How To Manage Anterior How To Manage Anterior Traumatic Instability of Traumatic Instability of

the Shoulderthe Shoulder

Presented by: Kevin Presented by: Kevin HilgenbergHilgenberg

Traumatic vs. AtraumaticTraumatic vs. Atraumatic

Shoulder instability is classified as either Shoulder instability is classified as either traumatic or atraumatic based on the traumatic or atraumatic based on the mechanism of injury. mechanism of injury.

The shoulder most commonly dislocates in the The shoulder most commonly dislocates in the anterior direction from an acute traumatic anterior direction from an acute traumatic event that results in stretching and detachment event that results in stretching and detachment of the anterior capsule and labrum. of the anterior capsule and labrum.

Atraumatic instability of the shoulder occurs Atraumatic instability of the shoulder occurs from chronic microrepetitive injuries, such as from chronic microrepetitive injuries, such as when a person is involved with overhead sports when a person is involved with overhead sports or associated with generalized soft-tissue laxity. or associated with generalized soft-tissue laxity.

Why is this Important?Why is this Important?

Traditional treatment for both injuries has been Traditional treatment for both injuries has been a conservative approach, consisting of a conservative approach, consisting of immobilization, rehabilitation, and a delay in immobilization, rehabilitation, and a delay in return to vigorous activity. return to vigorous activity.

This treatment is often quite successful in This treatment is often quite successful in preventing recurrent dislocations in the patient preventing recurrent dislocations in the patient with atraumatic (Multidirectional) instability. with atraumatic (Multidirectional) instability.

However, those patients who suffer an acute However, those patients who suffer an acute traumatic anterior dislocation often experience traumatic anterior dislocation often experience further dislocations or subluxations, with further dislocations or subluxations, with recurrence rates as high as 94% in patients recurrence rates as high as 94% in patients younger than 20 years.younger than 20 years.

•The young athletic population that places high demands on the upper extremity by engaging in strenuous activities are the ones who suffer from traumatic dislocations the most.

•However, the most frequent adverse consequence of any initial shoulder dislocation is recurrence, which occurs most commonly in this same active patient population and becomes less frequent with age.

•Re-dislocation recurs in over 80% of people aged 20 years or under, 60% of people aged between 20-40 years, and less than 15% of people aged 40 years or older.

Anterior DislocationAnterior Dislocation

Almost 95% of shoulder Almost 95% of shoulder dislocations result from dislocations result from either a forceful collision, either a forceful collision, from falling on an from falling on an outstretched arm, or from outstretched arm, or from a sudden wrenching a sudden wrenching movement with the arm in movement with the arm in an abducted, externally an abducted, externally rotated position.rotated position.

Multidirectional InstabilityMultidirectional Instability

Atraumatic instability of the Atraumatic instability of the shoulder occurs from chronic shoulder occurs from chronic microrepetitive injuries, such as microrepetitive injuries, such as when a person is involved with when a person is involved with overhead sports or associated with overhead sports or associated with generalized soft-tissue injury and generalized soft-tissue injury and only accounts for 5% of anterior only accounts for 5% of anterior shoulder dislocations, from minor shoulder dislocations, from minor incidents such as raising the arm or incidents such as raising the arm or moving during sleep moving during sleep

Anatomy BasicsAnatomy Basics There are numerous discrete thickenings of the There are numerous discrete thickenings of the

capsule known as ligaments that surrounds the capsule known as ligaments that surrounds the shoulder, providing compression of the humeral shoulder, providing compression of the humeral head and deterring excessive movement in any head and deterring excessive movement in any one direction from the glenoid fossa. one direction from the glenoid fossa.

They are named the superior glenohumeral They are named the superior glenohumeral ligament (SGHL), the middle glenohumeral ligament (SGHL), the middle glenohumeral ligament (MGHL), and the inferior glenohumeral ligament (MGHL), and the inferior glenohumeral ligament (IGHL). ligament (IGHL).

The IGHL has been identified as the primary The IGHL has been identified as the primary static constraint against anterior, posterior, and static constraint against anterior, posterior, and inferior translation in cadaveric specimens when inferior translation in cadaveric specimens when the humerus is abducted beyond 45 degrees. the humerus is abducted beyond 45 degrees.

•With the arm in 90-degrees of abduction and in external rotation the IGHL is tightened maximally making it vulnerable for injury.

•In this position the IGHL becomes the most significant ligament in containing the humeral head from dislocating.

Dislocation ConsequencesDislocation Consequences•When the humeral head does dislocate it causes a capsulolabral avulsion at the anterior-inferior glenoid rim known as a “Bankhart” lesion, and is recognized as a cause for recurrent shoulder instability.

