Shoulder Dislocation in the Older

Patient
Abstract
Approximately 20% of all shoulder dislocations occur in patients
aged >60 years. Older patients who sustain a primary shoulder
dislocation are much less likely than younger patients to suffer
from recurrence. However, older patients are more likely than
younger patients to sustain injuries to the rotator cuff, axillary
nerve, or brachial plexus. Rotator cuff tears are signicantly more
common than nerve palsies, and rotator cuff tears can be mistaken
for nerve palsies. Older patients with persistent shoulder pain and
dysfunction after dislocation should be carefully evaluated for
rotator cuff pathology. Although dislocation is a common injury in
the older population, these concomitant injuriesespecially of the
rotator cuffare often missed.
A
lthough the incidence of shoul-
der dislocation is similar be-
tween young and elderly persons,
1
most of the literature has tradition-
ally focused on young patients be-
cause of the high rate of recurrent
dislocations in this population.
2
Shoulder dislocations in older pa-
tients tend to occur as the result of
low-energy mechanisms and are as-
sociated with less risk of recurrent
dislocation; however, pain and dis-
ability can persist for years as a re-
sult of associated rotator cuff tears
and nerve injuries.
3,4
Careful patient
evaluation and treatment selection
are important to provide adequate
care to older patients with shoulder
dislocation.
Mechanism of Injury and
Pathoanatomy
Approximately 20% of shoulder dis-
locations occur in patients aged 60
years.
5
The rate of recurrent shoulder
dislocation is reportedly as high as
90% in patients in their 20s and 30s,
but it is <10% in patients aged 40
years.
6
Differences in mechanism of
injury are largely responsible for the
increased incidence of instability in
younger patients and the increased
likelihood of rotator cuff tear in pa-
tients aged 40 years.
In young patients, McLaughlin and
MacLellan
6
describe an anterior
mechanism of injury in the dislo-
cated shoulder. In younger patients
with strong, healthy rotator cuff tis-
sue, a high-energy insult results in
failure of the weaker anterior static
restraints (ie, labrum, capsule).
McLaughlin
7
speculated that, in
older patients, the posterior mecha-
nism constraints, composed of the
rotator cuff, are more susceptible to
injury as the result of weakening of
the cuff tendons caused by degenera-
tion associated with aging. As a con-
sequence, young patients present
with Bankart tears, that is, displaced
tears of the anterior-inferior labrum
and inferior glenohumeral ligaments,
whereas older patients typically pre-
Anand M. Murthi, MD
Miguel A. Ramirez, MD
From the Department of Orthopedics
and Sports Medicine, Union
Memorial Hospital, Baltimore, MD.
Dr. Murthi or an immediate family
member serves as a paid consultant
to or is an employee of Zimmer,
Ascension, and Arthrex. Neither
Dr. Ramirez nor any immediate
family member has received
anything of value from or has stock
or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2012;20:
615-622
http://dx.doi.org/10.5435/
JAAOS-20-10-615
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.
Review Article
October 2012, Vol 20, No 10 615
sent with rotator cuff tears (Figure
1).
This difference in injury mecha-
nisms explains the different recur-
rence rates between the two popula-
tions. In the young, Bankart tears
render the shoulder inherently unsta-
ble with the loss of the static re-
straints. In patients aged 40 years,
the rotator cuff usually tears. How-
ever, the rotator cuff plays a lesser
role in shoulder stability, and, in gen-
eral, only massive tears result in re-
current instability.
8
Therefore, older
patients tend to redislocate at a
much lower rate than do their
younger counterparts.
2
Hence, surgi-
cal management of shoulder disloca-
tion in older patients should focus on
reconstruction of the rotator cuff
rather than on capsulolabral recon-
struction.
9
Patient Evaluation and
Physical Examination
Careful physical examination is cru-
cial because shoulder dislocation can
be missed on initial presentation.
