Primary Shoulder Dislocation Research Articles

Ruhigstellung in Außenrotation bei primärer Schulterluxation

The standard method of treating acute primary dislocation of the glenohumeral joint is immobilization of the arm in adduction and internal rotation with a sling. The recurrence rate for anterior instability after nonoperative treatment in young active patients is extremely high (up to 90%) and well reported. A new method of immobilization with the arm in external rotation improves the position of the displaced labrum on the glenoid rim. With the use of control MRI before and after immobilization in external rotation, a study on this new repositioning of the labrum is evaluated. Ten patients (mean age 30.4 years) with primary anterior dislocation of the shoulder and Bankart lesion as shown on MRI but with no hyperlaxity of the contralateral side were immobilized in 10-20 degrees of external rotation for 3 weeks. Scans with MRI were taken in internal and external shoulder rotation post trauma and in internal rotation after 6 weeks. All patients were reevaluated after 6 and 12 months. Dislocation and separation of the labrum were both significantly less with the arm in external rotation due to the tension of the anterior capsule and the tendon of the subscapularis muscle. In the MRI taken in internal rotation 6 weeks post trauma, all Bankart lesions were fixed in reposition after three weeks of immobilization in external rotation. At 12-month follow-up, the average Constant Score was 96.1 points (range 63-100), and the Rowe Score was 91.5 points (range 25-100). One patient had traumatic redislocation after 8 months. After primary shoulder dislocation, immobilizing the arm in 10-20 degrees external rotation provided stable fixation of the Bankart lesion in an anatomic position. First long-term indications from an ongoing prospective study of recurrence rates after immobilization in external rotation are promising.

CORRELATION BETWEEN BANKART AND HILL‐SACHS LESIONS IN ANTERIOR SHOULDER DISLOCATION

Bankart lesions and Hill-Sachs lesions are commonly associated with anterior shoulder dislocations. The presence of Bankart lesion indicates the need for surgical repair. Magnetic resonance imaging (MRI) has been shown to be sensitive in detecting these two lesions. The aim of this study is to investigate the correlation between Bankart lesions and Hill-Sachs lesions on MRI for patients with traumatic anterior shoulder dislocations. Between 2003 and 2005, 61 patients from Alfred and Sandringham Hospitals had an MRI as part of the investigation for traumatic anterior shoulder dislocations. The MRI scans were reviewed and subsequently confirmed by a radiologist to show the presence or absence of Bankart and Hill-Sachs lesions. The data were then analysed by a statistician. Although patients with one of these lesions were more than two-and-a-half times as likely to have the other, small study numbers precluded this result from achieving statistical significance. (odds ratio, 2.67 (0.83-8.61), P = 0.10). Younger age was a strong predictor of a recurrence of shoulder dislocation (odds ratio, 0.93 (0.89-0.98), P = 0.005). The presence of Bankart or Hill-Sachs lesions on MRI for the primary shoulder dislocation group was similar to the recurrent group (73% vs. 72% for Bankart lesion and 67% vs. 70% for Hill-Sachs lesion). There is a strong correlation between both lesions. This apparent trend can be useful in predicting the presence of a Bankart lesion when a Hill-Sachs lesion is identified on a plain radiograph. This study suggests the consideration of surgical repair after identification of a Hill-Sachs lesion on plain radiographs, especially for younger patients where the rate of re-dislocation is high.

Posttraumatic anterior-inferior instability of the shoulder: arthroscopic findings and clinical correlations

The main purpose of our study was to evaluate intra-articular lesions in glenohumeral-instability with arthroscopy and correlate them with clinical findings as well as history of instability. In this prospective multi-centre study, we evaluated arthroscopic findings in 303 patients with posttraumatic anterior-inferior instability of the shoulder. The study cohort was divided into 2 groups: patients with a history of one dislocation (Group 1, n=61, 20.1%) and patients with a history of more than one dislocation (Group 2, n=242, 79.9%). In Group 1, 37 patients had an IGHL-lesion, 31 a MGHL-lesion and 41 a Hill-Sachs lesion. In Group 2, 182 patients had an IGHL-lesion, 172 a MGHL-lesion and 203 a Hill-Sachs lesion. The percentage of lesions in Group 2 (IGHL-75.2%, MGHL-71.1%, Hill-Sachs-83.9%) was significantly higher than in Group 1 (IGHL-60.7%, MGHL-50.8%, Hill-Sachs-67.2%, P=0.0233, P=0.0026, and P=0.0033, respectively). Within Group 2 we found significantly more Hill-Sachs-lesions with a history of an increasing number of recurrences (P=0.0436). We also found an increase of IGHL- and MGHL-lesions with an increasing number of recurrences, but this difference was not significant. The distribution of lesion types of the anterior labrum-ligament complex showed no significant difference between the two groups, apart from a higher incidence of ALPSA-lesions within Group 2 (34.7% versus 18.0% in Group 1). The results of this study show that recurrences after primary posttraumatic anterior-inferior shoulder dislocation cause increasing ligamental damage as well as increasing Hill-Sachs lesions within the gleno-humeral joint. Thus we conclude that early surgical stabilization after posttraumatic anterior-inferior shoulder dislocation is necessary to prevent increasing damage within the shoulder joint.

