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Anterior Dislocations of the Shoulder: Prognosis and Treatment
Anterior Dislocations of the Shoulder Prognosis and Treatment
CARTER R. ROWE, M.D., F.A.C.S.
DR. McLAUGHLIN and I have agreed to split this subject. I will cover the young patient; and Dr. McLaughlin will cover the middle-aged and older patient whose problem is complicated by cuff tears or tuberosity fractures. This is, in fact, a very reasonable division of anterior dislocations of the shoulder, as their prognosis and treatment naturally fall into these two categories. 3 Actually, as many primary anterior dislocations of the shoulder occur after the age of 45 as before this age (Fig. 1). There is a difference, however, in the incidence of recurrence prior to and after age45 (Table 1). A very high incidence of recurrence is noted in the teens and twenties with a gradual decrease in recurrence up to age 45 or 50, at which time there is a sudden drop in the recurrence rate. Perhaps the most reasonable flnswer for this is that, after 45 or 50, people become less flexible, their supporting tissues are tighter, and their activities are less vigorous. DECADE
AT
WHICH
OCCURRED
INITIAL (500
DISLOCATION
CASES)
100 90 80
~
~ ~
70
~
60
'"C:i
50
1;
''~""
40 30
20 10
o
10
20
30
40
50
60
70
eo
90
AGE ~251
CASES-----.+--249
CASES~
Fig. 1. As many initial or primary dislocations occur prior to age 45 as afterward.
1609
1610
CARTER R. ROWE
Table 1 AGE OF PATIENT AT THE TIME OF PRIMARY DISLOCATION IN RELATION TO THE INCIDENCE OF RECURRENCE
AGE OF PA TlENT
NUMBER OF PRIMAR Y DISLOCA TlONS
NUMBER OF RECURRENCES
INCIDENCE OF RECURRENCE
I - 10 YEARS
100%
11 - 20
49
46
94%
21 - 30
64
51
79%
31 - 40
16
50% 24%
41 - 50
33
51 - 60
63
61 - 70
50
71 - 80
32
6%
81 - 90
10
0%
321 TOTAL SHOULDERS 324 (3 BILATERAL CASES) UNDER 20 YEARS 20 - 40 YEARS OVER 40 YEARS
14%
8
16'1,
136
42%
94% RECURRED 74% RECURRED 14% RECURRED
(From Rowe, C. R., and Sakellarides, H. T.: Factors Related to Recurrences of Anterior Dislocations of the Shoulder. Clin. Orthop. 20: 40-48, 1961.)
FACTORS INFLUENCING THE INCIDENCE OF RECURRENCE OF ANTERIOR SHOULDER DISLOCATIONS
Age
The age of the patient at the time of his primary initial dislocation remained the most important and consistent determinant in the incidence rate of recurrence. In analyzing other factors related to recurrences, the "recurrers" were always of a younger age group than the "nonrecurrers." Let us consider, for instance, initial anterior dislocations associated with fractures of the greater tuberosity. We found that in 66 instances there was a very low recurrence rate, namely 4.5 per cent. However, the average age of the patient in this group was 66 years, which has an expectancy of recurrence in the vicinity of only 10 to 12 per cent. Immobilization
We have documented information on 324 dislocations occurring for the first time and their response to different methods of immobilization (Table 2).
A nterior Dislocations of the Shoulder
1611
Table 2 IMMOBILIZA TION AFTER PRIMARY DISLOCATIONS
AVERAGE AGE THOSE THOSE WHO DID WHO DID NOT RECUR RECUR
NUMBER OF DISLOCATIONS
NUMBER RECURRED
NONE
66
46 (70%)
56 YRS.
20 YRS.
SLING 1 - 3 WEEKS 3 - 6 WEEKS
79 27
36 (46%) 10 (37%)
57 YRS. 66 YRS.
25 YRS. 30 YRS.
SLING & SWATHE OR STRAPPING 1 - 3 WEEKS 3 - 6 WEEKS
97 49
25 (26%) 16 (33%)
54 YRS. 50 YRS.
28 YRS. 18 YRS.
6
3 (50%)
35 YRS.
15 YRS.
TYPE OF IMMOBILIZA TION
CAST 3 - 6 WEEKS
TOTAL
324
136
(From Rowe, C. R., and Sakellarides, H. T., op. cit.)