10
Upon arrival to an emergency de-
partment or physicians office, a pa-
tient with a suspected shoulder dislo-
cation should receive a standard
radiographic trauma series consisting
of a true AP view of the shoulder in
the scapular plane (ie, Grashey), an
axillary lateral view, and a true
scapulolateral view. Images should
be critically evaluated for evidence of
glenohumeral joint reduction and for
subtle signs of previous dislocation
(ie, glenoid rim fractures, erosions),
such as a Hill-Sachs lesion or a bony
Bankart lesion. The greater tuberos-
ity of the humerus should also be
closely evaluated because subtle frac-
tures may be missed on overpene-
trated radiographs.
Physical examination is done with
the goal of measuring joint stability
and diagnosing associated injuries.
Inspection may reveal muscular atro-
phy, which may be an indicator of a
chronic problem such as chronic ro-
tator cuff tear or nerve palsy. Obvi-
ous deformity, such as loss of the
contour of the coracoid, indicates an
anterior dislocation, whereas a
prominent coracoid may suggest pos-
terior shoulder dislocation.
Examination of shoulder passive
range of motion is crucial. Loss of pas-
sive range of motion may be suggestive
of fracture, shoulder subluxation/
dislocation, or glenohumeral joint stiff-
ness, such as arthritis or adhesive cap-
sulitis. Inability to externally rotate the
arm may suggest posterior shoulder
dislocation in which the dislocated hu-
meral head is mechanically blocked by
the glenoid. Isolated loss of active range
of motion may suggest rotator cuff tear
rather than nerve palsy. The acromio-
clavicular joint, greater tuberosity, bi-
ceps groove, and coracoid are potential
sources of shoulder pain and should be
palpated.
The rotator cuff should be thor-
oughly examined. Resisted thumb-
down shoulder abduction in the
scapular plane suggests supraspina-
tus pathology. Similarly, weakness on
resisted external rotation in adduc-
tion and at 90 of abduction is sug-
gestive of infraspinatus and teres mi-
nor pathology, respectively. Several
physical examination tests have been
described to assess for subscapularis
tears, but the most commonly used
tests are the belly press and modified
A and B, Illustrations of the posterior mechanism of injury in shoulder dislocation in an elderly patient. A low-velocity
fall on the outstretched hand causes the humeral head to subluxate anteriorly. The force created (large arrows) results
in stretching of the anterior capsule and subscapularis tendon and tearing of the weaker posterior rotator cuff or
supraspinatus tendon.
Figure 1
Shoulder Dislocation in the Older Patient
616 Journal of the American Academy of Orthopaedic Surgeons
lift-off.
11
Provocative testing is com-
pleted with testing for shoulder
apprehension/relocation signs to ob-
tain evidence of existing shoulder in-
stability.
Finally, a thorough neurovascular
examination is performed, with spe-
cial attention paid to the axillary
nerve. Axillary nerve palsy usually
presents as a painless loss of shoul-
der abduction and loss of sensation
in the proximal-lateral aspect of the
arm. The arm is evaluated for bra-
chial plexus injury, which usually
manifests as sensory and/or motor
weakness distally in the arm. Vascu-
lar injury is assessed by inspecting
for evidence of expanding hema-
toma, which may indicate arterial/
venous injury after a recent disloca-
tion. Distal radial and ulnar pulses
should be evaluated and compared
with those of the contralateral side.
Imaging Studies
Radiographs play a limited role in
direct evaluation of rotator cuff pa-
thology. However, they can identify
associated pathologies, such as tu-
berosity excrescences. A high-riding
humeral head may also suggest un-
derlying chronic rotator cuff pathol-
ogy. MRI has become the preferred
modality to evaluate rotator cuff
tears and assess associated shoulder
injuries (Figure 2).
Ultrasonography is a cost-effective
and noninvasive imaging modality
for evaluating rotator cuff tears. In
one study, ultrasonography correctly
identified 45 of 46 full-thickness ro-
tator cuff tears and predicted the de-
gree of retraction and width of rota-
tor cuff tears with accuracy similar
to that of MRI.
