25
Dislocations of the glenohumeral joint
SHANMUGANATHAN RAJASEKARAN, RISHI MUGESH KANNA, JAYARAMARAJU DHEENADHAYALAN
Introduction 297
Pathoanatomy of the shoulder dislocation 297
Mechanism of injury 298
Clinical evaluation 298
Radiographic evaluation 298
Treatment 299
Complications 299
NATIONAL BOARD STANDARDS
Understand the anatomy of the shoulder joint
To know the important shoulder stabilizers
Pathoanatomy of shoulder dislocations
INTRODUCTION
Dislocations of the shoulder joint are very common
injuries, accounting for up to 45% of all dislocations.1
Anterior dislocations occur more frequently than posteri-
or dislocations while inferior and superior dislocations are
rare. The high incidence of shoulder dislocation is related
to the fact that the shoulder joint is a totally
unconstrained joint and thus allows the greatest range of
motion of any articulation in the body. The glenoid fossa
articulates with only 25% of the articular surface of the
humeral head and, although it is augmented by the
labrum, it contributes lit- tle to the stability of the joint.
The labrum, joint capsule, glenohumeral ligaments
(superior, middle and inferior) and adhesivecohesive
forces owing to the presence of syn- ovial fluid provide
passive stability while the deltoid, long head of biceps and
the rotator cuff provide active stability to the shoulder
joint. So the ligaments serve as static restraints and
the muscles serve as dynamic stabilizers (Fig. 25.1).
The rotator cuff muscles (supraspinatous,
infraspinatous and teres minor) with the subscapularis
Recurrent shoulder instability: TUBS and AMBRI 300
Posterior dislocation of the shoulder 300
Inferior glenohumeral dislocation (luxatio erecta) 301
Superior glenohumeral dislocation 301
Summary 301
References 302
Know the types of dislocations
Be able to conduct closed reductions
Know the indications and principles of surgical treatment
and the long head of biceps are the important muscular
stabilizers. The neurovascular bundle lies close to the low-
er body of the glenohumeral joint and can be injured in
anteroinferior dislocations.
PATHOANATOMY OF THE SHOULDER
DISLOCATION
Shoulder dislocations are usually traumatic events and are
always associated with stretching and tearing of the cap-
sule. See fig. 25.2 for the anatomy. In younger patients, the
anterior capsule and labrum are avulsed from the glenoid
(Bankarts lesion) and this may also occasionally include a
small fragment of the bone (bony Bankarts lesion). The
soft-tissue avulsion is usually off the glenoid, but occa-
sionally it can be off the humerus with avulsion of gleno-
humeral ligaments (HAGL lesion). When the humeral
head dislocates anterior to the glenoid fossa, a compres-
sion fracture can occur on the posterolateral part of the
humeral head owing to the force of impaction of the head
 Complications 299

on the anterior edge of the glenoid (HillSachs lesion). MECHANISM OF INJURY

This is seen in 27% of acute anterior dislocations and
74% of recurrent anterior dislocations. In more elderly Anterior glenohumeral dislocation may occur as a result
patients beyond the age of 40, associated rotator cuff of either direct or indirect trauma.2 Indirect trauma to the
tears can occur. There is considerable discussion on the upper extremity with the shoulder in abduction, extension
pathology that predisposes to recurrent dislocation. It is and external rotation is the most common mechanism.
usually a combination of factors, as studies have shown Direct, anteriorly directed impact to the posterior shoul-
that sec- tioning of the anterior capsule alone does not der may produce an anterior dislocation. Recurrent dislo-
lead to insta- bility. cations with minimal trauma may occur in patients with
Dislocations are commonly classified by direction congenital or acquired ligamentous laxity.
(ante- rior, inferior, posterior or multidirectional), onset
(acute, recurrent or chronic) and aetiology (traumatic,
minimally traumatic, atraumatic or microanterior
CLINICAL EVALUATION
instability). Anterior dislocation of the shoulder is the
most common, accounting for about 90% of shoulder
The patient typically presents with the dislocated shoulder
dislocations.
held in slight abduction and external rotation with the arm
supported with the opposite hand. Any attempt at move-
ments produces severe pain. There is flattening of the
Posterior Anterior roundness of the shoulder owing to a relative prominence
of the acromion, a hollow beneath the acromion laterally
Supraspinatus and a palpable mass anteriorly.
A careful neurovascular examination is important to
Coracoacromian assess the integrity of the axillary nerve (sensation over the
arch deltoid) and the musculocutaneous nerve (sensation on
Coracohumeral
Infraspinatus ligament the anterolateral forearm). Sometimes patients may pres-
Superior
ent after spontaneous reduction. Here, a typical history
glenohumeral and apprehension of the patient to abduct or extensively
ligament rotate the shoulder must raise suspicion of a dislocation.
Teres minor
Middle
glenohumeral
ligament RADIOGRAPHIC EVALUATION
Inferior
glenohumeral Anteroposterior and trans-scapular lateral (Y) views are
ligament adequate to confirm the diagnosis (Fig. 25.3). Only if the
direction of the dislocation is not clearly evident should an
axillary view be obtained as this may produce pain and
Figure 25.1 Anatomy of the shoulder joint as viewed from the severe spasm to the patient. Radiographs must be exam-
humeral articular surface. The static and dynamic stabilizers of ined for associated tuberosity fractures and other bony
the shoulder joint are shown. injuries. Special views of the shoulder such as the