1. Those patients who received no immobilization to their shoulders had a recurrence rate of 70 per cent. 2. When a sling was used for immobilization from one to three weeks, 46 per cent of the dislocations recurred; from three to six weeks, 37 per cent recurred. 3. Those patients in whom a sling and swathe were used from one to three weeks had a 26 per cent recurrence rate, and those from three to six weeks a 33 per cent recurrence rate. 4. The use of a plaster shoulder spica with the arm in internal rotation and adduction from three to six weeks resulted in a 50 per cent recurrence rate. This would indicate that immobilization for a period of three weeks would be adequate. However, immobilization beyond this time was not associated with a reduction in the incidence of recurrence. Note also the relation of the age factor.
The Type of Injury The severity of the initial injury causing the dislocation seemed to be reflected in the incidence of recurrence (Table 3). The more severe the initial injury, the lower the recurrence rate. This is reasonable since one may expect that the greater the injury, the greater the repair and scar tissue resulting. Certainly, the easier the shoulder goes out, the easier it may be reduced, and dislocate again. Age continues to be a factor.
1612
CARTER
R.
ROWE
Table 3 INCIDENCE OF RECURRENCE IN RELATION TO THE TYPE OF INJURY NUMBER OF PRIMARY DISLOCA TIONS
NUMBER .. INCIDENCE OF RECURRENCES
A VERAGE AGE OF RECURRERS
A VERAGE AGE OF NON-RECURRERS
7
6 (86%)
23
35
71
45 (63%)
27
46
TRANSMITTED TRAUMA 90
36 (40%)
35
55
DIRECT BLOW TO SHOULDER
73
18 (25%)
22
53
UNKNOWN GAMES, FALLS 76 ETC.
26 (34'1'.)
28
60
TYPE OF INJUR Y NO TRAUMA TWISTING
TOTAL
317
131
(From Rowe, C. R., and Sakellarides, H. T., op. cit.)
Type of Dislocation
Whether the initial dislocation was "traumatic" or "atraumatic" proved to be most significant. In analyzing 500 initial or primary shoulder dislocations, we found that 6 per cent were "atraumatic" and 94 per cent were the result of trauma. Further study of these two groups was most significant and gave us a specific guide in evaluating the patient with a recurrent dislocating shoulder (Charts 1 and 2). A warning to beware of the patient whose shoulder dislocated initially without significant trauma is clearly called for. This small group of atraumatic dislocations or recurrences must be evaluated very carefully, The surgeon should know specifically whether these shoulders are unstable in more than one direction. He should also Chart 1 THE ATRAUMATIC GROUP
ANATOMICAL VARIATIONS ARE COMMON. MUSCLES, TENDON, GLENOID FOSSA, HUMERAL HEAD. SHOULDER INSTABILITY MAYBE ANTERIOR, POSTERIOR, OR INFERIOR. SOME INDIVIDUALS MAY DISLOCATE AND REDUCE THEIR SHOULDERS VOLUNTARILY. SURGICAL REPAIR UNPREDICTABLE; MORE THAN ONE OPERATION MAY BE NECESSARY.
A nterior Dislocations of the Shoulder
1613
Chart 2 THE PRIMARY TRAUMATIC DISLOCATION
INDIVIDUALS ARE USUALLY OF NORMAL PHYSICAL BUILD. SHOULDER INSTABILITY IN ONE DIRECTION ONLY. GOOD RESPONSE TO SURGICAL REPAIR.