12
Ultrasonography al-
lows for dynamic evaluation of the ro-
tator cuff and may be especially help-
ful in patients in whom MRI findings
are equivocal. Results are operator-
dependent, however, and ultrasonogra-
phy does not provide adequate infor-
mation regarding glenohumeral bone
loss and arthritis, which can influence
treatment decisions in persons with ro-
tator cuff tears.
In patients in whom medical co-
morbidities or indwelling metallic
implants preclude MRI, CT arthrog-
raphy is a reasonable modality to as-
sess rotator cuff and labral integrity
and can be used to evaluate muscle
atrophy. In a study of 33 patients as-
sessed 4 to 6 weeks following pri-
mary shoulder dislocation, Ribbans
et al
13
visualized labral tears in
100% of the young patients (aged
<50 years) and in 75% of the older
patients (aged 50 years) with dislo-
cation. Rotator cuff tear was found
in 63% of older patients and none of
the younger patients.
Associated Injuries
Concomitant rotator cuff tear with an-
terior dislocation of the shoulder is well
documented in older patients.
3-5,9,14,15
The incidence of rotator cuff tear in
conjunction with shoulder disloca-
tion in patients aged 40 years
ranges from 35% to 86%.
3,5,14,15
In
older patients, a posterior mecha-
nism of failure is observed with
AP (A) and scapular Y (B) radiographs of a 70-year-old man with anterior shoulder dislocation. C, T2-weighted coronal
magnetic resonance image of the same patient demonstrating a massive, retracted supraspinatus tear (arrow).
Figure 2
Anand M. Murthi, MD, and Miguel A. Ramirez, MD
October 2012, Vol 20, No 10 617
weakening and disruption of the ro-
tator cuff, but the anterior capsulo-
ligamentous complex remains in-
tact.
7
Tearing of these structures is
more prevalent in the older patient
because rotator cuff degeneration is
correlated with increasing age. In
fact, Yamaguchi et al
16
demonstrated
a 50% chance of bilateral rotator
cuff tear in patients aged 66 years.
As a result, in older patients, the de-
generative cuff is more likely to tear
than are the much stronger capsular
attachments. A study by Porcellini
et al
17
supports this hypothesis. They
found a strong correlation between
dislocation and supraspinatus tear in
150 patients between 40 and 60
years of age who underwent arthros-
copy for rotator cuff tears, instabil-
ity, or both. No correlation was ob-
served between dislocation and
capsular or Bankart lesions.
Although older patients with ante-
rior shoulder injuries are at higher
risk of nerve injury than are younger
patients,
18
care must be taken not to
misdiagnose rotator cuff tears as
nerve palsies in older patients.
4
In a
study of 31 patients (average age,
57.5 years) who were unable to ab-
duct their arms following reduction
of an anterior glenohumeral disloca-
tion, 29 were presumed to have an
axillary nerve injury; however, this
was actually the case for only 4 pa-
tients. All 31 patients underwent
single-contrast arthrography of the
shoulder, and each study showed ex-
travasation of the contrast material,
confirming a rotator cuff tear. Rota-
tor cuff injury should be ruled out in
all patients older than age 40 years
who present with signs and symp-
toms of nerve palsy after shoulder
dislocation.
Many older patients have age-
related attritional tears that were
asymptomatic prior to shoulder dis-
location. Therefore, it is crucial to
obtain a careful history of any preex-
isting symptoms of rotator cuff dys-
function. It is important to obtain a
thorough history of preinjury pain
and disability to elucidate whether
the patient had a symptomatic rota-
tor cuff. Once adequate assessment is
made of past and current disabilities
attributable to the rotator cuff, a
treatment decision can be made. In
our practice, older patients who have
minimal pain and intact strength are
treated nonsurgically. Only tears that
cause significant pain and/or disabil-
ity are managed surgically.
