Derek S. Shia, M.D.
Traumatic shoulder dislocations are the most commonly occurring large joint dislocations. As a group, these occur most commonly in young males and is especially common in contact sports such as football, wrestling, hockey and lacrosse. The shoulder is a complex joint composed of the ball, humeral head, and the socket, glenoid. The glenoid has a very shallow concavity unlike other joints, such as the hip, which allows the shoulder to have a tremendous range of motion allowing the arm to be successfully positioned in space. The downside to this freedom of motion is an increased risk of instability.
The shoulder can dislocate in any direction, but the most common is an anterior dislocation. Anterior dislocations occur in 97% of cases. The second most commonly occurring direction is a posterior dislocation. Anterior dislocation usually occurs with a posterior directed force on the arm when the shoulder is in an abducted and externally rotated position, similar to the position of the arm when cocking back to throw a ball. For this reason, many overhead athletes may be prone to continued instability despite non-operative management. Posterior dislocations on the other hand, occur with a force directed on the arm when it is flexed and adducted as if trying to scratch your opposite shoulder.
The shoulder has both static and dynamic restraints that combine to keep the shoulder in a reduced position. The static restraints when an injury occurs cannot be altered without surgery and include the labrum, glenoid, and ligaments. The dynamic stabilizers of the shoulder include the rotator cuff and the scapular stabilizer muscles. When there is an injury to the static restraints of the shoulder the dynamic stabilizers can be utilized to try and overcome the static restraint limitations to provide a stable shoulder. The use of physical therapy can help optimize the dynamic stabilizers and is the foundation of non operative management surrounding shoulder dislocations.
The acute management of a shoulder dislocation requires prompt recognition of the problem followed by appropriate treatment which results in reduction of the joint. Many times this can occur on the playing field with the assistance of a trained professional. Many techniques have been described to achieve this and patients typically feel significant relief after the reduction has been successfully performed. Delayed reduction can lead to significant problems including nerve and vessel injury so prompt reduction of the shoulder is recommended as soon as a trained professional can be located.
After reduction has been obtained, it is important to obtain radiographs (xrays) of the shoulder. There are two important reasons that x-rays need to be obtained: 1. It is important to objectively determine whether the shoulder has been relocated and is in the correct position. 2. It is vitally important to determine whether a fracture has occurred to either the humeral head or glenoid. Fractures of either bone can significantly affect the treatment options and whether surgery will be necessary.
Dislocations that occur during an athlete’s season can often be temporized with the ability to return to the field in a relatively short period of time if no fracture or tendon injury is present. Depending on the athletes sport a brace is sometimes recommended to prevent further instability events.
The difficulty of these braces is that they are typically bulky and do not allow abduction and external rotation. For an overhead athlete such as a quarterback these braces cannot be worn due to the position necessary to throw a ball. Non-operative management of athletes that are in season typically involves a short period of immobilization for 7-10 days combined with physical therapy. Return to play can be instituted after obtaining pain-free range of motion with no objective or subjective feelings of instability.
The risk of recurrent dislocation is related to several factors including age, activity level, and contact sports. In patients under the age of 20 there is a >90% chance of recurrent instability. Recurrence rates in patient over the age of 30 falls significantly and is a little less than 30%.
Recurrent instability, ie. multiple dislocations, of the shoulder is typically an indication for surgical intervention. The typical injury of the shoulder is a Bankart lesion, which occurs in over 95% of shoulder dislocations, and is a result of a tear of the anterior inferior labrum of the glenoid. Other types of injuries also commonly occur around the shoulder such as rotator cuff tears but usually happen in patients over the age of 45 years. In the vast majority of the cases, surgery can be performed arthroscopically to address the pathology in the shoulder.
This is usually performed with three small incisions about 1 cm in length. Immobilization is required over the first month. Physical therapy is started after surgery and is usually continued for 4 months after surgery and return to play can typically be achieved in 6-9 months.
Alan M. Reznik, M.D., MBA
The shoulder is the junction of three bones: the upper arm bone (humerus), the collarbone (clavicle), and the shoulder blade (scapula). The shoulder joint is the result of the head of the humerus bone fitting in the cavity (glenoid cavity) of the shoulder blade. Like a golf ball sitting on a tee, it doesn’t take a lot to dislodge or dislocate the humeral head (Ball) from the glenoid (Tee).