Figure 25.2 (ae) The normal shoulder anatomy

and the various pathological lesions in an anterior
shoulder dislocation. (a) Normal anatomy of the
shoulder. (b) Anterior capsular tear. (c) Capsular
Bankart's lesion (avulsion of the capsule from the
anterior glenoid). (d) Bony Bankart's lesion.
(e) HillSachs lesion (fracture of the posterolateral
(a) (b) (c) surface of the humeral head).

(d) (e)

(a) (b)
Figure 25.3 (a,b) Anterior glenohumeral dislocation. (a) The
anteroposterior radiograph of the shoulder shows the
dislocated humeral head lying anteroinferiorly under the
coracoid process. (b) The axillary view shows the humeral head
lying anterior
to the glenoid fossa. Note the empty glenoid fossa in both the
views (arrows).
HillSachs view (tangential view of the anteroinferior
glenoid rim), West Point axillary view and Stryker notch
view (to visualize a posterolateral humeral head defect) are
not mandatory in the acute setting.
CT may be useful in defining humeral head or glenoid
impression fractures, and anterior labral bony injuries.
MRI may be used to identify rotator cuff, capsular and
glenoid labral lesions. Both CT and MRI are usually not
required in the evaluation of acute dislocations.
TREATMENT
Treatment of the first episode of dislocation
Reduction of the dislocation must be performed at the ear-
liest as it provides prompt relief of pain. This can usually
be achieved even without full anaesthesia, provided the
reduction is done gently with good muscle relaxation.
Numerous techniques of reduction have been
described. Hippocrates proposed a method of reduction in
which one foot is placed across the axillary fold and onto
the chest wall to provide countertraction, with traction
and gentle internal rotation of the affected upper extremity.
Later Kocher proposed a technique using traction and
external rotation and gently levering the humeral head on
the anterior glenoid to effect reduction. These methods are
rarely followed now as they are associated with increased
risk of humeral fracture. The two commonly performed
methods are either the Stimson prone reduction technique
or the reduction by traction with abduction and external
rotation (Milch technique). In the Stimson technique, after
injection of 1020 mL of 1% lidocaine into the gleno-
humeral joint, the patient is placed prone on an examina-
tion table with the involved arm hanging in a dependent
position from the edge of the table. Eventually, with suffi-
cient fatigue in the shoulder musculature, the joint can be
easily reduced into normal position.
In the more commonly performed method of reduc-
tion by traction, the patient lies supine with analgesia
obtained either by intravenous sedation or, preferably,
by a subclavian perivascular block regional anaesthesia.
An assistant applies countertraction by holding the two
ends of a sheet passed around the thorax near the axilla
and the forearm is gently pulled in a line of 30 of
abduc- tion, 20 of forward flexion and gradually
externally rotated. The traction must be gentle and
sustained, avoiding sudden and forceful attempts as this
may lead to a fracture, especially in the elderly. Once
sustained gentle traction has been given, as the shoulder
muscles fatigue, the shoulder is adducted and gently
internally rotated to reduce the joint.
In the rare event of inability to reduce an acute anteri-
or dislocation, soft-tissue interposition must be suspected.
This may require open reduction. Other indications for
operative intervention are a grossly displaced greater
tuberosity fracture that does not fall into position or a gle-
noid fracture that is greater than 5 mm in size.
Post-reduction treatment
The shoulder is usually immobilized for a brief period in a
sling until pain relief is achieved, but the length of
immo- bilization has no effect on the susceptibility for
further recurrent dislocations. A range of motion and
rotator cuff strengthening exercises should be initiated at
the earliest but abduction and external rotation should be
avoided.
COMPLICATIONS
Early complications
These include nerve injuries involving the axillary and/or
musculocutaneous nerves in approximately 514% of
dislo- cations. These are usually neurapraxia and almost
always recover spontaneously. Both neural and vascular
injuries can occur in young adults involved in high-velocity
injuries. The greater tuberosity may shear off during the
dislocation; however, it usually falls into place during
reduction. If it remains displaced, internal fixation is
required. Vascular injuries involve the axillary artery and
typically can occur in elderly patients with atherosclerosis.
They can also occur at the time of an open or closed
reduction.
Late complications
Recurrent anterior dislocation is the most common com-
plication after dislocation and the incidence is related to
the age at the time of initial dislocation the lower the
