Before starting on this section, it is vital that you can answer the following questions:

  1. What type of joint is the glenohumeral joint?  
  2. What makes the glenohumeral joint unstable and why?
  3. What ligaments and muscles support the glenohumeral joint?

Not quite sure what the answers are? Do not worry, click on the button below!

After completing the “Shoulder Dislocation” section, you will be able:

  • To apply knowledge of the glenohumeral joint to explain the pathophysiology
  • To explain the clinical presentation and immediate management
  • To describe the diagnosis
  • To discuss the management (acute and chronic)
  • To validate knowledge by completing the quiz

Anterior Dislocation of the Glenohumeral Joint

Sport Risk Factors

Contact sports such as Rugby, Hockey, Basketball and Football.

Vinette

Jonny Wilkinson, 2003 World Cup winner,  gets tackled very hard and is taken to the ground. During the tackle, his arm was forcefully abducted and externally rotated. As he gets up he is in extreme pain and is carrying his affected arm with his other arm. You also notice a bony bulge on the anterior aspect of the shoulder joint.

Pathophysiology

Shoulder dislocation of the glenohumeral joint is THE most common dislocation in adults because the glenohumeral joint is a shallow socket supported by ligaments and muscles. The dislocation is either anterior (95%) or posterior (5%). Anterior dislocation of the glenohumeral joint is discussed on this page:

 1. TRAUMA: Typically young males present following contact sports especially rugby

 2. Arm forced into excessive abduction, extension, and external rotation

 3. Head of the humerus becomes displaced anteriorly, medially and inferiorly – where the joint capsule is the weakest.

  • Empty space below the acromion (empty socket) with the humeral head anterior.

+/- Can occur with axillary nerve damage, as axillary nerve runs near the joint.

  • anterior dislocation movement postcrop
  • anterior dislocation post crop 1

Clinical Presentation

  • Pain (extreme)
  • Limited movement of shoulder jointpatient typically carrying affected arm with the other arm
  • Loss of shoulder contour (flattening of deltoid)
  • Empty space below the acromion (empty socket) with the humeral head bulging anteriorly – may also be palpated in the axilla.
  • +/- axillary nerve damage: Loss of sensation to the regimental badge area and loss of movement of the deltoid.

Immediate Management

  • Refer immediately to the Emergency department for expertise in radiography and reduction


 

Diagnosis

  • Clinical diagnosis and examination
  • X-Ray – head of the humerus displaced anteriorly, medially and inferiorly.

Management (acute dislocation)

Management of an acute dislocation normally through reduction. Surgery is indicated in young/athletes or recurrent dislocations.

Reduction

 1. PRE-REDUCTION CHECK:

  • Pulses and nerves (including the axillary nerve supplying the sensation over the deltoid area)
  • X-Ray: check for fractures.

 2. REDUCTION + ANALGESIA:

  • Simple reduction method: apply longitudinal traction to the arm in abduction, and replace the head of the humerus by gentle pressure
  • Or use Kocher’s method: TIP: * mnemonic alert * TEAM.

T: Traction.

E: External rotation.

A: Adduction.

M: Medial (Internal) rotation.

  • RISK: humeral # (fracture).

 3. POST-REDUCTION CHECK:

  • Pulses and nerves.
  • X-Ray: head of the humerus lies in the centre of the ‘Y’ with the coracoid process anterior and the acromion posterior. Also, the X-ray checks that no iatrogenic fractures have occurred during reduction.

 4. SUPPORT:

  • Support the arm in internal rotation with a broad arm sling and refer to fracture clinic for follow-up

Click here for the NICE Guidance.

Management (chronic dislocation)

  • Advise avoiding activities that causes dislocations
  • Refer to physiotherapist for a stability/strengthening programme
  • Refer to an orthopaedic specialist
  • Surgery

Click here for the NICE Guidance.

References

Baldwin A, Hjelde N, Goumalatsou C, Myers G. (2016). Oxford Handbook of Clinical Specialities. 10th ed. Oxford: Oxford University Press.

British Medical Journal: Best Practice. (2016). Joint Dislocation. [online]. Available at: http://bestpractice.bmj.com/best-practice/monograph/583.html [accessed 1 March 2017].

National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2015). Shoulder Pain. [online]. Available at: https://cks.nice.org.uk/shoulder-pain#!topicsummary [accessed 1 March 2017].

Teach Me Anatomy. (2017). The Shoulder Joint. [online]. Available at: http://teachmeanatomy.info/upper-limb/joints/shoulder/ [accessed 1 March 2017].

Tortora G, Derrickson B. (2011). Principles of Anatomy and Physiology. 13th ed. Chichester: John Wiley & Sons.

 

Image References

Jonny Wilkinson.   Pathophysiology 1.   Pathophysiology 2.   Clinical Presentation.   Immediate Management.   Diagnosis.   Management (acute) 1 and 3.   Management (acute) 2.