Associated Fractures
Bony injuries associated with shoulder
dislocations include compression frac-
tures of the humeral head (ie, Hill-
Sachs lesion), anterior glenoid rimfrac-
tures, and greater tuberosity fractures.
Older patients, especially elderly pa-
tients with osteoporosis, may sustain
large Hill-Sachs lesions fromeven low-
velocity falls. These lesions may predis-
pose them to increased instability and
to the need for shoulder arthroplasty to
address loss of articular congruity and
relatively easy engagement during for-
ward elevation and external rotation,
which leads to anterior shoulder sub-
luxation or dislocation.
The Hill-Sachs posterolateral hu-
meral head defect is a compression
fracture caused by the anterior gle-
noid rim as the humeral head dislo-
cates from the glenoid fossa. This le-
sion is seen in most anterior inferior
shoulder dislocations and is largest
in recurrent and chronic disloca-
tions. Special radiographic views,
such as the AP in internal rotation
view and the Stryker notch view, are
useful to identify humeral head de-
fects. MRI can show bony pathol-
ogy, but CT, with or without three-
dimensional reconstruction, is best
to determine the extent of the le-
sion.
19
Greater tuberosity fractures are the
most common fractures associated
with anterior shoulder dislocation,
and occurrence increases with in-
creasing age.
2
Several authors have
found that patients with isolated
greater tuberosity fracture have a
better prognosis than do patients
with rotator cuff tear.
2,20
There is a
decrease in the incidence of recurrent
shoulder dislocation in older patients
with greater tuberosity fracture be-
cause the rotator cuff mechanism is
effectively repaired when the fracture
unites.
2,20
Hovelius et al
2
observed no
recurrence in patients with a greater
tuberosity fracture compared with a
32% recurrence rate in patients
without a fracture.
It is our current standard practice
to manage nondisplaced fractures
nonsurgically and to operate on frac-
tures displaced >5 mm, especially
those displaced into the subacromial
space. However, the decision for sur-
gical versus nonsurgical treatment
should take into account the activity
level of the patient. Special attention
should be paid to the individual pa-
tients preoperative function as well
as his or her postinjury goals. Pa-
tients who are poor surgical candi-
dates and those with low postinjury
functional goals should be treated
nonsurgically.
Glenoid fractures associated with
humeral head dislocations are typi-
cally avulsion fractures that occur
when the humeral head impacts the
anterior capsule and labrum. In older
patients, the glenoid fractures be-
cause the bone is weaker and osteo-
porotic.
20,21
If fracture is suspected or
if there is evidence of potential insta-
bility, an axillary radiograph and/or
CT scan may reveal the glenoid le-
sion, which can be associated with
recurrent instability.
22
Peripheral Nerve Injury
Nerve injury associated with anterior
shoulder dislocations is more common
in older persons than in their younger
counterparts.
18
The axillary nerve is
Shoulder Dislocation in the Older Patient
618 Journal of the American Academy of Orthopaedic Surgeons
the most commonly affected, with a
reported incidence of 9.3% to
63%,
5,8,15,18
followed by the suprascap-
ular nerve (29%), musculocutaneous
nerve (19%), radial nerve (22%), and
ulnar nerve (8%).
18
The increased in-
cidence in older patients may be at-
tributable to age-related degenerative
changes in neural tissue, which ren-
der the nerve more susceptible to in-
jury in closed trauma.
5
Clinical features of axillary nerve
palsy include deltoid weakness or wast-
ing that may be accompanied by sen-
sory deficit on the lateral shoulder. Al-
though suggestive, these features are
not diagnostic in older patients. It is
critical to rule out massive rotator cuff
tear before diagnosing a nerve palsy.
For patients with persistent symptoms
3 to 4 weeks after dislocation and with
MRI findings that are negative for ro-
tator cuff tear, it is reasonable to obtain
electrodiagnostic studies to evaluate
the axillary nerve.
