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JOURNAL READING

Presented by:
M. Rizqi Firyal
71 2016 048
+ 20% shoulder dislocations  aged >60 y.o.

 Primary shoulder dislocation


 Older age recurrence > younger age patients
 Older age injury > younger age patients
 rotator cuff
 axillary nerve
 brachial plexus.
 Rotator
cuff tears are significantly more
common than nerve palsies
 can be mistaken

 Persistentshoulder pain & dysfunction after


dislocation in Older patients
 carefully evaluate rotator cuff pathology
 Rotator cuff injury  common, often missed
 Shoulder dislocation insidence
 Young & elderly insidence is similar
 Higher rate of recurrence in young patients

 Shoulder dislocations in older patients


 Low-energy mechanisms, less risk of recurrence
 Persistence pain and disability + for years
 + rotator cuff tears & nerve injuries
+ 20% shoulder dislocations  aged >60 y.o.

 Recurrency
 90%  age of 20s & 30s
 <10%  age ≥ 40 y.o.

 Differencesin mechanism of injury are


largely responsible
 incidence of instability @ younger pt.
 rotator cuff tear ↑ likelihood @ pt. Age > 40 y.o.
YOUNGER PT. (Patients) OLDER PT. (Patients)

“Anterior mechanisms” “Posterior mechanisms”

 Strong & healthy  Weakening rotator


rotator cuff tissues cuff tendons
 High energy insults  Degeneration (aging)
 failure of the weaker  more susceptible to
anterior static injury
restraints
 labrum, capsule
YOUNGER PT. (Patients) OLDER PT. (Patients)

 Bankart tears  Rotator cuff tears


 displaced tears of the
anterior-inferior labrum
 displaced inferior
glenohumeral ligaments
YOUNGER PT. (Patients) OLDER PT. (Patients)

 Bankart tears  Rotator cuff tears


 loss of the static  Lesser role in
restraints shoulder stability 
 Unstable shoulders more stable shoulders
 only massive tears 
unstable shoulders
YOUNGER PT. (Patients) OLDER PT. (Patients)

 Higher recurrency  Lower recurrency


 Surgical management  Surgical
 capsulolabral management
reconstruction
 rotator cuff
reconstruction
A low-velocity fall
on the outstretched
hand

humeral head
subluxate anteriorly
The force
(large arrows)

stretching the
anterior capsule &
subscapularis tendon

tearing the weaker
posterior rotator cuff
OR
tearing the
supraspinatus tendon
 Careful physical examination  crucial
 can be missed on initial presentation

 Suspectedshoulder dislocation pt  receive


a standard radiographic trauma series
 a true AP view of the shoulder in the scapular
plane (ie, Grashey),
 an axillary lateral view,
 a true scapulolateral view.
 Images  critically evaluate:
 glenohumeral joint reduction
 subtle signs of previous dislocation (ie, glenoid
rim fractures, erosions),
 Hill-Sachs lesion OR bony Bankart lesion, etc.

 closely evaluate:
 The greater tuberosity of the humerus
 missed subtle fractures (overpenetrated
radiographs)
 The goal of pysical examination:
 Measure joint stability
 Diagnose associated injuries

 Inspection
 + Muscular atrophy  chronic  rotator cuff or
nerve palsy

 Obvious deformity
 + Contour loss of coracoid  anterior dislocation
 + Prominent coracoid  + posterior dislocation
 Examinate shoulder passive ROM  crucial

 Loss of passive ROM, suggests:


 fracture
 shoulder subluxation/dislocation
 glenohumeral joint stiffness (arthritis or adhesive
capsulitis)

 Inability external arm rotation, suggests:


 posterior shoulder dislocation
 the dislocated humeral head is mechanically blocked
by the glenoid.
 Isolated loss of active ROM, suggests:
 rotator cuff tear (rather than nerve palsy)

 Papation (potential sources of shoulder


pain):
 acromioclavicular joint
 greater tuberosity
 biceps groove
 coracoid
 Examine thoroughly the rotator cuff

 Resisted
thumb down shoulder abduction in
the scapular plane  + supraspinatus
pathology.

