chronic posterior dislocation If a patient, especially an older patient, has had a chronic posterior
dislocation for months or years and if there is minimal pain and a
functional range of motion, then surgery may not be indicated. However,
if disability exists and there is good bone stock to the glenohumeral
joint, then open reduction with a subscapularis or lesser tuberosity
transfer or shoulder arthroplasty can be considered. (Rowe and Zarins,
1982)Preferred method of treatment Our management of acute traumatic posterior dislocations begins with
a definition of the extent and chronicity of the injury. A complete
radiographic evaluation is necessary, including anteroposterior and
lateral views in the plane of the scapula and an axillary view. Careful
note is made of associated fractures, including the extent of the
impression fracture of the anteromedial humeral head. Under anesthesia
and muscle relaxation, a gentle closed reduction is attempted using
axial traction on the arm. If the head is locked on the glenoid rim,
gentle internal rotation may stretch out the posterior capsule to
facilitate reduction. Lateral traction on the proximal humerus may
unlock the humeral head. Once it is unlocked, the humerus is gently
externally rotated. After reduction is achieved and confirmed by
postreduction radiographs, the reduction is maintained for three weeks
by a cummerbund "handshake" cast or orthotic (see figure) in neutral
rotation and slight extension. External rotation and deltoid isometrics
are carried out during this period of immobilization. After removal of
the cast, a vigorous internal and external rotator strengthening
program is initiated. Range of motion is allowed to return with active
use, beginning with elevation in the plane of the scapula. Vigorous
physical activities are not resumed until the shoulder is strong and
three months have elapsed since reduction. Swimming is encouraged to
develop endurance and muscle coordination.
When there is a humeral head defect comprising 20-40% of the humeral
head, a subscapularis transfer into the defect is considered to prevent
recurrent instability. When the humeral head defect is greater than
40%, a proximal humeral prosthesis is considered to replace the lost
articular surface. When the dislocation is obviously chronic,
consideration can be given to accepting the dislocation and focusing on
enhancing the patient's ability to carry out activities of daily living.
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