8,20,23
Gumina and
Postacchini
5
used electrophysiologic
studies to evaluate nerve palsies in
patients with shoulder dislocations.
Of the 545 patients with anterior
shoulder dislocations, 108 were aged
60 years. Of these 108 patients,
9.3% experienced weakness on
shoulder abduction and decreased
sensation in the deltoid region. Elec-
trophysiologic studies established
that seven patients (6.5%) had
neurapraxia of the axillary nerve,
whereas three (2.8%) had axonotme-
sis. All recovered completely within
1 year without further intervention.
Formal management of these le-
sions is usually unnecessary. Most
patients with nerve dysfunction
spontaneously recover without inter-
vention.
8,18
Brachial Plexus Injury
The brachial plexus lies immediately
anterior, inferior, and medial to the
glenohumeral joint. This anatomic
relationship places the brachial
plexus at risk during anterior shoul-
der dislocation. Brachial plexus inju-
ries resulting from anterior shoulder
dislocation are typically infraclavicu-
lar lesions and mainly affect the axil-
lary nerve and the posterior cord.
24
The primary mechanism of injury is
stretching of the brachial plexus,
which can occur during anterior dis-
location, causing neurapraxia that
typically resolves completely in 4 to
6 months in 80% of cases.
24,25
If no
sign of nerve recovery is documented
on electromyography at 3 to 4
months, exploration of the plexus is
recommended.
24,26,27
Terrible Triad of the
Shoulder
The concurrent incidence of anterior
shoulder dislocation, rotator cuff
tear, and brachial plexus injury has
been coined the terrible triad of the
shoulder.
28
The first documented case
reports noted the difficulty of diag-
nosing rotator cuff tear in the pres-
ence of brachial plexus palsy.
29
This
has important functional conse-
quences because the results of early
rotator cuff repair are better than
those of delayed repair.
29
In a study
of six patients with a mean age of 57
years and with terrible triad injury,
approximately 74 of forward flex-
ion and 9 lb of forward flexion
strength was gained by a mean of 5.6
years after rotator cuff repair.
30
Five
patients recovered from their nerve
injury.
Vascular Injury
Vascular injury to the axillary artery is
an uncommon but well-described se-
quela to anterior shoulder dislocation
in the elderly.
31
More than 90% of
axillary artery injuries resulting from
shoulder dislocations occur in pa-
tients aged >50 years.
32
The proposed
mechanism is aging-related sclerotic
changes in arteries and loss of elastic-
ity, causing tearing rather than stretch-
ing of the arteries. A mechanism has
been described in which the hyperab-
ducted humeral head exposes the axil-
lary artery and pushes it against the
pectoralis major muscle, which acts as
a fulcrum and contributes to arterial
injury.
33
The third part of the axillary
artery, defined as the segment below
the lower edge of the pectoralis minor
muscle, is the location of injury in up
to 86% of patients.
31
Most axillary ar-
tery injuries occur when chronically
dislocated shoulders in older patients
are reduced closed. In chronic unre-
duced shoulders, the axillary artery is
scarred down and tethered by the pec-
toralis minor muscle. The excessive
force required to reduce a chronically
dislocated shoulder is enough to cause
injury to the axillary artery.
19
Signs and symptoms of damage to
the axillary artery include pallor, par-
esthesia, decreased temperature, di-
minished or absent radial pulse, and
an expanding axillary hematoma.
Prompt diagnosis and management
are crucial to prevent irreparable
harm to the extremity. Exploration is
obligatory in any patient with hema-
toma, ischemia, and absence of a ra-
dial pulse.
32,34
In patients with dimin-
ished distal pulses, angiography
should be obtained because collat-
eral flow could be responsible for the
presence of a radial pulse.
31
Vascular
surgery consultation is warranted in
these patients.