 Weakness on resisted external rotation in


adduction and at 90° of abduction  +
infraspinatus & teres minor pathology
 themost commonly used tests 
+ subscapularis tears:
 belly press test
 modified lift-off test

 Provocative testing  + evidence of shoulder


instability
 Examine thoroughyly neurovascular
 Specially  axillary nerve

 Axillary nerve palsy, + presents:


 a painless loss of shoulder abduction, and
 loss of sensation in the proximal-lateral aspect of
the arm.
 Evaluate arm:
 Sensory and/or motor weakness  distal arm 
+ brachial plexus injury

 Assess vascular injury


 expanding hematoma  indicate arterial and/or
venous injury

 Evaluate distal radial & ulnar pulses


 Compare with the contralateral side
 Radiographs
 Limited role in direct evaluation of rotator cuff
pathology
 Can identify associated pathologies (ie.
Tuberosity excrescence)
 High-riding humeral head  + chronic rotator
cuff pathology

 Preferred modality  MRI


AP (A) and
scapular Y (B)
radiographs of a
70-year-old man
with anterior
shoulder
dislocation.
AP (A) and
scapular Y (B)
radiographs of a
70-year-old man
with anterior
shoulder
dislocation.
 T2-weighted
coronal MRI of the
same pt
demonstrating a
massive, retracted
supraspinatus tear
(arrow).
 USG  evaluate rotator cuff tears
 cost-effective, noninvasive
 accuracy similar to that of MRI
 “Equivocal” findings of MRI  USG is helpful
 results are operator dependent

 USG  does not provide adequate info


 glenohumeral bone loss & arthritis  influence
treatment decisions
 Patientsw/ medical comorbidities or
indwelling metallic implants
 Can’t do the MRI imaging
 Use CT arthrography instead
 assess rotator cuff & labral integrity
 evaluate muscle atrophy
 Primary shoulder dislocation
 Labral tears  75% older pt’s, 100% younger pt’s
 Rotator cuff tear  63% older pt’s, 0% younger
pt’s
 Concomitant rotator cuff tear + anterior
dislocation of the shoulder

 Rotator cuff tear + shoulder dislocation


 Age >40 y.o.  incidence rate 35-86%
 In older patients,
 “posterior mechanism”  observe weakening
(degeneration/aging) & disruption of rotator cuff

 anterior capsuloligamentous complex remains


intact.
 Bilateral rotator cuff tear  50% in pts age
>66 y.o.

 In older patients,
 Degenerative cuff  more likely to tear
 Stronger capsular attachments
 Dislocation + supraspinatus tear
 Strong corelation  150 pts, age 40-60 y.o.
(underwent arthroscopy)

 Dislocation & capsular / Bankart lesions


 No correlations
 Older pts w/ anterior shoulder injuries
 Higher risk of (axillary) nerve injury
 Don’t misdiagnose rotator cuff tears & nerve
palsies

 Ruled out rotator cuff injury in:


 All patients older age >40 y.o. and
 signs & symptoms of nerve palsies, after shoulder
dislocation
 Olderpatients w/ age-related attritional
tears prior to shoulder dislocation
 can be asymptomatic

 Crucial, carefully obtain:


 History of any preexisting symptoms of rotator
cuff dysfunction
 History of preinjury pain & disability
 Older patients +
 minimal pain + intact strength  Non-surgical
treatment
 Significant pain  Surgical treatment
 Bony injuries associated with shoulder
dislocations include:
 compression fractures of the humeral head (ie,
Hill-Sachs lesion),
 anterior glenoid rim fractures,
 greater tuberosity fractures.
 Older patients + osteoporosis
 low-velocity falls  + large Hill-Sachs lesions
 increased instability
 + need shoulder arthroplasty  address loss of
articular congruity, anterior shoulder subluxation or
dislocation
 TheHill-Sachs posterolateral humeral head
defect
 compression fracture
 caused by the anterior glenoid rim (humeral
head) dislocates from the glenoid fossa
 Most in anterior inferior shoulder dislocations,
 largest recurrency,
 chronic
 TheHill-Sachs posterolateral humeral head
defect, Imaging studies:
 Radiographic AP (internal rotation view), Stryker
notch view  show defect
 MRI  show bony pathology
 CT  w/wo 3-dimensional reconstruction;
BEST(determine the extent of the lesion)
 Greater tuberosity fractures
 Most common w/ anterior shoulder dislocation
 Occurrence ↑ with ↑ age
 Better prognosis than rotator cuff tear
 Older pts  ↓ recurrency incidence
 rotator cuff mechanism is effectively repaired when
the fracture unites.
 Study  (0% recurrence w/ fractures, 32% recurrence
w/o fractures)
 Greater tuberosity fractures
 Nondisplaced  manage non surgically
 Displaced >5 mm  manage surgically
 poor surgical candidates, low postinjury functional
goals  treat nonsurgically.
 Glenoidfractures associated with humeral
head dislocations
 avulsion fractures
 the humeral head impacts the anterior capsule &
labrum.
 Older pts  weaker bone & osteoporotic

