What is Shoulder Dislocations Overview?
Shoulder dislocations make up half of all serious joint dislocations, with the front part of the shoulder dislocating most often. The reason for this is that the shoulder joint is relatively unstable. This is because the shoulder socket, also known as the glenoid, is shallow and only connects with a small part of the upper arm bone, or the humeral head.
What Causes Shoulder Dislocations Overview?
The shoulder joint is known to dislocate more frequently than any other joint in the body. This means the shoulder can move out of its usual position, either forward, backward, or downward, and it can either be partial or complete dislocation. The most common type, however, is forward dislocation. This condition may involve stretching or tearing of the fibrous tissue that connects the bones, making the dislocation more complex.
Quite a powerful force, like a hit to the shoulder, is needed to dislocate the bones. Similarly, extreme rotation can cause the shoulder to pop out from its socket. Contact sports are often a cause of dislocated shoulders, but they can also happen due to trauma from car accidents or falls.
Risk Factors and Frequency for Shoulder Dislocations Overview
The shoulder is most susceptible to dislocation, which can happen in various directions: front, back, downwards, or front upwards. Of these, the frontward direction is the most common. If you’ve had a shoulder dislocation before, you’re more likely to have another one because the healing process might not have gone well, or the tissue around the shoulder has become loose. Younger people, especially those who are active, are more prone to repeated dislocations. Those who’ve damaged their rotator cuff (a group of muscles and tendons that surround the shoulder joint) or broken the glenoid (the socket part of the shoulder) also have a higher risk of dislocation.
- The shoulder is the joint that gets dislocated the most often.
- Dislocations can happen in different directions: front (most common), back, down, or front up.
- If you have had a shoulder dislocation before, you are at a higher risk for another one.
- The tissue around the shoulder might not have healed correctly or has gone loose, which can lead to dislocation.
- Young, active people are more likely to experience repeated dislocations.
- If you’ve injured your rotator cuff or broken the shoulder socket, you have a higher risk of dislocation.
Signs and Symptoms of Shoulder Dislocations Overview
When a person experiences a dislocation, they might notice a sensation of their joint popping or feel a sudden pain, which limits the movement of the joint. Some even feel as though the joint is rolling out of its usual place. It’s also important to note if the person has had any previous dislocations. At the time of the dislocation, some patients may also experience stinging or a numb sensation in their arm due to the stretching of nerves.
During a physical examination, doctors will check for signs that confirm a suspected dislocation. Symptoms might include a reduced and painful range of motion. For an anterior shoulder dislocation, the arm may be held away from the body and rotated outwards. Particularly in people with less body fat, the top of the upper arm bone may be felt prominently at the front of the shoulder, and there may be an empty space at the back of the shoulder. For posterior dislocations, the arm might be turned inward and drawn toward the body. The likelihood of missing a posterior dislocation is quite significant, as the patient may appear to be only protecting their arm.
It’s critical for the doctor to perform a detailed examination of the nerves and blood vessels before fixing the dislocated joint. There’s a high chance of injury to the axillary nerve during shoulder dislocation – as high as 40%. Hence, doctors need to record the nervous and muscular examination before and after treating any dislocated shoulder.
Testing for Shoulder Dislocations Overview
When treating a patient with a potential shoulder dislocation, it’s crucial to check for any interruptions in nerve or blood flow. Injuries to the axillary nerve are particularly common. This nerve controls the deltoid and teres minor muscles and the sensation in the lateral shoulder. In fact, over 40% of shoulder dislocations come with axillary nerve damage, though this usually gets better once the shoulder is popped back in.
A dislocated shoulder is often easy to spot, but taking images before popping the shoulder back in can help spot any related bone fractures; these occur in about a quarter of all dislocations. But if the patient has certain types of fractures, like those of the tuberosity and surgical neck, the dislocation should not be corrected in the emergency department.
There can also be other complications with a shoulder dislocation. One is a Bankart lesion, which happens when the rim of the shoulder socket gets torn, sometimes accompanied by a bone chunk that gets torn away. Another complication is a Hill-Sachs deformity, where the humeral head (top of the upper arm bone) gets compressed due to dislocation. Similar-but-opposite deformities can happen with posterior (backward) dislocations.
