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Shoulder DislocationAka: Glenohumeral Dislocation

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  1. See Also
    1. Shoulder Subluxation
  2. Types: Dislocation
    1. Anterior dislocation (most common, 90% of dislocations)
      1. Results from fall on externally rotated, abducted arm
    2. Posterior dislocation
      1. Large force directed against internally rotated arm
      2. Often occurs secondary to generalized Seizure
      3. Some patients can posteriorly dislocate voluntarily
    3. Multidirectional instability
      1. Lax joint capsule allows multidirectional dislocation
    4. Inferior dislocation (Luxatio erecta): Rare Fracture
      1. Associated with Fracture and neurovascular injury
  3. Pathophysiology: Mechanism
    1. Young patient: Direct trauma or sports injury
    2. Older patient: Results from fall (often with Fracture)
  4. Pathophysiology: Mnemonic TUBS-AMBRI
    1. First Type of shoulder dislocation (TUBS)
      1. Traumatic mechanism of injury
      2. Unilateral shoulder involvement
      3. Bankart and Hill-Sachs glenohumeral Fractures
        1. Bankart lesion (Glenoid fossa avulsion)
        2. Hill-Sachs lesion (Humeral head avulsion)
      4. Surgery often required for management
    2. Second Type of shoulder dislocation (AMBRI)
      1. Atraumatic mechanism
      2. Multidirectional instability
      3. Bilateral shoulder involvement
      4. Rehabilitation as primary management
      5. Inferior Capsular shift surgery
        1. Indicated for failed conservative therapy
  5. Signs
    1. Acromion much more prominent
    2. Humeral head fullness absent under deltoid
      1. Leaves prominent cavity
    3. Severe pain with any range of motion
      1. Arm "locked" in place (may be cradled by other hand)
      2. Patient refuses to move arm
    4. Anterior dislocation
      1. Arm held externally rotated
      2. Anterior shoulder appears full with anterior bulge
      3. Space below acromion appears empty
      4. Internal rotation painful
    5. Posterior dislocation
      1. Arm held in internal rotation
      2. Forearm rests on abdomen
      3. Anterior shoulder flat
      4. External rotation painful
      5. Assess neurovascular structures
        1. Check axillary nerve with deltoid sensation
  6. Imaging: Shoulder XRay
    1. XRay mandatory for evaluating concurrent injuries
      1. Except recurrent dislocator with atraumatic mechanism
      2. Except on sideline with patient in field
        1. Timely reduction outweighs risk
    2. Views
      1. Anteroposterior (AP)
      2. Lateral (transaxillary lateral often easiest)
  7. Management
    1. Acute Management: Shoulder Dislocation Management
    2. Chronic Management and prevention of recurrence: Shoulder Instability
  8. Course: Primary Dislocation
    1. Age under 30 years
      1. Recurrence rate: 50%
      2. Surgery indicated for recurrent dislocation
        1. Restrict rotation
        2. Reinforce joint capsule
    2. Age over 40 years
      1. Shoulder stiffness common
      2. Dislocation recurs less frequently
    3. Age over 50 years
      1. Risk of concurrent Rotator Cuff Rupture: 50%
  9. References
    1. Hendey (2000) Ann Emerg Med 36:108
    2. Hovelius (1996) J Bone Joint Surg 78-A:1677

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