Traumatic Shoulder Dislocation in Children and Adolescents

Shoulder dislocation is rarely seen in children. Very few studies in the literature have assessed traumatic glenohumeral joint dislocation in young patients. A retrospective multicenter review of cases with traumatic shoulder dislocation in children presenting over the last 5 years was performed. In all centers, the dislocated joint was reduced and X-ray was performed before and after reduction. Fractures or nerve injuries were excluded. Immobilization for 2 weeks followed. The overall recurrence rate after a first traumatic dislocation was 29 out of 54 (53.7%). It was important to differentiate between traumatic and atraumatic etiologies. The literature on traumatic shoulder dislocation in children of all ages was also reviewed. It can be concluded that after primary traumatic shoulder dislocation in children < 14 years, the management of choice is reduction, X-ray confirmation, immobilization, and clinical examination after a couple of weeks. The recurrence rate in children before the puberty is so low that a conservative treatment can be recommended. Because of the high recurrence rate (80–90%) in adolescents (≥ 14 years), arthroscopy and stabilization should be performed. In adolescents with primary traumatic shoulder dislocation, we therefore highly recommend reduction, X-ray, and clinical examination, followed by arthroscopy with refixation of the labral lesion and subsequent reduced functional treatment.

Longer immobilization extends the “symptom-free” period following primary shoulder dislocation in young rugby players

The purpose of this study was to evaluate the effect of longer immobilization following primary shoulder dislocation in young rugby players for the prevention of recurrence. We sent a questionnaire regarding shoulder dislocation to all senior high school and college rugby teams in the southwest region of Japan. We received replies from 5476 players in 196 teams (i.e., answers were received from 76% of the teams). Based on the answers from the 79 rugby players who had undergone shoulder dislocations and who were eligible for the study, we divided them into two groups; group I: immobilization for 0–3 weeks at the time of the initial dislocation (n = 61), and group II: immobilization for 4–7 weeks (n = 18). We compared the time-course from primary dislocation to recurrence between the two groups, using the Kaplan-Meier method. The age range at the time of the primary dislocation was 14–23 years (average, 16.7 years). The probability of recurrence in groups I and II, respectively, was 78% and 44% after 1 year; and 85% and 69% after 2 years. The median period from return to rugby to recurrence was 4 months in group I and 14 months in group II. The symptom-free period was extended when immobilization was carried out for 4 weeks or more, in comparison with the symptom-free period in those who had immobilization for 3 weeks or less.

Diagnosis and therapeutic management following traumatic anterior shoulder dislocation according to extrinsic prognostic factors

We examined the importance of preoperative CT- and NMR-imaging concerning the detection of a bankart-lesion by a retrospective evaluation of 36 patients with primary traumatic or posttraumatic recurrent shoulder dislocations. Because of unfavourable extrinsic prognostic factors, we advised shoulder arthroscopy and surgical stabilization in all cases. Intraoperatively 35 of 36 patients (97%) presented a bankart-lesion. Preoperatively a bankart-lesion was detected in 32 cases (91%) by CT (n = 29) or NMR (n = 7). We could predict the probability of a bankart-lesion with a high reliability by clinical evaluation alone due to several risk-factors. All patients had at least 2 unfavourable prognostic factors. Under these circumstances we could assume a bankart-lesion with a probability of 97%. Therefore in our opinion preoperative CT or NMR is not advised as standard diagnostic procedure in patients with high-risk of recurrence according to extrinsic prognostic factors. We recommend preoperative CT or NMR when the estimation of prognostic factors concerning the risk of redislocation is doubtful and in case of difficult clinical and ultrasound examination regarding shoulder laxity or rotator cuff lesions.