When it comes to relocating the dislocated shoulder, patients often need something to manage pain like fentanyl, midazolam, ketamine, etomidate, or propofol. This is done while carefully monitoring patient breathing. If these aren’t needed, injecting some local anesthetic like lidocaine into the joint might help.
However, not all dislocations should be corrected in the emergency department. For anterior (forward) dislocations, this is the case when there are fractures of the humeral neck, subclavicular or intrathoracic dislocations, multiple injury attempts leading to neurovascular compromise, or suspected arterial injuries. For posterior dislocations, this is the case for delayed presentations or complex fractures/dislocations. Cases of inferior (downward) dislocations with humeral neck or shaft fractures, or potential vascular injuries, should also be handled in a surgical setting.
Treatment Options for Shoulder Dislocations Overview
There are several techniques doctors use to put a dislocated shoulder back into place. Here are the ones most commonly used and how they work:
Scapular Manipulation: Said to be successful 80-100% of the time, this can be done with the patient either sitting up or lying face down. The doctor stands behind the patient and uses their thumbs to push on the patient’s shoulder blade. An assistant grabbing the patient’s wrist and elbow can provide helpful traction. This method can work subtly without an obvious “clunk,” and there’s a reduced risk of fracturing other parts of the shoulder.
External Rotation Technique: This technique works by relaxing the muscles inside the shoulder that have become tensed up, letting the muscles on the outside of the shoulder pull the bone back into place. The patient lies on their back with their elbow at a right angle, and the doctor slowly rotates their forearm outwards. Over a span of 5 to 10 minutes, the arm naturally moves into a position that lets the shoulder return to its normal position.
Cunningham Technique: The patient sits facing the doctor and places one hand on the doctor’s shoulder. The clinician then massages the patient’s upper arm muscles and asks them to pull their shoulder blades together and straighten their back. This technique has become popular because it usually doesn’t require any sedation.
Milch Technique: This technique is often used if the external rotation technique hasn’t worked. The patient lies on their back, and the doctor rotates their arm away from their body and above their head, while applying direct pressure to the shoulder.
Stimson Technique: The patient lies on their stomach with the dislocated arm hanging off the bed. A weight is attached to the hand, and the pull of gravity helps the shoulder to relocate. Most of the time, this works within half an hour, and the doctor doesn’t need to be there the whole time.
Traction-Countertraction: A sheet is placed under the patient’s armpit, and one person pulls on the patient’s wrist or elbow while another pulls on the sheet from the other side. This creates a counter-pressure that can guide the shoulder back into place.
Spaso Technique: The patient lies down, and the doctor pulls the arm upwards and towards the outside of the body.
Fares Technique: The patient lies down with his/her arm at the side. The doctor pulls on the wrist and moves the arm back and forth while also pulling it away from the body. If the shoulder isn’t back in place by the time the arm is at a right angle to the body, the doctor adds an outward rotation.
Fulcrum Technique: With the patient lying down or sitting, a rolled towel or sheet is placed in the armpit area for leverage. The doctor then adducts (moves the lower arm toward the body) while putting a back-and-outward force on the shoulder. It requires more force and might have increased complications.
Kocher’s and Hippocratic Technique: These techniques are not recommended any longer because of a high risk of complications. The Patient’s foot is placed in patient’s armpit before traction is applied.
Posterior Shoulder Reduction: In this scenario, the patient lies on their back. An assistant applies forward pressure on the shoulder while the doctor pulls on the bone and rotates it internally and externally.
After the shoulder has been put back in place, the patient should wear a sling, have their blood circulation and nerve function checked, get an X-ray or other image of the shoulder, and make a follow-up appointment with an orthopedic surgeon.
What else can Shoulder Dislocations Overview be?
There are several medical conditions that may cause shoulder pain. Some of these conditions can include the following:
- Injury to the acromioclavicular joint (where your collarbone meets the highest point of your shoulder blade)
- Bicipital tendonitis (inflammation in the main tendon that attaches the top of the biceps muscle)
- Fracture of the collarbone
- Damage to the rotator cuff (group of muscles and tendons that secure the shoulder joint)
- Shoulder dislocation (when the arm bone is forced out of your shoulder socket)
- Swimmer’s shoulder (overuse or acute injury due to swimming)
Remember, it’s always important to visit a healthcare professional if you’re experiencing ongoing or severe shoulder pain. They can help determine the cause and suggest appropriate treatment options.