 Suspected/potential instability  axillary


radiograph and/or CT scan
 reveal glenoid lession (associated w/ recurrent
instability)
 More common  in older pts
 neural tissue degenerative aging
 more susceptible to closed trauma injury

 Mostcommon  axillary nerve (63%),


followed:
 suprascapular nerve (29%),
 radial nerve (22%),
 musculocutaneous nerve (19%),
 ulnar nerve (8%)
 Axillary nerve palsy
 deltoid weakness / wasting
 + sensory deficit on the lateral shoulder
 “not diagnostic”

 Rule out massive rotator cuff tear first


 before diagnosing a nerve palsy.
 Persistentsymptoms (3-4 weeks after
dislocation)
 Negative MRI (rotator cuff tear)  obtain
electrodiagnostic studies
 evaluate the axillary nerve
 Study electrophysiologic studies w/
anterior shoulder dislocation pts
 108/545 pts  age ≥60 y.o.
 9.3% w/ weakness on shoulder abduction & decreased
deltoid sensation
 Study:
 6,5%  axillary nerve neurapraxia
 2,8%  axonotmesis
 All recovered completely within 1 year without
further intervention.
 Formal management  usually unnecessary
(spontaneously recover w/o intervention)
 Liesimmediately anterior, inferior, & medial
to the glenohumeral joint
 Anatomically riskful during anterior shoulder
dislocation.
 typically infraclavicular lesions
 mainly affect axillary nerve & posterior cord
 Primary mechanism of injury
 stretched brachial plexus  neurapraxia
 Resolves completely in 4-6 months (80% cases)
 No sign of nerve recovery  exploration of the plexus
is recommended
 Terrible Triad of the Shoulder:
 anterior shoulder dislocation
 rotator cuff tear
 brachial plexus injury
 Case reports
 Brachial plexus palsy presents  difficulty
diagnosing rotator cuff tear
 Functional conseqquences  early repair are better
than delayed repair

 Patients (+ 57 y.o.) + terrible triad injury


 After 5 years rotator cuff repair  Increased
ROM/flexion strength
 Some recovered from nerve injury
 Vascularinjury + anterior shoulder
dislocation
 Axillary artery  uncommon, but sequela in
elderly
 >90% pts age >50 y.o.

 The proposed mechanism


 aging-related sclerotic arteries changes & loss of
elasticity
 causing tearing (rather than stretching)
 The proposed mechanism
Hyperabducted humeral head

exposes the axillary artery

pushes artery against the pectoralis major muscle

arterial injury

 third
part of the axillary artery (segment
below the lower edge of the pectoralis minor
muscle)  + 86% injury location
 Mostly occur
 chronic dislocated shoulders  in older pts 
after closed reduction

 In chronic unreduced shoulders


 axillary artery  scarred down  tethered by
the pectoralis minor muscle
 The excessive force required  axillary artery
 Signs and symptoms:
 pallor
 paresthesia
 decreased temperature
 an expanding axillary hematoma  exploration
 diminished / absent radial pulse  exploration
 + colateral flow  obtain Angiography  + vascular
surgery
+ subclavian/axillary artery injury
 high suspect of associated brachial plexus injury
 Do exploration at the same time of arterial exploration
 Don’t wait 2-3 months
 The recurrence rate
 much lower in older pts (sustain rotator cuff
ruptur)
 higher in younger pts (stabilizing tructures &
glenohumeral ligamets were teared)

 Study  pts age ≥40 y.o.


