SHOULDER DISLOCATIONS IN PATIENTS OLDER THAN 40 YEARS OF AGE

Trauma to the shoulder girdle has known associations with neurological and/or vascular injury. The presentation of these can be subtle and could potentially be missed, particularly if the clinician does not maintain a high index of suspicion and clinically examine and investigate appropriately. A missed injury could be detrimental for the patient, both increasing morbidity and affecting long-term outcome. This is especially true for neurological injury, in which missing the window for effective reinnervation procedures can have a lifelong negative impact. Nerve injuries can be difficult to classify clinically in the initial stages and it is crucial to know when nerve conduction studies and imaging are useful, and when early nerve exploration is warranted. Injuries to neurological or vascular structures generally benefit from a multidisciplinary approach to achieve the best outcomes. This article describes common nerve and vascular injuries associated with shoulder girdle trauma, along with approaches to assessment, investigation and timely management.

It is estimated that 5–30% of traumatic anterior shoulder dislocations are accompanied by greater tuberosity fracture (GTF), and the pathomechanism of these fractures is not yet clear. Our hypothesis is to examine the relationship between the scapula morphology and anterior shoulder dislocation (ASD) accompanying GTF.

The patients were divided into two groups according to the accompanying GTF. 40 patients with isolated traumatic ASD and 31 patients with accompanying GTF were included in the study. Critical shoulder angle (CSA), glenoid inclination (GI), acromial index (AI) and greater tuberosity angle (GTA) values were measured in two sessions by two independent observers in the standard antero-posterior radiographs of the patients in both groups.

The mean CSA was 40.82°±3.19° and 35.49°±2.19° in accompanying GTF group and the isolated ASD group, respectively. The mean CSA was significantly higher in accompanying GTF group than isolated ASD group(P<0.001). The GI was significantly higher in the isolated ASD than in accompanying GTF group (P = 0.001). The mean GI was 18.7°±6.85° and 10.45°±4.87° in accompanying GTF group and the isolated ASD, respectively. Cut-off value of CSA and GI was 38° (88.2% sensitivity,88.9% specificity) and 14.5° (70.6% sensitivity and 72.2% specificity), respectively. There was no significant difference regarding the mean GTA and AI values between GTF group and the isolated ASD group (P = 0.98, P = 0.63).

Increased CSA and GI values are associated with traumatic anterior shoulder dislocation accompanied by greater tuberosity fracture.

To compare the clinical outcomes of operative and nonoperative management, identify risk factors for recurrent instability, and identify risk factors for progression to surgery after failed nonoperative management for patients with first-time anterior shoulder dislocation after the age of 50 years.

An established geographic medical record system was used to identify patients who experienced a first-time anterior shoulder dislocation after the age of 50 years. Patient medical records were reviewed to identify treatment decisions and outcomes of interest, including rates of frozen shoulder and nerve palsy, progression to osteoarthritis, recurrent instability, and progression to surgery. Outcomes were evaluated using Chi-square tests and survivorship curves were generated using Kaplan-Meier methods. A Cox model was developed to evaluate for potential risk factors of recurrent instability and progression to surgery after an initial trail of at least 3 months of nonoperative treatment.

179 patients were included with a mean follow-up of 11 years. 14% (n = 26) underwent early surgery within 3 months and 86% (n = 153) were initially treated nonoperatively. Mean age (59 years), was similar for both groups, but those that underwent early surgery had an increased rate of full-thickness rotator cuff tears (82% vs 55%; P = .01), labral tears (24% vs 8.0%; P = .01), and humeral head fracture (23% vs 8.5%; P = .03). When comparing the early surgery group to the nonoperative group, there were similar rates of persistent moderate-severe pain (19% vs 17%; P = .78) and frozen shoulder (8 vs 9%, respectively; P = .87) at final follow-up. Although nerve palsy (19% vs 8%; P = .08) and progression to osteoarthritis (20% vs 14%; P = .40) were more common in surgical patients, they experienced lower rates of recurrent instability after surgical intervention (0% vs 15%; P = .03) compared to nonoperatively treated patients. Increasing number of instability events prior to presentation was the greatest risk factor for recurrent instability (HR 232; P < .01). Fourteen percent (n = 21) failed initial nonoperative treatment and proceeded to surgical intervention at an average of 4.6 years after the initial instability event, and the greatest risk factors for progression to surgery were recurrent instability (HR 3.41; P < .01).