know whether the patient is able to dislocate or subluxate his shoulder spontaneously, and reduce it spontaneously. A small group of patients with atraumatic recurrences are able to actually "flip" their shoulders in and out, anteriorly, inferiorly and posteriorly. These patients respond poorly to conservative treatment as well as to surgical repair. The unsuspecting surgeon may find that, after performing an anterior repair, the patient returns to his office with his shoulder dislocated posteriorly or inferiorly. TREATMENT
Treatment of the Initial Shoulder Dislocation
Everyone has his favorite method of reducing a shoulder. Much depends on the type of the patient, the degree of muscle spasm and the length of time the shoulder has been dislocated. The routine carried out in the Emergency Ward of the Massachusetts General Hospital seems a good one. The adult patient is relaxed with intravenous meperidine (Demerol), 50 mg. The shoulder is suspended in gentle traction for 10 to 15 minutes, during which time the surgeon may leave the room and perform some other duty. He returns and usually finds that the shoulder will respond to a very mild manipulation without general anesthesia. At times he will find that the shoulder is reduced. A favorite method of reduction is the one described by Cooper and CottonI • 2 of elevating the arm gradually into the overhead position and with the thumb lifting the humeral head up into the glenoid. Thus, the shoulder is reduced much in the manner in which it was dislocated. Immobilization
The wrap-around sling (Fig. 2) is comfortable and effective. It can be made cheaply of canvas in the sewing room of the hospital. After three weeks of immobilization, graduated resistance exercises are started in (a) abduction, (b) internal rotation and (c) external rotation. If the patient is past 50 years of age, we very likely will use a sling only for comfort, allowing motion to take place as tolerated.
1614
CARTER R. ROWE
Fig. 2. This canvas sling supports the arm and prevents external rotation and abduction of the arm. Also the pull of the sling on the neck is eliminated. (Illustration by Mrs. Muriel McLatchie Miller from Rowe and Marble in Cave, E. F. (Ed.): Fractures and Other Injuries. Chicago, Year Book Medical Publishers, 1958, p. 267. By permission.)
REFERENCES 1. Cooper, Astley: Dislocations and Fractures of the Joints. London, Carey & Lea, 1825, pp. 307-308. 2. Cotton, F. J.: Dislocations and Joint Fractures. Philadelphia, W. B. Saunders Co., 1910, p. 164. 3. Rowe, C. R. and Sakellarides, H. T.: Factors related to recurrences of anterior dislocations of the shoulder. Clin. Orthopedics, Vol. 20, J. B Lippincott Co., Philadelphia, 1961, pp. 40-48.
275 Charles Street Boston 14, Massachusetts
CARTER R. ROWE, M.D., F.A.C.S.
DR. McLAUGHLIN and I have agreed to split this subject. I will cover the young patient; and Dr. McLaughlin will cover the middle-aged and older patient whose problem is complicated by cuff tears or tuberosity fractures. This is, in fact, a very reasonable division of anterior dislocations of the shoulder, as their prognosis and treatment naturally fall into these two categories. 3 Actually, as many primary anterior dislocations of the shoulder occur after the age of 45 as before this age (Fig. 1). There is a difference, however, in the incidence of recurrence prior to and after age45 (Table 1). A very high incidence of recurrence is noted in the teens and twenties with a gradual decrease in recurrence up to age 45 or 50, at which time there is a sudden drop in the recurrence rate. Perhaps the most reasonable flnswer for this is that, after 45 or 50, people become less flexible, their supporting tissues are tighter, and their activities are less vigorous. DECADE
AT
WHICH
OCCURRED
INITIAL (500
DISLOCATION
CASES)
100 90 80
~
~ ~
70
~
60
'"C:i
50
1;
''~""
40 30
20 10
o
10
20
30
40
50
60
70
eo
90
AGE ~251
CASES-----.+--249
CASES~
Fig. 1. As many initial or primary dislocations occur prior to age 45 as afterward.
1609
1610
CARTER R. ROWE
Table 1 AGE OF PATIENT AT THE TIME OF PRIMARY DISLOCATION IN RELATION TO THE INCIDENCE OF RECURRENCE
AGE OF PA TlENT
NUMBER OF PRIMAR Y DISLOCA TlONS
NUMBER OF RECURRENCES
INCIDENCE OF RECURRENCE
I - 10 YEARS
100%
11 - 20
49
46
94%
21 - 30
64
51
79%
31 - 40
16
50% 24%
41 - 50
33
51 - 60
63
61 - 70
50
71 - 80
32
6%
81 - 90
10
0%
321 TOTAL SHOULDERS 324 (3 BILATERAL CASES) UNDER 20 YEARS 20 - 40 YEARS OVER 40 YEARS
14%
8
16'1,
136
42%
94% RECURRED 74% RECURRED 14% RECURRED
(From Rowe, C. R., and Sakellarides, H. T.: Factors Related to Recurrences of Anterior Dislocations of the Shoulder. Clin. Orthop. 20: 40-48, 1961.)