The fragility of the shoulder is reinforced by a series of ligaments, and a rim of tissue that surrounds the cavity called the glenoid labrum. If excessive force is applied to the arm, the shoulder may become “dislocated,” that is, the head of the humerus may be forced out of the cavity and the supporting ligaments of the shoulder may be torn, displaced or stretched out of shape.
When the shoulder dislocates, the smooth cartilage surface of the humerus (“ball”) slides over the rim of the glenoid portion of the scapula (the lip of the cup or golf tee). At the time of shoulder dislocation, or more often at the time of relocation, this can cause a complication and damage to the head of the humerus (the “ball” portion of the joint.) This occurs when the humeral head passes into, or out of, the socket as the ball is impinged against the sharp glenoid rim. The back of the ball can be fractured or dented just like a dent in your car after a fender bender. The dent from this injury is referred to as a “Hill Sachs Lesion.” An x-ray of a dislocated shoulder is shown below in figure 1a.
An arthroscopic photo of the damage to the ball is shown below. The larger this dent is, the easier the shoulder will dislocate again. At the same time the ligaments in the front of the shoulder are avulsed or torn off the rim of the Glenoid (as shown in the drawing above). It is the combination of the dent size and ligament damage that is the true measure of future instability of the shoulder.
A Bankhart procedure, Labral repair or Gleno-humeral ligament repair, are surgical techniques for the repair of the damage from a single or recurrent shoulder joint dislocations. In this procedure, the torn labrum (or lip of the socket) with the attached ligaments are reattached to the proper place in the shoulder joint. By re-attaching these ligaments and cartilage we can prevent future dislocations. With the proper tightening of the lining, the Hill Sachs Lesion (the dent) will not hit the rim with routine motion. The shoulder is made stable and the re-injury risk is greatly reduced by avoiding “dent/ rim” contact. Dr. Reznik does this repair through the arthroscope with sutures and tiny absorbable anchors. The goal is to restore normal function in a minimally invasive way as an out patient procedure. If the ligaments alone are torn or stretched and the labrum is still attached they can be repaired in a similar manor.
Frequently the ligaments and the capsule lining are stretched out of shape. This may also cause instability, subluxation or recurrent dislocations. Many of these patients cannot work overhead or throw any object. They also have difficulty with overhead sports. When this occurs the loose capsule can be tightened at the same time the ligaments are repaired. This is referred to a “Capsular Shift” procedure.
Dr. Reznik also performs this surgery with a minimally invasive technique through an arthroscope (fiber optic scope) with little disruption to the other shoulder structures. The surgery is done on an out patient basis which allows patients to be home in a few hours instead of days. On rare occasions the dent is so large that is needs to be grafted. Arthroscopic assisted methods are available for this procedure as well.
Maintain dressing. You may add 4x4 bandages if needed for drainage through dressing. Use ice pack for 20 minute periods throughout today. KEEP SLING ON AT ALL TIMES.
Move fingers and wrist often. Expect some swelling. If you have skin color changes or changes in sensation in your arm, notify the doctor. When sleeping, place 1 or 2 pillows under the operative side elbow to keep arm in place. Begin grip strengthening and wrist range of motion exercises tonight. (See exercise list below.)
Most patients find sleeping in a semi-upright position is more comfortable for the first few days after shoulder surgery. A reclining chair is often most comfortable.
Post-op Day 1: The Day after Surgery
Follow the same instructions as for the day of surgery noted above
Day 2: (48 hours post-operatively):
Remove the dressing. The Xeroform gauze strips (small yellow ‘tapes’) can be removed at the time of your first dressing change. You can shower with the dressing off. Do the elbow exercises and shoulder pendulum motion in the shower (see the exercises below.) Support the affected arm with the opposite hand. You may wash under the arm, but do not use a large amount of soap. Too much soap may dry out the skin and cause a rash. After a short shower, dry the shoulder well. Pat the incisions dry, don’t rub the scabs off. Cover each incision with a plain Band-Aid. Do not use and creams or ointments on the incisions.