•The most common bony lesion associated with traumatic glenohumeral instability is a compression fracture at the posterior-lateral margin of the humeral head known as a “Hill-Sachs” lesion, which if large may increase the recurrence rate following repair.

•Both of these conditions should be repaired through surgical intervention for normal biomechanics to be restored to the shoulder.

Clinical PresentationClinical Presentation

The patient with an The patient with an acute anterior acute anterior dislocation is in distress dislocation is in distress and complains of acute and complains of acute pain. pain.

The affected limb has The affected limb has decreased ROM and a decreased ROM and a loss of deltoid contour.loss of deltoid contour.

The pt. will often The pt. will often complain that it felt as complain that it felt as though the shoulder though the shoulder slipped out of joint.slipped out of joint.

Initial TreatmentInitial Treatment

After a thorough history and physical examination are After a thorough history and physical examination are performed, radiographs are obtained and a diagnosis performed, radiographs are obtained and a diagnosis of an acute traumatic anterior dislocation is made, of an acute traumatic anterior dislocation is made, initial treatment consists of a closed reduction of the initial treatment consists of a closed reduction of the shoulder.shoulder.

A gravity-assisted reduction maneuver or a traction-A gravity-assisted reduction maneuver or a traction-countertraction method is used for reduction. When countertraction method is used for reduction. When performing the reduction, analgesia and/or IV sedation performing the reduction, analgesia and/or IV sedation is routinely used, unless the dislocation is evaluated is routinely used, unless the dislocation is evaluated immediately and reduced rapidly.immediately and reduced rapidly.

It is extremely important that after reduction is It is extremely important that after reduction is successfully performed, that the neurovascular successfully performed, that the neurovascular examination is repeated and more radiographs are examination is repeated and more radiographs are taken to determine if any injury occurred during the taken to determine if any injury occurred during the reduction. reduction.

What not to do!!What not to do!!

Good ExamplesGood Examples

Conservative TreatmentConservative Treatment

Non-surgical treatment is historically the Non-surgical treatment is historically the treatment of choice for an acute, initial, treatment of choice for an acute, initial, traumatic anterior shoulder dislocation.traumatic anterior shoulder dislocation.

This generally consists of a period of This generally consists of a period of immobilization, a supervised rehabilitation immobilization, a supervised rehabilitation program, and restriction from return to program, and restriction from return to vigorous activity for a limited time period. vigorous activity for a limited time period.

The aim of this treatment is to allow soft-The aim of this treatment is to allow soft-tissue healing, maximize strength of the tissue healing, maximize strength of the dynamic stabilizers of the shoulder, and dynamic stabilizers of the shoulder, and minimize recurrence.minimize recurrence.

Conservative treatmentConservative treatment

Conservative TreatmentConservative Treatment

Numerous studies have shown that conventional, Numerous studies have shown that conventional, non-operative treatment of shoulder dislocations in non-operative treatment of shoulder dislocations in the younger more active population results in a high the younger more active population results in a high rate of recurrence. rate of recurrence.

Non-operative treatment for acute traumatic anterior Non-operative treatment for acute traumatic anterior dislocations has resulted in recurrent instability rates dislocations has resulted in recurrent instability rates ranging from 17% to 96% in patients under 30 years ranging from 17% to 96% in patients under 30 years of age (Bottoni 2002). of age (Bottoni 2002).

This high rate of recurrence in young patients is what This high rate of recurrence in young patients is what has sparked the recent investigations in the role of has sparked the recent investigations in the role of operative treatment of patients after suffering a operative treatment of patients after suffering a primary anterior dislocation of the shoulder. primary anterior dislocation of the shoulder.

SurgerySurgery

Surgical management of anterior shoulder Surgical management of anterior shoulder instability is successful 80-100% of the time instability is successful 80-100% of the time (Burgess 2003). (Burgess 2003).

The open surgical stabilization of the shoulder The open surgical stabilization of the shoulder has been the gold standard for many years with has been the gold standard for many years with a success rate of 91% to 96%, with success a success rate of 91% to 96%, with success defined as the absence of further complaints of defined as the absence of further complaints of subluxation or dislocation (Satterwhite 2000). subluxation or dislocation (Satterwhite 2000).

Open anterior stabilization is associated with a Open anterior stabilization is associated with a 12 degree loss of external rotation of the 12 degree loss of external rotation of the shoulder (Paxinos 2001). shoulder (Paxinos 2001).

SurgerySurgery

With the introduction of arthroscopy, the physician With the introduction of arthroscopy, the physician is able to address the intraarticular pathology while is able to address the intraarticular pathology while allowing the individual a better opportunity to allowing the individual a better opportunity to return to full functional activity. return to full functional activity.

