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
- systematic review operative v non operative for first time dislocation
- arthroscopic bankart repairs
- 10 prospective studies with 569 patients
- redislocation: surgery 10% v 67%
- further surgery: 7% v 47%
- return to sports: 93% v 81%
Associated injuries
Bony bankart / glenoid rim fractures
Indications for surgery
Glenoid fossa fractures
- 25 - 30%, displaced
- open v arthroscopic screw fixation
www.boneschool.com/glenoid-fractures
Acute bony bankart / glenoid rim fractures
- ? acute repair to reduce instabilty
- ? avoid Latarjet procedure later
Results
- systematic review of arthroscopic bony bankart repair
- 21 studies with 769 patients
- recurrent instability 12%
- return to sport 91%
Technique
Arthroscopic suture anchor fixation bony bankart
Vumedi arthroscopic anchor fixation glenoid fracture video
Arthroscopy techniques anterior glenoid rim arthroscopic anchor fixation PDF
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
