Epidemiology
Most common form of shoulder instability
- young males
- M:F = 2:1
Etiology
Fall on outstretched arm
Indirect external rotation and abduction moment on arm
Examination
Very painful & tender shoulder
Arm held across abdomen
Hollow under acromion and fullness in anterior shoulder
Xray
True AP
Scapular Lateral
Axillary Lateral
Garth (aim beam caudally)
Management
Reduction techniques
| Stimpson |
Harvard Traction /Countertraction method |
Kocher | Hippocrates |
|---|---|---|---|
|
Patient prone Arm hanging over side of bed Weight applied to wrist |
Patient supine Traction with abduction Countertraction via sheet around axilla |
Externally rotate and maximally abduct arm Relocate via adduction Nil IR til located to avoid humeral fracture |
Foot in arm pit Apply longitudinal traction |
 |
+/- conscious sedation | +/- conscious sedation | +/- conscious sedation |
Rehabilitation
Sling versus external rotation brace
Itoi et al JBJS Am 2007
- RCT ER brace v sling 198 patients 3 weeks duration
- relative risk reduction 38%
- 26% recurrence v 42% (p < 0.03)
- particularly beneficial if < 30
Duration of immobilization
Prognosis
Age at first dislocation
Simonet and Cofield 1982
- overall incidence of recurrence 33% over 4 years
- 66% in patients < 20 years
- 17% in patients 20 - 40 years
Athletes
Re-dislocation more common in athletes
Surgery for first time dislocation
Robinson et al JBJS Am 2008
- prospective randomised control trial arthroscopic surgery in first time dislocators
- 88 patients under 35, arthroscopic stabilisation v arthroscopic lavage
- reduced risk of recurrence by 80%
- patient satisfaction and shoulder scores significantly improved
Kirkley et al Arthroscopy 2005
- RCT of 40 patients for arthroscopic stabilisation v immobilisation
- 3 recurrences in surgical group, 9 in non surgical group
- small improvement in shoulder scores in operative group
Jakobsen et al Arthroscopy 2007
- RCT 76 patients
- arthroscopy to diagnose labral injury
- either open repair or non operative
- 74% unsatisfactory results at 8 years in non operative group
- 75% good results in operative group (1 redislocation)
Associated injuries
Bony bankart / glenoid fracture
Indications
- > 25 - 30%
- displaced
Management
- open or arthroscopic
- fix with 1 or 2 cannulated screws
Greater tuberosity fractures
Indications
- > 5 mm displacement
Management
- ORIF
- screw + suture repair
- screw alone in young patient
Rotator Cuff Tear
Incidence
Berbig et al J Should Elbow Surg 1999
- prospect ultrasound on 167 patients with dislocation
- full thickness tears in 31.7%
- only acute tears in patients younger than 60
- control group had no FT tears in patients younger than 60
Management
Voos et al Am J Sports Med 2007
- retrospective review of arthroscopic repair of RC and labrum
- average age 47, 16 patients
- good or excellent results in > 90%
Nerve injury
Axillary nerve palsy
Musculocutaneous Injury