Arthroscopic techniques for acute anterior Arthroscopic techniques for acute anterior instability have been developed to reattach the instability have been developed to reattach the labrum without an open incision and without labrum without an open incision and without subscapularis detachment. subscapularis detachment.

The reported re-dislocation rates for arthroscopic The reported re-dislocation rates for arthroscopic anterior shoulder stabilization are greater than anterior shoulder stabilization are greater than those reported for open procedures 5%-15% vs. those reported for open procedures 5%-15% vs. 6%. However, arthroscopic procedures are 6%. However, arthroscopic procedures are associated with less loss in external rotation than associated with less loss in external rotation than open procedures (Paxinos 2001). open procedures (Paxinos 2001).

Flow ChartFlow Chart

SummarySummary

The outcome of non-operative treatment for acute The outcome of non-operative treatment for acute traumatic anterior instability of the shoulder traumatic anterior instability of the shoulder especially in the younger population is poor. especially in the younger population is poor.

Through continued significant advances in Through continued significant advances in methods to restore the malfunctioning anatomic methods to restore the malfunctioning anatomic structures using surgical intervention the patient structures using surgical intervention the patient is most likely to return to full functional ability with is most likely to return to full functional ability with a reduced risk of recurrent dislocation. a reduced risk of recurrent dislocation.

Through clearer understanding of age-related Through clearer understanding of age-related recurrence rates, differences between traumatic recurrence rates, differences between traumatic and atraumatic dislocations, and the most current and atraumatic dislocations, and the most current treatment options available, Physician Assistants treatment options available, Physician Assistants can more accurately diagnose and treat these can more accurately diagnose and treat these patients. patients.

ReferencesReferences

Andrews, J., Wilk, K. Andrews, J., Wilk, K. The Athletes ShoulderThe Athletes Shoulder. Churchill Livingston Inc., New York, . Churchill Livingston Inc., New York, 1994.1994.

Bottoni, C. et. al. Bottoni, C. et. al. A Prospective, Randomized Evaluation of Arthroscopic A Prospective, Randomized Evaluation of Arthroscopic Stabilization Versus Non-operative Treatment in Patients with Acute Traumatic, Stabilization Versus Non-operative Treatment in Patients with Acute Traumatic, First-Time Shoulder Dislocations. First-Time Shoulder Dislocations. American Journal of Sports MedicineAmerican Journal of Sports Medicine 2002; 30; 2002; 30; 576. 576.

Burgess, B. et. al. Burgess, B. et. al. Traumatic Shoulder Instability: Non-Surgical Management Traumatic Shoulder Instability: Non-Surgical Management Versus Surgical Intervention. Versus Surgical Intervention. Orthopaedic NursingOrthopaedic Nursing 2003; 22; 345-350. 2003; 22; 345-350.

DeBerardino, T. et. al. DeBerardino, T. et. al. Prospective evaluation of Arthroscopic Stabilization of Prospective evaluation of Arthroscopic Stabilization of Acute, Initial Anterior Shoulder Dislocations in Young Athletes: Two to Five Year Acute, Initial Anterior Shoulder Dislocations in Young Athletes: Two to Five Year Follow-Up. Follow-Up. American Journal of Sports MedicineAmerican Journal of Sports Medicine 2001; 29; 586. 2001; 29; 586.

Hovelius, L. et. al. Hovelius, L. et. al. Primary Anterior Dislocations of the Shoulder in Young Primary Anterior Dislocations of the Shoulder in Young Patients. A Ten-Year Prospective Study.Patients. A Ten-Year Prospective Study. The Journal of Bone and Joint SurgeryThe Journal of Bone and Joint Surgery 1996; 78; 1677-84. 1996; 78; 1677-84.

Paxinos, A. et. al. Paxinos, A. et. al. Advances in the Management of Traumatic Anterior and Advances in the Management of Traumatic Anterior and Atraumatic Multidirectional Shoulder Instability. Atraumatic Multidirectional Shoulder Instability. American Journal of Sports American Journal of Sports MedicineMedicine 2001; 31; 819-828. 2001; 31; 819-828.

Walton J. et. al. Walton J. et. al. The Unstable Shoulder in the Adolescent AthleteThe Unstable Shoulder in the Adolescent Athlete. . American American Journal of Sports MedicineJournal of Sports Medicine 2002; 30; 758. 2002; 30; 758.

Yvonne, E. et. al. Yvonne, E. et. al. Evaluation and Management of Recurrent Anterior Shoulder Evaluation and Management of Recurrent Anterior Shoulder Instability. Instability. Journal of Athletic TrainingJournal of Athletic Training 2000; 35; 273-277. 2000; 35; 273-277.