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Static Stabilizers
Bony congruity is achieved with the
concavity of the glenoid; this is further
increased due to asymmetric deposition
of cartilage, with the peripheral articular surface being thickest.10,11 The glenoid labrum increases the depth and
width of the joint approximately twofold.12 Loss of the labrum decreases
translational resistance by 20%.13
The three glenohumeral ligaments
are discrete capsular fibrous bands
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Figure 1
Classifications
Illustration of the dynamic and static stabilizers of the shoulder. IGHL = inferior
glenohumeral ligament, MGHL = middle glenohumeral ligament, SGHL = superior
glenohumeral ligament
Dynamic Restraints
Dynamic stabilizers include all shoulder muscles that create a concavity
compression force across the joint.
Balance between anterior and posterior forces allows the humeral head
to remain centered in the glenoid.9
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Mechanisms of Injury
Several different mechanisms have
been proposed for posterior dislocation. Direct high-energy trauma with
the shoulder in adduction, flexion, and
internal rotation is the most frequent
cause of posterior dislocation.2,15
Posterior shoulder dislocation may
also be caused by seizures or electrocution.8 Dislocation due to seizure is
the result of unbalanced contraction of
the shoulder muscles.16 In adduction,
internal rotation, and flexion, the
Clinical Evaluation
Physical examination is particularly
important in acute posterior shoulder
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Figure 2
A, AP radiograph of the shoulder with the trough line visible (arrow). This is representative of the anterior humeral head
impaction. B, Axillary radiograph demonstrating posterior dislocation with a significant reverse Hill-Sachs lesion. C, AP
radiograph demonstrating the lightbulb sign (arrows).
Imaging
To minimize the risk of missing a posterior glenohumeral dislocation, the
evaluation should include standard
AP and Velpeau radiographs.1-4,21 An
axillary view is useful to evaluate
associated head impaction (ie, reverse
Hill-Sachs lesion) and glenoid rim
fractures.21 A Velpeau view is
acceptable if the patient is unable to
achieve sufficient abduction. Other
indirect signs that can be seen on
standard radiographs include the
lightbulb sign, loss of the half-moon
sign, and the trough line23 (Figure 2).
March 2014, Vol 22, No 3
Associated Injuries
Isolated posterior dislocations of the
proximal humerus are rare, and associated injuries often are missed or
diagnosed in a delayed fashion.7 Historically, bony and soft-tissue injuries
were thought to occur in 49% of
dislocations,21 but a recent systematic
review indicated that up to 65% of
dislocations had associated bony or
Figure 3
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Figure 4
patients.26 Bone defects are common, with significant reverse HillSachs lesions found in 29% of
shoulders7 and posterior rim fracture seen in approximately 5% of
shoulders.4 The frequency and significance of these defects can
increase with delayed or chronic
presentation.5
Rotator cuff tears are found in 13%
of patients evaluated with MRI;
however, the odds ratio of finding
a tear is 4.6 times higher in the
absence of an associated fracture or
reverse Hill-Sachs lesion.7 Thus, in
the patient with a dislocation but
without concomitant fracture on
CT, a focused rotator cuff physical
examination and MRI evaluation
are strongly suggested. Nerve palsy
secondary to posterior glenohumeral
dislocation is rare, occurring in ,1%
of injuries.7 The axillary nerve is the
most commonly injured.
Management
Nonsurgical
Definitive treatment options for posterior shoulder dislocations are varied,
and the decision must be individualized to each patient. In the elderly
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low-demand patient, chronic posterior dislocation can be tolerated provided pain is minimal and anterior
elevation is sufficient for activities
of daily living.27,28 This treatment
option has been dubbed supervised
neglect.28,29 Nonsurgical treatment
also may be appropriate in patients
with cognitive impairment or other
severe medical comorbidities.
Closed reduction can be attempted
in the presence of an acute dislocation
in an elderly low-demand patient
with a reverse Hill-Sachs lesion measuring ,20%. Recurrent dislocation
or failed reduction warrants a discussion with the patient and family
about definitive treatment. In an
active and independent patient, the
goal of treatment of acute and
chronic dislocations is to restore
shoulder stability and mobility. Isolated closed reduction is reserved for
acute posterior instability with
a reverse Hill-Sachs lesion of #20%
that is stable after reduction.
Careful imaging evaluation should
be done prior to any reduction
maneuver to avoid displacing a neck
fracture. In the presence of suspected
fracture, an urgent CT scan should be
obtained before reduction. An attempt
at closed reduction of posterior shoulder dislocation requires complete
sedation to allow gentle manipulation.