In the presence of subclavian or
axillary artery injury, the treating
surgeon should also have a high in-
dex of suspicion for associated bra-
chial plexus injury.
35
If there is con-
cern for brachial plexus injury,
brachial plexus exploration should
be performed at the time of arterial
exploration rather than waiting 2 to
3 months, as is classically taught.
32
Recurrent Instability
The recurrence rate after initial shoul-
der dislocation is much lower in older
Anand M. Murthi, MD, and Miguel A. Ramirez, MD
October 2012, Vol 20, No 10 619
patients than in younger ones, possibly
because older patients tend to sustain
rotator cuff ruptures whereas younger
patients tear the anterior stabilizing
structures and glenohumeral liga-
ments.
7
In one study of patients aged
40 years, only 4% experienced re-
current shoulder dislocations.
14
An-
other study found the average age of
patients with recurrent dislocations
to be 55 years, with an incidence of
11%.
8
In the patient with a combined dis-
placed anteroinferior labral tear (ie,
Bankart tear) and acute rotator cuff
injury, the surgeon should consider
performing a combined repair to
promote shoulder stability. Our algo-
rithm is to repair the labrum with
minimal capsular shift and address
the rotator cuff tear. Postoperative
stiffness is a concern with such a
combined repair; thus, the appropri-
ate therapy should be promoted to
begin early motion within a pro-
tected range.
Chronic Unreduced
Dislocations
Chronic shoulder dislocation is un-
common. These injuries are typically
found in older patients, and trauma
is the most common etiology. Shoul-
der dislocation is considered chronic
when the glenohumeral joint is dislo-
cated for several days. The primary
complaint of patients with chronic
shoulder dislocations is loss of mo-
tion with pain. On physical examina-
tion, old anterior dislocations pre-
sent with restriction of abduction
and internal rotation and old poste-
rior dislocations demonstrate restric-
tion of abduction and external rota-
tion. The most common neurologic
deficit involves the axillary nerve and
presents as deltoid weakness. Disuse
atrophy can be apparent depending
on the length of time the shoulder
has been dislocated.
Suspected chronic shoulder dislo-
cation should be confirmed radio-
graphically. Further imaging with
standard and three-dimensional CT
is useful to evaluate the associated
bony injuries.
Not all patients with chronically
dislocated shoulders require treat-
ment. Patients with a functional up-
per extremity despite slight discom-
fort and limited motion may opt to
leave the shoulder dislocated. Non-
surgical treatment should be consid-
ered for patients who are poor surgi-
cal risks. Pain relief is the primary
indication for reduction of a chroni-
cally dislocated glenohumeral joint.
Restoration of motion is secondary.
The first treatment option to con-
sider is closed reduction. Patient age,
duration of dislocation, vascular sta-
tus, and degree of humeral osteopo-
rosis must be considered before per-
forming this maneuver. Closed
reduction should not be attempted
on a shoulder with a 20% impres-
sion defect of the humeral head or
on a shoulder that has been dislo-
cated longer than 4 weeks.
36
Closed
reduction should be done under gen-
eral anesthesia with total muscle re-
laxation and minimal traction with-
out leverage to avoid fracture of the
proximal humerus or rupture of the
axillary artery.
If closed reduction is not possible,
open reduction should be consid-
ered. This surgery is difficult for
many reasons. First, there is poten-
tial difficulty in reducing the humeral
head into the glenoid fossa because
of fibrosis and capsular bowstringing
across the glenoid.
37
Second, contrac-
tion of rotator cuff muscles and the
usual humeral head defect make
maintenance of the reduction diffi-
cult. Neviaser
37
recommends a strip-
ping operation wherein the capsule,
rotator cuff, and fibrous adhesions
are stripped before reduction is at-
tempted.
Large humeral head defects (>45%
of the humeral head) are best man-
aged with hemiarthroplasty.
