Treatment of Traumatic Dislocations.
Last updated Thursday, February 10, 2005
Chronic traumatic anterior dislocations
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.
How useful was this page or article?
|
|