Treatment of Traumatic Dislocations.
Last updated Thursday, February 10, 2005
Management after reduction of an anterior dislocatEvaluation 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.
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