38
With
this procedure, retroversion of the
humeral component can be de-
creased to reduce the tendency of the
head to subluxate posteriorly in pos-
terior dislocation. In a study of 11
patients (12 arthroplasties) treated
with hemiarthroplasty for chronic
shoulder dislocation, significant im-
provement in flexion (P = 0.021), ab-
duction (P = 0.007), and external ro-
tation (P = 0.003) range of motion
was noted at an average 37-month
follow-up.
39
Reverse shoulder arthro-
plasty should be considered for pa-
tients aged 70 years who present
with chronic, symptomatic shoulder
dislocations with humeral head bone
loss and rotator cuff deficiency.
Management
Management of shoulder dislocation
in the older patient begins in the
emergency department with prompt
closed reduction of the dislocation.
Most acute dislocations are readily
reducible under sedation in the emer-
gency department. Chronic disloca-
tions (ie, treated 3 to 4 weeks postin-
jury) may require closed reduction in
the operating room under complete
muscular paralysis. In one study,
88% of patients had uneventful
closed reduction in the emergency
department, 5% needed general an-
esthesia, and only 3% required open
reduction.
8
Thorough neurovascular examina-
tion should be performed, and vascu-
lar surgery consultation should be
obtained if warranted. The patient is
discharged in a sling for comfort.
Early range-of-motion exercises and
physical therapy are started within
the first week to prevent posttrau-
matic shoulder stiffness. Patients be-
gin with passive pendulum and Cod-
man exercises and add progressive
passive and active range of motion
under the supervision of a therapist
Shoulder Dislocation in the Older Patient
620 Journal of the American Academy of Orthopaedic Surgeons
for 3 to 4 weeks. Patients who fail
physical therapy in 3 to 4 weeks and
have persistent cuff weakness should
be evaluated with MRI to screen for
underlying pathology. However, if on
initial presentation significant cuff
weakness exists, earlier imaging may
be indicated. Surgeons must main-
tain a very high index of suspicion,
especially in older and elderly pa-
tients who acutely lose function after
shoulder dislocation. The most com-
mon injury is a traumatic rotator
cuff tear in the setting of attritional,
degenerative tissue. Failure to iden-
tify this injury could result in
chronic, painful dysfunction.
Outcomes of Rotator Cuff
Repair
The main difference between pri-
mary shoulder dislocation in older
patients versus young patients is that
older patients with known traumatic
rotator cuff injury are more likely to
be treated surgically. In older pa-
tients with shoulder dislocation,
early diagnosis and repair of the
traumatic rotator cuff tear yields op-
timal outcomes.
14
Other authors
have also shown better outcomes
with surgical management than non-
surgical management of rotator cuff
tear.
3,4,40
Patients aged 40 years who are
treated surgically for shoulder dislo-
cations have shown equivalent redis-
location rates compared with pa-
tients aged <40 years who have
undergone surgical treatment (P >
0.05).
41
An increase in Constant
scores has been reported in patients
aged 40 to 60 years who were
treated arthroscopically for rotator
cuff tears.
17
Summary
The pathology of shoulder disloca-
tion in older patients is significantly
different from that in younger pa-
tients. Whereas dislocation leads to
capsulolabral tears in the young, it
typically results in rotator cuff tears
or fractures in the elderly. Older pa-
tients are more likely than younger
patients to sustain injuries to the ax-
illary nerve or brachial plexus. This
is because of lesser compliance in the
older shoulder. However, neural in-
jury should not be assumed in all
cases. Patients should be assessed for
rotator cuff tear. Treatment should
be focused on early closed reduction
and physical therapy with the goal of
restoring motion and strength. For
older patients who fail nonsurgical
treatment, early diagnosis and treat-
ment of the associated rotator cuff
tear can lead to satisfactory out-
comes.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 6
and 12 are level III studies. References
2-5, 8-11, 13-18, 20-35, and 37-41
are level IV studies. Reference 1 is
level V expert opinion.
References printed in bold type indicate
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