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Management of the First-Time Traumatic Anterior Shoulder Dislocation

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Management of the First-Time Traumatic Anterior Shoulder Dislocation CONCISE REVIEW CiSE Clinics in Shoulder and Elbow Clinics in Shoulder and Elbow Vol. 21, No. 3, September, 2018 https://doi.org/10.5397/cise.2018.21.3.169 Management of the First-time Traumatic Anterior Shoulder Dislocation Sung Il Wang Department of Orthopaedic Surgery, Chonbuk National University Medical School, Research Insitute for Endocrine Sciences and Research Insitute of Clinical Medicine of Chonbuk National University–Biomedical Research Insitute of Chonbuk National University Hospital, Jeonju, Korea Traumatic anterior dislocation of the shoulder is one of the most common directions of instability following a traumatic event. Although the incidence of shoulder dislocation is similar between young and elderly patients, most studies have traditionally focused on young pa- tients due to relatively high rates of recurrent dislocations in this population. However, shoulder dislocations in older patients also require careful evaluation and treatment selection because they can lead to persistent pain and disability due to rotator cuff tears and nerve injuries. This article provides an overview of the nature and pathology of acute primary anterior shoulder dislocation, widely accepted management modalities, and differences in treatment for young and elderly patients. (Clin Shoulder Elbow 2018;21(3):169-175) Key Words: Glenohumeral joint; Shoulder dislocation; Treatment Introduction the shoulder will invariably be damaged, rendering the joint un- stable. The glenohumeral joint has the greatest range of motion There are controversies over the best treatment for patients among all joints in the human body. To achieve increased with first-time anterior shoulder dislocation. Assessment of risk mobility, joint stability is sacrificed, making shoulder joint sus- factors for recurrence is essential when deciding on the treat- ceptible to dislocation. Of the large joints, the glenohumeral ment options, which can be done through either conservative joint is the most common for dislocation, with an incidence of treatment or surgical stabilization.6-8) The length of time and 11.2/100,000 per year and an estimated prevalence of 2% to 8% position of immobilization remains controversial in conservative in the general population.1-3) Anterior traumatic dislocation is the treatment. most common pattern, constituting about 96% of all glenohu- Although the incidence of shoulder dislocation is similar meral dislocations.4) There is a bimodal distribution of age for the between young and elderly patients,6) most studies in the lit- risk of first-time traumatic anterior shoulder dislocation. erature have traditionally focused on young patients, given the A high percentage of patients are men in their second or third relatively high rate of recurrent dislocations in this population.9) decades, who sustain the injury during contact sports, followed However, shoulder dislocations in older patients also require at- by elderly patients who sustain in the jury during low-velocity tention. Careful evaluation and treatment selection are crucial falls.5,6) Regarding the mechanism, dislocation most frequently in this population because they can lead to persistent pain and occurs when the arm is forced into an abducted and externally disability due to rotator cuff tears and nerve injuries. Hence, this rotated position. Following a dislocation, primary stabilizers of article aims to provide an overview of the nature and pathology Received July 3, 2018. Revised July 28, 2018. Accepted July 30, 2018. Correspondence to: Sung Il Wang Department of Orthopaedic Surgery, Chonbuk National University Medical School, Research Insitute for Endocrine Sciences and Research Insitute of Clinical Medicine of Chonbuk National University–Biomedical Research Insitute of Chonbuk National University Hospital, 567 Baekje- daero, Deokjin-gu, Jeonju 54896, Korea Tel: +82-63-250-1760, Fax: +82-63-271-6538, E-mail: [email protected], ORCID: https://orcid.org/0000-0002-3890-6516 Review article does not need an IRB approval. Financial support: None. Conflict of interests: None. Copyright © 2018 Korean Shoulder and Elbow Society. All Rights Reserved. pISSN 2383-8337 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. eISSN 2288-8721 Clinics in Shoulder and Elbow Vol. 21, No. 3, September, 2018 of acute primary anterior shoulder dislocation, widely accepted nerve more susceptible to injury in closed trauma.22) management modalities, and difference in treatment for young Vascular injury to the axillary artery is an uncommon but and elderly patients. well-described