Conservative treatment after first traumatic shoulder dislocation

Between January 1989 and March 1997, 175 patients with traumatic shoulder dislocation were treated by conservative means (median age 41 years, 39 F, 136 M). In 78 patients (17 F, 61 M) a clinical and radiological follow up (median 50 months, range 6-106) could be obtained. Additionally, a diagnostic ultrasound was carried out in all patients. The recurrence rate in the group younger than 30 years (G < 30; n = 35) was 86%; in the group older than 30 years (G > 30; n = 43) it was 21% (P < 0.05). Persisting neurological deficits were found in 6 patients (8%). According to the Rowe score, 16 patients (46%) of the G < 30 achieved excellent or good results, in the G > 30, 29 patients (67%). In 17% of cases, a glenohumeral arthrosis was diagnosed be radiological means. 18% had radiological signs of a previous fracture of the greater tuberosity. Hill-Sachs lesions were identified in 19% of cases. Rotator cuff tears were diagnosed in 9% by ultrasound. No relationship between the duration of immobilization and the recurrence rate was found (P = 0.95). The recurrence rate following primary shoulder dislocation depends primarily on the patients' age.

Arthroscopic stabilization of the shoulder for acute primary dislocations using a transglenoid suture technique

Many studies report the results of arthroscopic stabilization for recurrent shoulder instability, with widely variable recurrence rates; however, there are very few reports of the use of these techniques in acute first-time dislocations. We report the clinical outcomes of 17 patients who had arthroscopic stabilization using a transglenoid suture technique for acute primary dislocation. The surgery took place between March 1992 and March 1994 and, to date, there has been one recurrent dislocation (6%) and no recurrent subluxation. There were no major complications, although a number of patients found the knot tied over the infraspinatus fascia to be uncomfortable until it resorbed. All patients examined had normal power and range of motion, and a clinically stable shoulder. All 16 patients without recurrence were satisfied with their result. Nine patients returned to sports at the same or higher level, including such vigorous contact sports as Australian Rules football and rugby. Three patients did not return to the same level of sporting activity because of lack of confidence in the shoulder or a fear of dislocation despite no clinical evidence of instability. Five patients reported a lack of confidence in the shoulder without clinical evidence of instability. We suggest that arthroscopic stabilization with transglenoid sutures or a suture anchor technique is a reasonable option for the athlete with an acute primary shoulder dislocation who wishes to return to sports. Arthroscopy 1998 Mar;14(2):143-7

Shoulder injuries common in alcoholics. An analysis of 413 injuries.

We recorded prospectively all adult patients with a fracture of the proximal end of the humerus, clavicle and scapula or a primary shoulder or acromioclavicular dislocation in the city of Malmö in 1987. Altogether there were 413 injures. The hospital records from the Department of Alcohol Diseases were searched for these patients and for 2 age- and gender-matched controls for each patient. 12% of all patients with a shoulder injury were recorded as alcohol abusers. This number was significantly greater than that of the controls. The difference was more obvious in men than in women. In men between 30 and 64 years, almost half of the proximal humerus fractures and shoulder dislocations, one third of mid-clavicular fractures and two thirds of all lateral clavicle fractures were sustained by alcohol abusers. Our findings emphasize the significance of alcohol abuse in the etiology of shoulder injuries, especially in men. Most of the men with a fracture of the lateral clavicle are registered at the Department of Alcohol Diseases, making this injury a marker of alcohol abuse.

Magnetic resonance imaging evaluation of capsulolabral tears after traumatic primary anterior shoulder dislocation: A prospective comparison with arthroscopy of 25 cases

The purpose of our study was to evaluate the use of static magnetic resonance imaging (MRI) as a preoperative diagnostic tool in young patients with a traumatic primary anterior shoulder dislocation. Twenty-five patients who had acute primary traumatic anterior shoulder dislocation were examined with MRI and arthroscopy. The patients (18 male and 7 female) were between 16 and 39 years old (mean age, 27 years). They had no previous shoulder dislocations. The dislocations were confirmed radiographically. Examination with MRI and arthroscopy was performed within 10 days after the trauma. The MRI evaluation was performed before the arthroscopic examination, and the images were interpreted by an experienced magnetic resonance radiologist. No information from the MRI examination was available to the orthopedic surgeons before arthroscopy. The standard of reference for comparison was arthroscopy. Subacute MRI evaluation identified 15 labral tears, 12 Hill-Sachs lesions, 1 total rotator cuff lesion, 1 partial joint side rotator cuff lesion, and 1 partial rupture of the biceps tendon. Arthroscopic examination revealed 22 labral tears, 15 Hill-Sachs lesions, 1 total rotator cuff lesion, 1 partial joint side rotator cuff tear, 1 partial rupture of the biceps tendon, and 1 osseous Bankart lesion. Anterior capsulolabral tears and Hill-Sachs lesions appeared with a high incidence after acute anterior primary shoulder dislocation. Conventional MRI was only moderately reliable in the preoperative evaluation of labral tears and Hill-Sachs lesions, and it failed to give an accurate, differentiated preoperative diagnosis of the capsulolabral lesions.

