A dislocated shoulder occurs when the humerus separates from the scapula at the glenohumeral joint. The shoulder joint has the greatest range of motion of any joint in the body and as a result is particularly susceptible to dislocation and subluxation. Approximately half of major joint dislocations seen in emergency departments are of the shoulder. Partial dislocation of the shoulder is referred to as subluxation.
Prompt professional medical treatment should be sought for any suspected dislocation injury. Usually, a dislocated shoulder is kept in its current position by use of a splint or sling (however, see below). A pillow between the arm and torso may provide support and increase comfort. Strong analgesics are needed to allay the pain of a dislocation and the anxiety associated with it, and hence, conservative measures of pain relief should not be attempted.
Emergency department care is focused on returning the shoulder to its normal position via processes known as reduction. Normally, closed reduction, in which several methods are used to manipulate the bone and joint from the outside, is used. A variety of techniques exist, but some are preferred due to fewer complications or easier execution. In cases where closed reduction is not successful, surgical open reduction may be needed. Following reduction, x-ray imaging is often used to ensure that the reduction was successful and there are no fractures. The arm should be kept in a sling or immobilizer for several days, preferably until orthopedic consultation. Hippocrates' and Kocher's method are rarely used anymore. Hippocrates used to place the heel in the axilla and reduce shoulder dislocations. Kocher's method, if performed patiently and slowly, can be performed without anesthesia and if done correctly does not cause pain. Traction is applied on the arm and it is abducted. Then, it is externally rotated, and the arm is adducted following which it is internally rotated and maintained in the position with the help of a sling. A chest x-ray should be taken to confirm whether the head of humerus has reduced back into the glenoid cavity. This methodology is performed with external rotation of shoulder, and adduction of the elbow. Some do not recommend it because of possible neurovascular complications and proximal humerus fractures.
If no medical help is available, for anterior dislocations fairly simple methods can be attempted, such as Milch's method or Stimson's Method.
In Australia, an anterior dislocation reduction method that is commonly used is the Spaso technique. This technique was first used by Spaso Miljesic, a nurse specialising in orthopaedics at Western Health, Melbourne, Australia. The technique is reliable and simple. Holding the patient's wrist, gently flex the arm at the shoulder joint with an extended elbow until 90 degrees is achieved. Then apply gentle traction and external rotation. Listen for a clunk indicating relocation. If the patient experiences pain and muscle spasm, wait until it subsides and gently continue. Procedural sedation may be useful. A recent study found the Spaso technique useful in 87.5% of cases of anterior dislocation with no complications.
The most recent style of shoulder reduction is the Cunningham shoulder reduction, utilizing adduction of a flexed arm with concurrent bicipital massage and postero-superior shrug by the patient. This is a rather new technique but has seen positive outcomes in the ER.
Some cases require non-emergency surgery to repair damage to the tissues surrounding in the shoulder joint and restore shoulder stability. Arthroscopic surgery techniques may be used to repair the glenoidal labrum, capsular ligaments, biceps long head anchor or SLAP lesion and/or to tighten the shoulder capsule.
The time-proven surgical treatment for recurrent anterior instability of the shoulder is a Bankart repair. Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy can lessen pain and improve function for active individuals. When the front of the shoulder socket has been broken or worn, a bone graft may be required to restore stability. When the shoulder dislocates posteriorly (out the back), a surgery to reshape the socket may be necessary. Surgery to build up the back of the glenoid socket using an osteotomy and graft can restore shoulder anatomy and lessen pain and improve function. Conversely, there are new procedures that should be investigated as a possible alternative to open surgery.
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