 4% recurrent shoulder dislocations
 Average age  + 55 y.o. (incidence of 11%)
 Pts
w/ combined anteroinferior labral tear &
acute rotator cuff injury
 Consider perform combined repair  promote
shoulder stability
 repair the labrum
 minimal capsular shift
 address the rotator cuff tear
 Postoperative stiffness  concern
 appropriate therapy  begin early motion within
a protected range

 Uncommon  typically (trauma) in older pts

 Chronic shoulder dislocation


 glenohumeral joint is dislocated for several days
 Primary complains: loss of motion w/ pain
 Physical examination:
 restriction of abduction
 internal rotation (old anterior dislocation)
 external rotation (old posterior dislocation)

 Mostcommon neurologic deficit  axillary


nerve
 deltoid weakness
 If suspected  confirm radiographically
 Standard 3-dimensional CT (evaluate bony injury)

 Not all pts require treatment


 Functional upper extremities (+), slight
discomfort, limited motion
 Poor surgical risks  nonsurgical treatment
 Pain relief  primary indication
 Restoration of motion  secondary indication
 Thefirst treatment option  closed
reduction
 Consider : age, duration of dislocation, vascular
status, & degree of humeral osteoporosis

 Don’t do closed reduction on:


 ≥20% impression defect of the humeral head
 dislocated >4 weeks
 Done in general anesthesia w/ total muscle
relaxation & minimal traction
 avoid proximal humerus fracture / axillary artery
rupture

 Ifclosed reduction is not possible  open


reduction
 Open Reduction potential difficulty :
 fibrosis and capsular bowstringing across the
glenoid.
 contraction of rotator cuff muscles and the usual
humeral head defect

 Recommend  “stripping operation”


 capsule, rotator cuff, & fibrous adhesions are
stripped  before reduction is attempted
 Large humeral head defects (>45% of the
humeral head)
 Hemiarthroplasty
 reduce head posterior subluxate in posterior dislocation.

 Hemiarthroplasty
 significant improvement in flexion, abduction &
external rotation
 noted ROM  37-month follow-up

 Patients age > 70 y.o.


 Reverse shoulder arthroplasty
Begins in the emergency department
 prompt closed reduction of the dislocation
 Most of it are readily reducible
 + sedation use

 Chronic dislocations
 3-4 weeks post injury
 + closed reduction  operating room  under
complete muscular paralysis.
 In one study,
 88% uneventful closed reduction in the
emergency department
 5% needed general anesthesia
 3% required open reduction

 Neurovascular examination
 + vascular surgery concultation

 Thepatient is discharged in a sling for


comfort.
 Week 1
 early ROM exercise & physical therapy
 prevent posttraumatic shoulder stiffness

 Week 3-4
 passive pendulum and Codman exercises
 add progressive passive and active ROM
(therapist supervision)
 If fail + cuff weakness persist  re-evaluate w/
MRI
 However, if on initial presentation significant
cuff weakness exists, earlier imaging may be
indicated.

 Suspect: older/elder pts + lose function


after shoulder dislocation
 Failed identification  + result in chronic,
painful dysfunction
 Themain difference between primary
shoulder dislocation in older & younger pts
 Older pt + known traumatic rotator cuff injury
 more likely to be treated surgically
 Optimal outcome  early diagnosis + dislocation
repair
 Surgical management  better outcome

 Equivalent redislocation rate


 Age >40 y.o. surgical treatment & age < 40 y.o
w/ surgical treatment
 The pathology of shoulder dislocation in
older & younger patients is significantly
different

 Neural injury can happen to both


 Younger pts
 Dislocation  capsulolabral tears  rotator cuff
tears

 Older pts
 More likely to sustain injuries, lesser compliance
(axillary nerve or brachial plexus)
 Patients should be assessed for rotator cuff
tear.

 Treatment
 Focus on early closed reduction
 Physical therapy
 Goal: restoring motion and strength
 Evidence-based Medicine: Levels of evidence
are:
 Level III studies
 Level IV studies
 Level V expert opinion
 Published within the past 5 years.