Behandlungsergebnisse nach traumatischer Schulterluxation

In 80 patients with primary traumatic shoulder dislocation treated at the Heidelberg Orthopaedic University Hospital we had a follow-up examination. We wanted to know about age and sex of the patients, the number of redislocations in correlation to time and way of fixation. We had 70% male and 30% female patients with 97.5% of anterior dislocation. The minimum age was 16 and the maximum 87 years with an average of 44 years. 48 patients had a Desault bandage for 2 weeks and 32 had a shoulder-arm plaster cast for 3 weeks. There was no difference between both ways of fixation. We also could not see any better results after more than a 3 weeks' fixation. The most important fact for redislocation is the age and activity of the patients. A young man has a very high risk of redislocation within the first year.

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.

Nerve lesions in primary shoulder dislocations and humeral neck fractures. A prospective clinical and EMG study

The incidence of nerve injuries in primary shoulder dislocation and humeral neck fracture is uncertain. We made a prospective study of 101 patients, using clinical examination and extensive electrophysiological assessment when there was suspicion of nerve damage. We found electrophysiological evidence of nerve injury in 45%, most involving the axillary, suprascapular, radial and musculocutaneous nerves. There were significantly more nerve injuries in older patients and those with a haematoma. Most patients recovered partially or completely in less than four months, and only eight had persistent motor loss. Early diagnosis and physiotherapy are recommended.

The rate of recurrence of traumatic anterior dislocation of the shoulder. A study of 154 cases and a review of the literature.

We have reviewed the history of 154 primary, traumatic dislocations of the shoulder in order to determine the risk of recurrence. We found a recurrence rate of 68% in patients under the age of 20, after a follow-up period of 1-9 years (average 4.5 years). There was a highly significant difference (p < 0.0001) in the recurrence rate of patients under, and above, 30 years of age. Twenty per cent of the patients had a concurrent minor fracture at the shoulder with 2 out of 39 of the recurrent cases (5%) and 29 of the 115 non-recurrent cases (25%); this is also a significant difference (p < 0.01). Neither the need for general anaesthesia at primary injury nor the occupation of the patient was a relevant factor in the final outcome of the dislocation. Four nerve injuries were encountered (3%), with no severe sequelae at follow-up. The young patient with no concurrent fracture at the time of the primary shoulder dislocation has a high risk of recurrence.

Stellenwert der MR-Tomographie bei akuten Schulterluxationen

24 patients up to two weeks after primary traumatic shoulder dislocation were examined at 0.5 and 1.5 T. Surgical and/or arthroscopic correlation was available in 13, CT-arthrographic correlation in 16 patients. A joint effusion allowing sufficient evaluation of the capsulolabral complex was present in 21/24 (87.5%) cases. 11/14 patients with combined dislocated detachments of the glenoid labrum and capsular lesions were subsequently operated upon. Marrow edema of the humeral head was found in 16/19 Hill-Sachs lesions and in 4/5 fractures of the greater tuberosity. Two patients presented with a lesion of the long biceps tendon associated with rotator cuff tears and were also subsequently operated upon. MRI performed shortly after primary traumatic shoulder dislocation allows a comprehensive evaluation of the intraarticular lesions and decisively influences further therapy.

Recovery from primary shoulder dislocation and its complications.

Out of 226 patients with primary shoulder dislocation followed up for 1 year, 57 (25 per cent) had one or more complications. There were 25 plexus lesions, 19 axillary nerve lesions and 26 rotator cuff ruptures.The 127 patients over 50 years of age (56 per cent), plus 53 patients under 51 years, were immobilized for 1 week with a mitella. the remaining 46 patients under 51 years were immobilized for 3 weeks.Recovery was ascertained in terms of the time needed to regain normal mobility of the shoulder, the disappearance of signs of nerve lesions and the length of the sick leave period. A total of 163 (72 per cent) of the patients achieved normal mobility in 3 months, but 42 shoulders (19 per cent) were still not fully mobile after 1 year. the mobilization was significantly retarded by advanced age, long immobilization, long “non-reduced period”, rotator cuff rupture, and a severe primary dislocation. Students and office workers regained normal mobility of the shoulder in a shorter time than manual labourer...