Resume same activities as surgical day; use ice for 20 min. periods as needed.
Exercise: Once a day, in the shower, you may begin to flex and extend your elbow, keep your arm close to your body, rub palm over stomach, keep palm facing inward. Do your elbow, wrist, and hand exercises at least 2 other times each day.
The arm sling must remain on at all other times, including bedtime.
Day 3 - 4: Start formal physical therapy program. Continue home exercise as listed below (adjust exercises as per therapist’s instructions.
Day 4 – 10: Change Band-aids daily or as needed. Maintain sling use. Continue exercises as directed under Day 3.
Day 7 – 10: The first post-op visit: see Dr Reznik in the office. He will review your surgery with you and further instructions will be given for your rehabilitation and recovery.
Do three times each day as directed
Starting Day 1:
Hand Squeezes or Grip Strengthening: Using a small soft rubber ball or soft sponge, squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.
Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.
On Day 3 add:
Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This will decrease pain and prevent elbow stiffness.
On Day 4 add:
Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day.
Not before Day 7-10 add:
Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk” the fingers of the affected hand up the wall as high as comfort allows. Mark the spot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Walk your finders down the wall as well as up. If you will have weakness on the way down, so use the other arm to help.
Important: Do not let the hand drop down from the wall—this will be painful and strain the repair.
Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. When comfortable, try it holding a very small can. In a few days you can increase can size only as comfort allows. This exercise should not be painful. If painful decrease or eliminate the weight.
You may resume a regular diet when you return home. Start with tea or broth and advance slowly with crackers or toast, then a non-spicy sandwich. If you become nauseated, return to clear liquids. You can also try Tums, Zantac or Pepcid AC to help settle your stomach. After surgery you are encouraged to deep breathe and cough frequently (at lease 3-4 times per day). This will reduce mucous from building up in your lungs and will reduce the risk of developing pneumonia.
Pain Control: Take medication as prescribed by Dr. Reznik. Do not take all your meds at the same time. Take anti-inflammatory medication with food to avoid stomach upset. Please call our office with any questions regarding your medication. After surgery, some patients will see some swelling. Use an ice pack for 20 minutes periods throughout the first 24 hours after surgery and then as needed for comfort and to reduce swelling.
Blood Clots: Patients at high risk: These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.
Sling: Patients are to wear the pillow sling at all times (including while at sleep) for the first 3 weeks. Then, it is recommended that patients wear the sling with the pillow removed when going out for the next 3 weeks. This will help to alert others to avoid the affected arm during this important healing period. Move fingers and wrist often. Expect some swelling.
Dressing: The Xeroform gauze strips (small yellow ‘tapes’) can be removed after 48 hours. At this time you may shower with the dressing off. Do the elbow exercises and shoulder pendulum motion in the shower (see the exercises below). Pat the incisions dry, using care not to rub the scabs off and cover each incision with a plain Band-Aid. Do not use and creams or ointments on the incisions.
Exercise: You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help prevent blood clots.
Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. It is very important for you to start therapy when recommended.
Physical Therapy: Vital to your recovery of good shoulder function is a graduated activity and exercise program to increase muscle strength and motion. To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.
Call the physician or go to the ER if:
Driving: Patients cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12:00 position on the steering wheel and can move hands freely from the 9:00 – 3:00 position.
Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours) but should in general wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take an aspirin (unless allergic.)
Returning to Work: Patients with a small tear, and/or low demand work, can usually return to work within 3 weeks. They will still have restrictions on lifting and overhead use. Patients with higher demand jobs or repetitive arm use need at least 6 weeks. Any heavy labor with overhead lifting can take at least 4-6 months.
**Dental Work: You cannot have any routine dental work (including cleaning) for at least 3 months after your surgery, or you risk infecting the suture anchors. After 3 months, you may see the dentist, but for one year from date of surgery, you will need to take antibiotics before and after dental work. Call our office, and Dr. Reznik will give you a prescription.
Copyright © 2011, AMReznik. All rights reserved.