Although the majority of patients >50 years that experience ASI are treated nonoperatively, those that require surgery tend to have more significant injury pathology, a lower risk of recurrent instability after surgery, but a higher progression to osteoarthritis compared to patients that do not require surgical intervention. There was no difference in pain severity at final follow-up, rates of frozen shoulder or nerve palsy between patients who underwent initial nonoperative treatment after instability and those who underwent surgery. A history of multiple instability episodes prior to presentation was the greatest predictor of recurrent instability and failure of nonoperative treatment and progression to surgery.

Level III, retrospective cohort study.

To review closed reduction methods for anterior shoulder dislocation and perform the first comprehensive comparison of the individual methods in terms of success rate, pain, and reduction time.

We searched MEDLINE, PubMed, EMBASE, Cochrane, and ClinicalTrials.gov for randomized controlled trials registered until December 31, 2020. We performed a pairwise and network meta-analysis using a Bayesian random-effects model. Two authors independently performed screening and risk-of-bias assessment.

We found 14 studies with 1,189 patients. In a pairwise meta-analysis, no significant difference was found in the only comparable pair, namely, the Kocher method versus the Hippocratic method (success rate: odds ratio, 1.21; 95% confidence interval [CI], 0.53, 2.75: pain during reduction [visual analog scale]: standard mean difference, −0.33; 95% CI, −0.69, 0.02; reduction time [minutes]: mean difference, 0.19, 95% CI, −1.77, 2.15). In network meta-analysis, FARES (Fast, Reliable, and Safe) was the only method significantly less painful than the Kocher method (mean difference, −4.0; 95% credible interval, −7.6, −0.40). In the surface under the cumulative ranking (SUCRA) plot of success rate, FARES, and the Boss–Holzach–Matter/Davos method showed high values. For pain during reduction, FARES had the highest SUCRA value in the overall analysis. In the SUCRA plot of reduction time, modified external rotation and FARES had high values. The only complication was 1 case of fracture with the Kocher method.

Overall, Boss–Holzach–Matter/Davos, and FARES demonstrated the most favorable value for success rates, whereas both FARES and modified external rotation were more favorable in reduction times. FARES had the most favorable SUCRA for pain during reduction. Future work directly comparing techniques is needed to better understand the difference in reduction success and complications.

This article presents a case of missed locked anterior shoulder dislocation in the context of limited access to care during the COVID-19 pandemic. A previously healthy 25-year-old man with no orthopedic history presented to the emergency room of our hospital with a four-month history of worsening left shoulder pain. X-rays of the shoulder showed an anterior shoulder dislocation with a large Hills-Sachs and coracoid process fracture. The shoulder was stabilized using a Bristow procedure and the Hill-Sachs lesion was treated with a hemi cap resurfacing hemiarthroplasty. In addition, a biceps tenodesis was performed. On the follow-up visit the shoulder reduction was lost and the patient was consented for a revision procedure which consisted in a Bristow procedure and external fixation of the shoulder to maintain reduction. At the one-year follow-up the patient had gained significant range of motion and was painless.

Anterior shoulder dislocation is a common presentation to the emergency department (ED). Dislocations are spontaneous or traumatic. Generally, a reduction is performed under procedural sedation and analgesia (PSA). Other approaches include the use of intra-articular lidocaine or, in rare instances, nerve blocks. Here we discuss the case of a 66-year-old female patient who presented with left shoulder pain and limited range of motion after a fall. After discussing potential treatment options to reduce the dislocation, the patient agreed to a nerve block.

The dislocation was reduced successfully with a suprascapular nerve block (SSNB) without complications. The duration of the patient's ED stay was shorter than those who had received PSA.

SSNB could be an alternative method for shoulder dislocation reduction, particularly for patients who are obese, older, or have cardiopulmonary comorbidities.