Shoulder Dislocation
A joint dislocation occurs when the two joint surfaces, which normally sit in intimate contact with each other, are wrenched away from each other to lie apart without any relationship. Joints have a surrounding ligamentous bag called a joint capsule and this can be typically injured as the surfaces force their way past each other. The surfaces of the joints themselves can be damaged as they hit each other on the way to becoming dislocated. Other injuries which can occur include damage to the local nerves and ligaments.
Shoulder dislocation is the most common type of joint dislocation, accounting for nearly half of all such joint injuries. The shoulder dislocates frontwards, an anterior dislocation, in the vast majority of cases. The most common type of injury is one which forces the head of the arm bone forwards with the arm in a position of abduction, outward rotation and extension, the vulnerable position of the joint. Other mechanisms of injury can include a forceful abduction and outward rotation movement of the arm, a blow to the back of the upper arm and a fall onto the outstretched hand (FOOSH).
A posterior dislocation is uncommon and secondary to a stress on the arm when it is inwards across the body and inwardly rotated, with the large back and chest muscles sometimes pulling the joint out of its socket. This can occur if someone is electrocuted or if they have epileptic seizures, both of which can cause muscle spasms. The shoulder can dislocate downwards if there is a very forceful movement of the shoulder outwards and sideways, with the joint being levered out over part of the scapula above. This sort of dislocation should be closely monitored as complications of the injury are common with nerve damage, blood vessels injury and rotator cuff tears.
Dislocation can occur without trauma and in these cases the shoulder instability is often in all directions and more likely to occur in people who are hypermobile in their joints. This is known as multidirectional instability and is more common in younger people under thirty years old, occurring in both shoulders and tending to run in families. The joint problems may start with a subluxation which is a partial dislocation where the joint surface moves off the other one to some degree then snaps back again. Some people can dislocate their joint voluntarily and this may be connected with psychiatric difficulties in these patients.
The presentation of anterior dislocation of the shoulder is for the patient to hold their arm rotated outwards and slightly to the side, the arm bone head easily felt at the front of the joint. The shoulder muscles may be in a powerful spasm and trying to move the shoulder results in high levels of pain. A dislocation of the shoulder posteriorly shows itself by the patient keeping the arm close to the body and turned inwards, the head of the humerus being palpable at the rear of the joint, although this condition has been misdiagnosed as frozen shoulder.
The relocation of a shoulder dislocation is performed by surgeons in many different ways and the time from the incident to when the joint is finally relocated is the important matter. If the time is too long the muscle spasm increases and interferes with fixing the dislocation. An original way was to put a foot in the person’s axilla to make one end secure and traction the arm lengthways until the reduction is effected. Techniques have developed and an effective modern way is to abduct the shoulder whilst pushing the humeral head anteriorly, then rotate the arm externally and traction the arm, leading very often to success.
Pain is a major presentation problem in shoulder dislocation and there are many alternatives that the medical staff can apply to give good pain relief and ease the process of reduction. A recent reduction can be moderately easily relocated in the absence of strong painkillers or muscle relaxants. The most useful sedative drug will have a quick onset of action, be able to supply good muscular relaxation and with an action which goes off quickly to allow rapid recovery. After the joint is back in place a sling is used for up to three weeks to allow the capsular damage to heal.
Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in Manchester visit his website.
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