age, the higher the incidence of recurrence.
Susceptibility for redislocation is unrelated to the type or
length of post- reduction immobilization. Recurrent
dislocation is related
to ligament and capsular changes and occasionally to large
bony lesions such as the HillSachs or the bony Bankart
lesion. Patients may also have pain as a result of recurrent
subluxation or instability without an actual dislocation.
Shoulder stiffness can also occur because of prolonged
immobilization and is more common in patients over the
age of 40 years.
RECURRENT SHOULDER INSTABILITY:
TUBS AND AMBRI
There are two different types of recurrent shoulder insta-
bility, one that follows a previous traumatic shoulder dis-
location and the other that presents without any history
of previous trauma.3 The aetiology, presenting features,
pathology and management principles are different for
both these conditions.
After an acute traumatic dislocation, the type of recur-
rent instability observed is termed TUBS (traumatic, uni-
directional, Bankart lesion; surgery is often necessary).
These patients have no problems of generalized ligament
laxity and the dislocation is purely secondary to the distur-
bances caused by the previous trauma. They are usually
young patients and have excellent results following sur-
gery. Different types of surgical repair have been
described. At present both open and arthroscopic Bankart
repairs are in vogue.4 Arthroscopic repair is technically
difficult but the redislocation rates are comparable to
open Bankart repairs. We prefer the inferior capsular shift
reconstruc- tion, which addresses the Bankarts lesion and
also the lax- ity of the capsule and has a very high success
rate.
The other type of recurrent instability presents without
any previous history of trauma and is termed AMBRI
(atraumatic, multidirectional, bilateral, rehabilitation is the
primary mode of treatment; inferior capsular shift is per-
formed only rarely).5 Often the shoulder may show insta-
bility in two or more directions, and patients demonstrate
signs of general systemic laxity. The typical patient is a
double-jointed adolescent demonstrating a sulcus sign
and apprehension when stress is applied in both the
anteri- or and posterior directions. By strengthening the
dynamic stabilizers, it should be possible to overcome the
inherent glenohumeral joint laxity. Non-operative
treatment is the treatment of choice because operative
management is asso- ciated with a high failure rate. If
physical rehabilitation fails to provide adequate
improvement, however, these patients often require
surgical tightening of the entire shoulder cap- sule with the
inferior capsular shift procedure.6
POSTERIOR DISLOCATION OF THE SHOULDER
Posterior dislocation (Fig. 25.4) accounts for less than
10% of all shoulder dislocations.7 A high degree of suspi-
cion is necessary as up to 60% of posterior dislocations
are missed on initial examination.
(a) (b)
Figure 25.4 Anteroposterior (a) and axillary lateral
(b) radiographs of a neglected posterior dislocation of the
shoulder. The anterolateral aspect of the humeral head has a
defect (reverse HillSachs lesion; white arrow) that would prevent
a stable reduction of the dislocation. The empty glenoid fossa is
shown by the black arrow.
Mechanism of injury
A fall onto an adducted and forward flexed arm may result
in a posterior dislocation. But, more often, posterior dislo-
cations occur as a result of indirect injury that produces
marked internal rotation and adduction, such as during a
convulsion or an electrocution. A direct trauma applied to
the anterior shoulder may also result in a posterior trans-
lation of the humeral head.
Clinical evaluation
A posterior glenohumeral dislocation does not present with
striking deformity and the symptoms can be minimal,
lead- ing to frequently missed diagnosis. The shoulder
typically is in the position of adduction, flexion and
internal rotation. Limited forward elevation (often
<90) with restricted external rotation should raise
suspicion of the diagnosis. In thinner individuals, a
palpable mass posterior to the shoul- der and flattening of
the anterior shoulder may be obvious.
Radiographic evaluation
The findings in the standard anteroposterior views may
often appear normal unless carefully examined. The
humeral head, because it is medially rotated, loses its nor-
mal contour and is shaped like an electric light bulb. The
glenoid appears partially vacant (space between anterior
rim and humeral head >6 mm) vacant glenoid sign.
There is absence of the normal elliptic overlap of the
humeral head on the glenoid. The trough sign is an
impaction fracture of the anterior humeral head caused by
the posterior rim of glenoid, which is more visible on the
lateral view. Posterior dislocations are most readily recog-
nized on the axillary view. CT scans will also show clearly