Forceful manipulations often cause
humeral head fractures, which increases the chance of osteonecrosis and
has an adverse effect on prognosis. In
a series of 112 patients, 33% of
shoulders were successfully reduced
using in-line gentle traction.4
The Stimson technique is a passive
method used to manage acute posterior dislocation without associated
neck fracture or a significantly engaged
reverse Hill-Sachs lesion. The patient is
positioned prone on a table with the
arm in abduction over the side and
with 5 to 10 lb placed in the hand.30
Muscle spasms can eventually be
overcome with the weight to allow for
spontaneous reduction.
Surgical
Open Reduction
Following unsuccessful closed reduction, open reduction can be done
through either an anterior or a posterior approach. The approach is determined based on preoperative planning.
Isolated open reduction can be successful in acute dislocations with
reverse Hill-Sachs lesions measuring
,20%.
An anterior approach is done via
a standard deltopectoral incision,
where the humeral head lies deeper than
usual. Initially, the rotator interval is
opened to allow the introduction of
a finger into the glenohumeral joint to
aid in manual reduction of the shoulder.
In cases in which the shoulder is not
reducible through an open rotator
interval alone, a formal arthrotomy is
necessary. Management of the subscapularis is crucial and is dictated by
associated fractures. The two options
are peeling of the subscapularis and
lesser tuberosity osteotomy. In the setting of persistent posterior dislocation,
locked internal rotation limits access to
the subscapularis. The long head of the
biceps is useful in identifying the lateral
margin; frequently, the subscapularis
tendon lies beneath the conjoined
tendon.
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Figure 5
149
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Figure 6
A, Axial CT scan of a left shoulder with significant humeral head impaction. B, Axial CT scan of the same patient 3 months
after an allograft was implanted into the deficit. C, Axial CT scan of a different patient with a similar injury 3 months after
fracture disimpaction.
Figure 7
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Rehabilitation
Regardless of management type, the
shoulder is braced in 20 of external
rotation and abduction for 4 weeks to
aid healing of the posterior capsule.
Pendulum exercises and elbow range
of motion three times per day are
encouraged. At 4 weeks, unlimited
progressive range of motion is initiated
as well as isometric posterior rotator
cuff strengthening. Noncontact sports
are allowed 3 months after reduction or
surgery, and contact sports are permitted 4 to 6 months postoperatively.
Results
Approximately 18% of patients experience recurrent instability in the first
year following acute posterior dislocation.4 Risk factors for recurrence are
age ,40 years, seizure, and large
reverse Hill-Sachs lesion (.1.5 cm3).
Persistent functional impairment has
been noted 2 years after the initial
trauma, even without recurrent instability.4 Activities that require significant internal rotation may be
particularly difficult.
Typically, patients with persistent symptoms present with either
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Figure 8
Treatment algorithm for the surgical management of acute posterior shoulder dislocation.
Summary
Posterior shoulder dislocation is a relatively uncommon pathology, with
several typical modes of presentation.
Dislocation often goes undiagnosed in
the acute setting in patients who present following seizure, electric shock, or
high-energy trauma. Thus, particular
attention is required to diagnose the
injury in these patients. Imaging stud-
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References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, reference 4 is
a level II study. Reference 7 is a level
III study. References 2, 3, 6, 8, 15,
16, 21, 22, 24, 26, 27, 29, and 31 are
level IV studies. Reference 28 is level
V expert opinion.
References printed in bold type are
those published within the past 5
years.
1. Kowalsky MS, Levine WN: Traumatic
posterior glenohumeral dislocation:
Classification, pathoanatomy, diagnosis,
and treatment. Orthop Clin North Am
2008;39(4):519-533, viii.
2. McLaughlin HL: Posterior dislocation of the
shoulder. J Bone Joint Surg Am 1952;24(3):
584-590.
3. Hatzis N, Kaar TK, Wirth MA,
Rockwood CA Jr: The often overlooked
posterior dislocation of the shoulder. Tex
Med 2001;97(11):62-67.
4. Robinson CM, Seah M, Akhtar MA: The
epidemiology, risk of recurrence, and
functional outcome after an acute traumatic
posterior dislocation of the shoulder. J Bone
Joint Surg Am 2011;93(17):1605-1613.
5. Hawkins RJ: Unrecognized dislocations of
the shoulder. Instr Course Lect 1985;34:
258-263.
6. Rowe CR, Zarins B: Chronic unreduced
dislocations of the shoulder. J Bone Joint
Surg Am 1982;64(4):494-505.
7. Rouleau DM, Hebert-Davies J: Incidence of
associated injury in posterior shoulder
dislocation: Systematic review of the literature.
J Orthop Trauma 2012;26(4):246-251.
8. Goudie EB, Murray IR, Robinson CM:
Instability of the shoulder following
seizures. J Bone Joint Surg Br 2012;94(6):
721-728.
9. Tjoumakaris FP, Bradley JP: Posterior shoulder
instability, in Galatz LM, ed: Orthopaedic
Knowledge Update: Shoulder and Elbow 3.
Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2008, pp 313-320.
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