FACTORS INFLUENCING THE INCIDENCE OF RECURRENCE OF ANTERIOR SHOULDER DISLOCATIONS
Age
The age of the patient at the time of his primary initial dislocation remained the most important and consistent determinant in the incidence rate of recurrence. In analyzing other factors related to recurrences, the "recurrers" were always of a younger age group than the "nonrecurrers." Let us consider, for instance, initial anterior dislocations associated with fractures of the greater tuberosity. We found that in 66 instances there was a very low recurrence rate, namely 4.5 per cent. However, the average age of the patient in this group was 66 years, which has an expectancy of recurrence in the vicinity of only 10 to 12 per cent. Immobilization
We have documented information on 324 dislocations occurring for the first time and their response to different methods of immobilization (Table 2).
A nterior Dislocations of the Shoulder
1611
Table 2 IMMOBILIZA TION AFTER PRIMARY DISLOCATIONS
AVERAGE AGE THOSE THOSE WHO DID WHO DID NOT RECUR RECUR
NUMBER OF DISLOCATIONS
NUMBER RECURRED
NONE
66
46 (70%)
56 YRS.
20 YRS.
SLING 1 - 3 WEEKS 3 - 6 WEEKS
79 27
36 (46%) 10 (37%)
57 YRS. 66 YRS.
25 YRS. 30 YRS.
SLING & SWATHE OR STRAPPING 1 - 3 WEEKS 3 - 6 WEEKS
97 49
25 (26%) 16 (33%)
54 YRS. 50 YRS.
28 YRS. 18 YRS.
6
3 (50%)
35 YRS.
15 YRS.
TYPE OF IMMOBILIZA TION
CAST 3 - 6 WEEKS
TOTAL
324
136
(From Rowe, C. R., and Sakellarides, H. T., op. cit.)
1. Those patients who received no immobilization to their shoulders had a recurrence rate of 70 per cent. 2. When a sling was used for immobilization from one to three weeks, 46 per cent of the dislocations recurred; from three to six weeks, 37 per cent recurred. 3. Those patients in whom a sling and swathe were used from one to three weeks had a 26 per cent recurrence rate, and those from three to six weeks a 33 per cent recurrence rate. 4. The use of a plaster shoulder spica with the arm in internal rotation and adduction from three to six weeks resulted in a 50 per cent recurrence rate. This would indicate that immobilization for a period of three weeks would be adequate. However, immobilization beyond this time was not associated with a reduction in the incidence of recurrence. Note also the relation of the age factor.
The Type of Injury The severity of the initial injury causing the dislocation seemed to be reflected in the incidence of recurrence (Table 3). The more severe the initial injury, the lower the recurrence rate. This is reasonable since one may expect that the greater the injury, the greater the repair and scar tissue resulting. Certainly, the easier the shoulder goes out, the easier it may be reduced, and dislocate again. Age continues to be a factor.
1612
CARTER
R.
ROWE
Table 3 INCIDENCE OF RECURRENCE IN RELATION TO THE TYPE OF INJURY NUMBER OF PRIMARY DISLOCA TIONS
NUMBER .. INCIDENCE OF RECURRENCES
A VERAGE AGE OF RECURRERS
A VERAGE AGE OF NON-RECURRERS
7
6 (86%)
23
35
71
45 (63%)
27
46
TRANSMITTED TRAUMA 90
36 (40%)
35
55
DIRECT BLOW TO SHOULDER
73
18 (25%)
22
53
UNKNOWN GAMES, FALLS 76 ETC.
26 (34'1'.)
28
60
TYPE OF INJUR Y NO TRAUMA TWISTING
TOTAL
317
131
(From Rowe, C. R., and Sakellarides, H. T., op. cit.)
