Primary Anterior Shoulder Dislocation Research Articles

Reduction of traumatic, primary anterior shoulder dislocations with local anesthesia

This study evaluates the use of local anesthesia in the reduction of acute shoulder dislocations. Patients with a primary traumatic dislocation of the shoulder were randomly assigned to receive either local anesthesia or intravenous anesthesia. The patients were observed for any complication during and after the procedure, and the methods used were evaluated with a visual analog scale. In the period from November 1991 to September 1993, 81 patients were admitted to our departments, and 68 patients were included in the study. Average age was 48 years (range 15 to 79 years); 29 men and 39 women were studied. Thirty-five patients were randomly assigned to receive intravenous anesthesia; 33 had a successful reduction, and two had a failed reduction. Thirty-three patients received local anesthesia; 32 had a successful reduction, and one had a failed reduction. Ten patients treated with the intravenous method had respiratory depression, and six required an antidote. No systemic or local side effects and no neurovasculor injuries were recorded. We did not observe any superficial or deep infection in the local anesthetic group. No statistical difference was found between the average visual analog value scale in the two groups. Local anesthesia to reduce acute primary anterior dislocation of the shoulder is a simple and safe method.

Treatment of Primary Anterior Shoulder Dislocation in Patients Older Than 40 Years of Age

Primary shoulder dislocation in patients older than 40 years of age is frequently benign, but may be associated with significant rotator cuff or nerve injury. A series of such patients was observed to determine an effective treatment algorithm. Treatment of those dislocations associated with fractures of the greater tuberosity was determined by the fracture pattern. Four patients with glenoid fractures were all treated operatively. Patients without associated fractures were classified according to the absence or presence of significant pain or weakness after 3 weeks. Of 27 patients who were symptom free at 3 weeks, only four had associated problems after 3 months. All of 13 patients complaining of weakness or pain after 3 weeks had significant associated lesions (11 rotator cuff tears, 2 cuff tears plus neurologic deficit). The persistence of significant pain or weakness 3 weeks after primary dislocation in this age group is an indication for further investigation (arthrography or ultrasound). While recurrent instability is relatively uncommon, rotator cuff repair when appropriate in medically fit patients resulted in pain relief and return of strength.

The anterior labroligamentous periosteal sleeve avulsion lesion: A cause of anterior instability of the shoulder

Recurrent anterior unidirectional instability of the shoulder is not always associated with a classic Bankart lesion, which is an avulsion of the anterior labroligamentous structures from the anterior glenoid rim. Because the anterior scapular periosteum ruptures, the labrum and the attached ligaments are found to float out anterior to the glenoid rim when viewed arthroscopically. The anterior labroligamentous periosteal sleeve avulsion (ALPSA) of the supporting anterior inferior ligamentous and labral structures of the shoulder joint was found in four of eight acute primary anterior shoulder dislocations. This lesion differs from the Bankart lesion because the anterior scapular periosteum does not rupture, thereby allowing the labroligamentous structures to displace medially and rotate inferiorly on the scapular neck. These lesions eventually heal, and lead to recurrent anterior dislocations because of the subsequent incompetence of the anterior inferior glenohumeral ligament. An arthroscopic technique that converts the ALPSA lesion to a Bankart lesion and subsequently reconstructs the supporting anterior inferior structures of the shoulder has been successful in 26 cases (4 acute and 22 chronic) which were followed for > or = 2 years. Only one dislocation occurred, and it was the result of severe trauma.

Prognosis of primary anterior shoulder dislocation in young adults

From 1982 to 1987, 194 patients with 196 primary traumatic anterior shoulder dislocations were treated in our hospital. One hundred and sixty-six patients with 168 shoulder dislocations (87%) were available for study at follow-up an average of 4 years after treatment. The most important prognostic factor in relation to recurrence was the age of the patient at the time of the primary dislocation. The highest recurrence rate was found in patients of 30 years and younger (64%). Athletes in this age group had no worse a prognosis as to recurrence than non-athletes. A fracture of the greater tuberosity improved the prognosis significantly (P less than 0.01). Neither the presence of a Hill-Sachs lesion nor the period of immobilization influenced the recurrence rate in patients aged 30 years and younger.

Anterior Shoulder Dislocations in Sports???

Anterior shoulder dislocations, primary and recurrent, are among the most disabling injuries to the shoulder that can plague the athlete. The diagnosis is easily made by the following: the physical appearance of the shoulder; loss of capability by the athlete to internally and externally rotate the shoulder with the elbow at his side; by evaluating the mechanism of injury; and x-rays. Anterior shoulder dislocations should be reduced as soon as possible after diagnosis, to minimise the stretching effect on the neurovascular structures while the humeral head is dislocated. The reduction is not done to allow the athlete to return immediately to sport. Use of a simple traction method in the first 10 to 15 minutes following the injury will result in a successful reduction in the vast majority of dislocations. Reduction of the humeral head can be confirmed by the athlete regaining the capability to internally and externally rotate his shoulder with his elbow at his side. Following reduction, the athlete should begin a treatment regimen which includes a restrengthening programme emphasising the muscles of internal rotation and adduction plus rigid restrictions of activities until the goals of the rehabilitation programme are satisfied. The author's experience with this treatment regimen with athletes at the United States Naval Academy, has shown a decrease of the recurrence rate of primary anterior shoulder dislocations to 25% versus the 80% recurrence rate we have become familiar with from studies done which did not stress specific rehabilitation programmes. The athlete should also be instructed in a self-performed traction method for reduction should a redislocation occur, to minimise the stretching effect on the neurovascular structures and allow relief from discomfort. Surgery for primary and recurrent anterior dislocations should only be considered when the athlete fails to achieve the desired goals after participating in a specific, progressive, adequate rehabilitation programme.

Decreasing the incidence of recurrence of first time anterior shoulder dislocations with rehabilitation.

Studies of adolescent and young adult males sustaining primary anterior shoulder dislocations reveal the likelihood of recurrence to be virtually always above 50% and as high as 79% to 94%. Common among these investigations is the lack of a specific, rigidly adhered to rehabilitation program. During a 3 1/2 year period, 20 midshipmen at the United States Naval Academy sustained primary anterior shoulder dislocations. All participated in an identical treatment regimen which included a restrengthening program emphasizing the muscles of internal rotation and adduction, plus rigid restrictions of activities until the goals of their rehabilitation program were satisfied. Exercises progressed from isometrics through isotonics and isokinetics. Goals included return to full active, unrestricted duty and athletic participation which included participation in the sport that resulted in the original dislocation. Patients were followed for an average of 35.8 months (with a range of 17 to 45 months). During the period of study there were five recurrences (25%). A success rate of 75% would suggest that adherence to a specific, aggressive postdislocation rehabilitation program, plus rigid restrictions of activities until the goals of the program are satisfied, can substantially improve the likelihood of a full return to activity without recurrent shoulder dislocation.