sequelae to anterior shoulder dislocation in the elderly.25) More than 90% of axillary artery injuries resulting from Pathophysiology shoulder dislocations occur in patients aged 50 years or over.26) Proposed mechanisms are aging-related sclerotic changes in Several studies have reported the pathology of first-time trau- the arteries and loss of elasticity that cause tearing rather than matic anterior shoulder dislocation. Due to changes in age-relat- stretching of arteries. ed tissue elasticity, the pathology of anterior shoulder dislocation is also different between young and elderly patients. McLaughlin Management for First-time Shoulder and MacLellan10) have described an anterior mechanism of Dislocation injury in the dislocated shoulder in young patients. In younger patients with strong and healthy rotator cuff tissue, a high-energy Clinical Assessment insult can result in failure of weaker anterior static restraints A detailed history and examination are important in the as- (i.e., labrum, capsule).10) As a consequence, young patients are sessment of patients with first-time anterior shoulder dislocation. present with Bankart lesions, which are displaced tears of the Assessment should be aimed to establish satisfactory glenohu- anterior-inferior labrum and inferior glenohumeral ligaments. meral joint reduction, rotator cuff function, neurovascular status, Other lesions that might be associated with traumatic anterior and determination of the presence of a bony Bankart lesion, dislocations include superior labral tears from anterior to poste- as these factors can influence early management.27) A true an- rior (SLAP), bony Bankart, anterior labral periosteal sleeve avul- teroposterior, scapular Y, and axillary views should be obtained sion (ALPSA), humeral avulsion of the glenohumeral ligaments to determine the direction of the dislocation as well as other (HAGL) lesion, and rotator cuff tear.11) pathology that may be apparent before any attempt of manipu- Taylor and Arciero12) have documented that 97% of their pa- lation and reduction can be made.28) Post-reduction radiography tients have Bankart lesions. Similar findings have been reported is also mandatory to confirm a congruent reduction and reassess in the study of Baker et al.,13) showing incidence of 87% for Ban- the position of any associated fractures.29) If there is any doubt kart lesions, 64% for Hill-Sachs bony injury, and 18% for capsu- regarding the extent of osseous injury, a 3-dimensional com- lar tear and rotator cuff injury. Some studies have reported an puted tomography (CT) scan should be performed. incidence of 30% for ALPSA,14) 10% to 24% for SLAP,13,14) 12% A magnetic resonance imaging (MRI) is generally viewed as to 13% for bony Bankart,14,15) and 1% to 6% for HAGL lesion in the gold standard for soft tissue pathology associated with shoul- young patients during first-time dislocation.13-15) der instability. With MRI, capsular and ligament detachments, However, older individuals are at greater risk for rotator cuff labral lesions, rotator cuff tears, and articular cartilage lesions can injury due to weakened cuff tendons caused by degeneration be identified more accurately than on CT scan or radiography. associated with aging during first-time dislocation compared The addition of intraarticular contrast in an magnetic resonance with younger patients. McLaughlin and MacLellan10) have sug- arthrography identifies labral tears with a sensitivity of 88% to gested a posterior mechanism for such injury in older patients as 96% and a specificity of 91% to 98%.30,31) opposed to an anterior mechanism seen in younger individuals. However, initial MRI is not typically required to confirm a The rates of accompanying rotator cuff tears have been reported labral tear in traumatic anterior dislocations because it is known to range from 35% to 86% in patients older than 40 years with to have a prevalence of nearly 90% in such injuries of young anterior shoulder dislocation.16-20) Shin et al.21) have reported an patients. Nevertheless, if pain and instability persist after initial incidence of 49% for rotator cuff tears, 7% for Bankart lesions, closed reduction and immobilization in patients with higher risk and 1.5% for Hill-Sachs bony injury in patients older than 60 of recurrent instability (e.g., young age, male, contact sports, or years with first-time dislocation. Biceps rupture, greater tuberos- shoulder hyperlaxity), MRI should be performed to help better ity fracture, and neurovascular injuries with anterior shoulder counsel patients regarding the benefit of early shoulder stabiliza- dislocations are more common in older patients than in their tion surgery as an option to decrease the risk of recurrence
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