By Alan M. Reznik, M.D., MBA
There is a lot of excitement about “evidence-based” medicine these days. It is as if clinical research was absent in the past. We all know medicine is not the “Wild West” as some would portray it. Just the same, it is often helpful to point out new data that will be helpful in guiding treatment options and revisit good old data to stay the course. To that end, this is aimed at updating you on some of the recent evidence that may have sparked some discussion and may help you talk to your patients. In practice now for almost 25 years, adding a seasoned understanding to this data may also be helpful to you in your daily practice. The most important “take away message” here is that the data needs to be applicable (to the patient in front of you today) in order to make sense. There is so much on the web that confuses our patients. They just don’t know what applies to them. It is our unique responsibility to help them understand the subtle differences that is the essence of clinical acumen.
A general word or two about rotator cuff repairs: It is clear now that arthroscopic repair is the standard for almost all tears. It is also clear that tears come in many sizes and shapes. Most recent evidence-based article was in JBJS in Jan of 2014 issue (A Prospective Randomized Trial of Immobilization Compared with early motion By Jay D Keener, et al. JBJS 2014;96:11-19) talks about early rehab for tears (small to medium in size). It showed that early (protected) motion in a guided rehab program (as in our office) offers better function at 3 months of prolonged immobilization even though there is no statistical difference at 24 months in the two groups. In 114 of the 124 patients seen at 30 month follow up 92% of the tears were healed. In practice, the better three-month results mean an earlier return to light selected work (heavy laborers and workman’s comp are separate issues) and hence for my average patient the early motion program a real advantage. Here as in other studies a “no significant difference” in final outcomes is not necessarily the full story. Larger or very large tears present a different set of issues, don’t heal as well and present a real challenge when addressed later in their course. A new acute traumatic large tear is always best treated earlier than later.
After much discussion over the past three decades about the best way to treat clavicle fractures, a study published in the Sept. 4 issue of the Journal of Bone & Joint Surgery compared nonsurgical treatment, open reduction and plate fixation for midshaft displaced clavicle fractures. As reported in a prior newsletter, in a good evidence-based article by: C.M. Robinson, FRCSEd(Tr&Orth); et al.: Open Reduction and Plate Fixation versus Non-operative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter, Randomized, Controlled Trial: J Bone Joint Surg Am, 2013 Sep 04;95(17):1576-1584 goes a long way to answer this question.
According to the results of this study, improved outcomes and reduced rate of nonunion after acute displaced, midshaft clavicle fractures was associated with internal fixation using plates. It is important to note that after excluding nonunions from analysis, the authors found no significant differences in DASH or Constant scores at any time point during the study period. The implication of this finding was nonunion (the failure of healing) was the prime driver of the poor outcomes and 16 times more likely in the nonrepaired group. The results for displaced mid shaft fractures are therefore improved when the bone is fixed with a plate (preferably earlier, within two weeks of the injury) and the complications of a non-union can be avoided.
Also in the January issue of JBJS there is a comprehensive review of AC joint separations. (Xinning, Li, et al JBJS 2014; 96:73-84. This is more commonly known to most of us and our athletic patients as a “shoulder separation.” Usually it happens after a fall onto the outer edge of the shoulder as opposed to a “shoulder dislocation” (the ball is knocked out of the socket) usually after a forceful external rotation of the arm in an overhead position. For shoulder separations, in most cases, we see the deformity at the end of the collarbone. In higher-grade injuries the tip of the collarbone can “tent” the skin. There are many types of separations. They are most commonly graded one through six. Lower grades, grades one and two, minimally displaced and not tenting the skin, can be treated non-operatively and if there are symptoms at a later date they can be addressed nicely arthroscopically. Grade three is more displaced and controversial. Operative verses nonoperative treatment (with accepting a visible deformity) becomes a personal decision made with the patient after the risks and benefits are reviewed. Grade four, five and six are more significantly displaced (4-posterior,5-superior and 6-inferior, under the acromion) all need operative repair. There are many treatments and the method of ligament reconstruction recommended includes 5 key features, a method of repair and reconstruction of the torn ligaments incorporated in my practice over 10 years ago, and they are best depicted on my patient education pages on our website under my tab: http://www.togct.com/downloads/reznik/ AC_Joint_Reconstruction.pdf