Type of Dislocation
Whether the initial dislocation was "traumatic" or "atraumatic" proved to be most significant. In analyzing 500 initial or primary shoulder dislocations, we found that 6 per cent were "atraumatic" and 94 per cent were the result of trauma. Further study of these two groups was most significant and gave us a specific guide in evaluating the patient with a recurrent dislocating shoulder (Charts 1 and 2). A warning to beware of the patient whose shoulder dislocated initially without significant trauma is clearly called for. This small group of atraumatic dislocations or recurrences must be evaluated very carefully, The surgeon should know specifically whether these shoulders are unstable in more than one direction. He should also Chart 1 THE ATRAUMATIC GROUP
ANATOMICAL VARIATIONS ARE COMMON. MUSCLES, TENDON, GLENOID FOSSA, HUMERAL HEAD. SHOULDER INSTABILITY MAYBE ANTERIOR, POSTERIOR, OR INFERIOR. SOME INDIVIDUALS MAY DISLOCATE AND REDUCE THEIR SHOULDERS VOLUNTARILY. SURGICAL REPAIR UNPREDICTABLE; MORE THAN ONE OPERATION MAY BE NECESSARY.
A nterior Dislocations of the Shoulder
1613
Chart 2 THE PRIMARY TRAUMATIC DISLOCATION
INDIVIDUALS ARE USUALLY OF NORMAL PHYSICAL BUILD. SHOULDER INSTABILITY IN ONE DIRECTION ONLY. GOOD RESPONSE TO SURGICAL REPAIR.
know whether the patient is able to dislocate or subluxate his shoulder spontaneously, and reduce it spontaneously. A small group of patients with atraumatic recurrences are able to actually "flip" their shoulders in and out, anteriorly, inferiorly and posteriorly. These patients respond poorly to conservative treatment as well as to surgical repair. The unsuspecting surgeon may find that, after performing an anterior repair, the patient returns to his office with his shoulder dislocated posteriorly or inferiorly. TREATMENT
Treatment of the Initial Shoulder Dislocation
Everyone has his favorite method of reducing a shoulder. Much depends on the type of the patient, the degree of muscle spasm and the length of time the shoulder has been dislocated. The routine carried out in the Emergency Ward of the Massachusetts General Hospital seems a good one. The adult patient is relaxed with intravenous meperidine (Demerol), 50 mg. The shoulder is suspended in gentle traction for 10 to 15 minutes, during which time the surgeon may leave the room and perform some other duty. He returns and usually finds that the shoulder will respond to a very mild manipulation without general anesthesia. At times he will find that the shoulder is reduced. A favorite method of reduction is the one described by Cooper and CottonI • 2 of elevating the arm gradually into the overhead position and with the thumb lifting the humeral head up into the glenoid. Thus, the shoulder is reduced much in the manner in which it was dislocated. Immobilization
The wrap-around sling (Fig. 2) is comfortable and effective. It can be made cheaply of canvas in the sewing room of the hospital. After three weeks of immobilization, graduated resistance exercises are started in (a) abduction, (b) internal rotation and (c) external rotation. If the patient is past 50 years of age, we very likely will use a sling only for comfort, allowing motion to take place as tolerated.
1614
CARTER R. ROWE
Fig. 2. This canvas sling supports the arm and prevents external rotation and abduction of the arm. Also the pull of the sling on the neck is eliminated. (Illustration by Mrs. Muriel McLatchie Miller from Rowe and Marble in Cave, E. F. (Ed.): Fractures and Other Injuries. Chicago, Year Book Medical Publishers, 1958, p. 267. By permission.)
REFERENCES 1. Cooper, Astley: Dislocations and Fractures of the Joints. London, Carey & Lea, 1825, pp. 307-308. 2. Cotton, F. J.: Dislocations and Joint Fractures. Philadelphia, W. B. Saunders Co., 1910, p. 164. 3. Rowe, C. R. and Sakellarides, H. T.: Factors related to recurrences of anterior dislocations of the shoulder. Clin. Orthopedics, Vol. 20, J. B Lippincott Co., Philadelphia, 1961, pp. 40-48.
275 Charles Street Boston 14, Massachusetts