Immobilization after primary dislocation of the shoulder.

A total of 226 patients with primary shoulder dislocation were followed up for 1 year, the primary object being to observe the effect of immobilization on the incidence of redislocation. The shoulders were immobilized in a mitella for 1 week in all the 127 patients older than 50 years of age, and in 53 of the patients under 50 years of age. The shoulders of the remaining 46 patients (under 50 years) were completely immobilized with a stockinette-Gilchrist bandage for a period of 3 weeks. Thirteen per cent (30/226) suffered from one to four redislocations each during the follow-up period. Because most recurrences occurred in the patients under 30 years of age, these patients were compared with the older ones in the analysis. The frequency of redislocation was higher in the group of 53 patients under 30 years than in the older subgroup (P less than 0.001). Twenty-six of these 53 patients (under 30 years), who had been immobilized for 1 week, presented a higher frequency of redislocation than the remaining 27 patients subjected to 3 weeks' immobilization (P less than 0.05). Manual labourers experienced more numerous redislocations than office workers (P less than 0.01). The greater the initial trauma to the shoulder, the lower was the incidence of recurrence. There were only two among the 57 patients with early complications of the primary shoulder dislocation who had a redislocation (P less than 0.001). Residual stiffness was encountered more often in the patients over 30 years than in the younger ones (P less than 0.001). Following primary shoulder dislocation, 1 week's immobilization in a sling is sufficient in patients over 30 years, while in the case of most of the younger patients 3 weeks' complete immobilization of the shoulder is recommended.

Early complications of primary shoulder dislocations.

A prospective study of the complications of primary shoulder dislocation was carried out for the 3-year period 1973-1976. The clinical examination was made initially in the Casualty Department and the patient was re-examined in the Department of Physical Medicine. In the evaluation special attention was given to the condition of the rotator cuff, the blood vessels and the motor and sensory function of the affected extremity. Sixty-three out of 238 patients (26 per cent) presented with the following complications: 29 lesions of the brachial plexus, 21 of the axillary nerve and 28 ruptures of the rotator cuff tendon. Complications occurred more frequently in the age group over 50 years (P less than 0.001) and in manual labourers compared with office workers (P less than 0.05). If the humerus remained unreduced for more than 12 hours, the frequency of complications increased (P less than 0.01).

Prognosis in Dislocations of the Shoulder

1. Five hundred shoulders in a series of 488 patients, with a follow-up study on 313 shoulders (63 per cent), are reviewed relative to prognosis. 2. The study included patients treated over the past twenty years, with a mean follow-up period of 4.8 years. 3. In 38 per cent of the patients the dislocation recurred. 4. Primary shoulder dislocations were found to occur as frequently after forty-five years of age as before forty-five. 5. The incidence of recurrent dislocation of the shoulder was very high in the second decade (92 per cent), but showed marked decrease after age fifty (12 per cent). 6. The age of the patient at the time of the primary shoulder dislocation was the most significant single prognostic factor. 7. Throughout this study, the average age of those patients in whom redislocation did not occur was greater than in those in whom dislocation did recur. 8. Various phases of trauma in relation to dislocations were reviewed. Usually the greater the initial injury, the lower was the incidence of recurrence. 9. Fracture of the shoulder girdle was a complication in 24 per cent. The incidence of fracture of the greater tuberosity was 15 per cent. This complication was accompanied by an appreciable lowering of the incidence of recurrence (7 per cent). The exception was in chip fractures of the anterior glenoid rim. 10. Humeral-head defects were present in 38 per cent of the primary dislocations and in 57 per cent of recurrent dislocations. These were associated with an increase in the incidence of recurrence (82 per cent). 11. From our figures, the incidence of recurrence seemed to be affectd very little by the type and length of immobilization of the shoulder following dislocation. Although a high incidence of recurrence was noted in the group of patients for whom where was no immobilization or for whom there were very short periods of immobilization, long periods of immobilization were not associated with a significant decrease in recurrence. 12. The incidence of recurrent dislocation relative to handedness was not significant. 13. Following primary or initial dislocation, 70 per cent of the dislocations which recurred did so within two years. 14. Following operative procedures for the repair of recurrent shoulder dislocation, 52 per cent recurred within two years after operation. 15. The incidence of posterior dislocation was 2 per cent. 16. The incidence of bilateral dislocation was 2.4 per cent. 17. The incidence of associated nerve injury was 5.4 per cent. 18. The incidence of epileptics with shoulder dislocations was 2 per cent.