the posterior dislocation and the percentage of the humeral
head impacted during the dislocation.
Treatment
Closed reduction is best done under general anaesthesia.
With the patient supine, traction should be applied to the
adducted arm in the line of the deformity with gentle
lifting of the humeral head into the glenoid fossa. The
shoulder should never be forced into external rotation, as
this may result in a humeral head fracture if an impaction
fracture is locked on the posterior glenoid rim. If the head
is locked, axial traction should be accompanied by lateral
traction on the upper arm to unlock the humeral head from
the glenoid.
Post reduction, a radiograph should be done to confirm
reduction. If the shoulder is stable, a sling immobilization
is adequate. However if the shoulder subluxates or
redislo- cates, the shoulder is immobilized in a shoulder
spica in mild abduction and lateral rotation for a period of
3 weeks.
External rotation and deltoid isometric exercises may be
performed during the period of immobilization. After dis-
continuation of immobilization, an aggressive internal and
external rotator strengthening programme is instituted.
Open reduction is indicated if dislocation is irreducible
(impaction fracture on the posterior glenoid preventing
reduction). Major displacement of an associated lesser
tuberosity fracture or a fractured large posterior glenoid
fragment will require fixation. If the shoulder is unstable
secondary to a large humeral impaction fracture, a transfer
of the lesser tuberosity with attached subscapularis into
the defect (modified McLaughlin procedure) or a
hemiarthro- plasty (>40% involvement) is indicated.
Complications
Missed posterior dislocations are quite common and the
management has to be individualized depending on the
age of the patient, the duration since dislocation and the
pres- ence of any fracture. They will invariably require
surgery and good results can be obtained even when the
interven- tion is done as late as 6 months.
Recurrent dislocation may occur with large anterome-
dial humeral head defects and large posterior glenoid rim
fractures. They may require surgical stabilization to pre-
vent recurrence.
INFERIOR GLENOHUMERAL DISLOCATION
(LUXATIO ERECTA)
This very rare injury results from a hyperabduction force
causing impingement of the neck of the humerus on the
acromion, which levers the humeral head out inferiorly.
The patient typically presents in a characteristic salute
fashion, with the humerus locked in abduction and
Summary 301
forward elevation. Pain is usually severe; the humeral head
is palpable on the lateral chest wall and
axilla.
Injury to the axillary artery or brachial plexus is com-
mon and must be looked for. Associated rotator cuff tears,
pectoralis injury and proximal humeral fracture are also
common. Anteroposterior and axillary views are typically
diagnostic, with inferior dislocation of the humeral head
and superior direction of the humeral shaft along the gle-
noid margin.
Closed reduction may be accomplished by the use of
tractioncountertraction manoeuvres. Axial traction in
line with the humeral shaft, with a gradual decrease in
shoulder abduction and countertraction applied with a
sheet around the patients thorax, usually achieves reduc-
tion. Failure of closed reduction is due to the humeral
head buttonholing through the inferior capsule and soft-
tissue envelope. Open reduction is then indicated.
SUPERIOR GLENOHUMERAL DISLOCATION
This very rare injury occurs with extreme anterior and
supe- rior directed force applied to the adducted upper
extremity, such as a fall from a height onto the upper
extremity. The humeral head is forced superiorly from the
glenoid fossa. Typically it is accompanied by fractures of
the acromion, clavicle, coracoid and humeral
tuberosities, as well as by soft-tissue injury to the rotator
cuff, glenohumeral capsule, biceps tendon and surrounding
musculature.
The patient typically presents with a foreshortened upper
extremity held in adduction and a palpable humeral head
above the level of the acromion. The anteroposterior
radiograph is typically diagnostic, with dislocation of the
humeral head superior to the acromion process. Closed
reduction with axial traction applied in an inferior direction
and lateral traction applied to the upper arm achieves reduc-
tion. Irreducible dislocations may require open reduction.
SUMMARY
The wide range of motion allowed by the shoulder joint
enables us to keep the upper limb at various positions in
space. However, in order to achieve such mobility, the
bony stability of the joint is reduced and depends mainly
on various static and dynamic soft-tissue stabilizers. As
such, the shoulder is one of the most commonly dislocated
joints in the human body. Most traumatic dislocations are
anterior and are treated efficiently by closed methods of
reduction. Late instability is a potential complication that
may require surgical stabilization procedures, either open
or arthroscopic. With the increasing interest in recre-
ational and sporting activities, the incidence of gleno-
humeral instability may be increasing. Effective shoulder
rehabilitation techniques are available for these multidi-
rectional instabilities and surgery is reserved for select
patients only.