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词条 Dislocated shoulder
释义

  1. Signs and symptoms

  2. Diagnosis

     Anterior (forward)  Posterior (backward)  Inferior (downward) 

  3. Treatment

     Reduction  Post-reduction  Surgery 

  4. Prognosis

  5. See also

  6. References

  7. External links

{{Distinguish|Separated shoulder}}{{Infobox medical condition (new)
| name = Dislocated shoulder
| synonyms =
| image = Dislocated shoulder X-ray 10.png
| caption = Anterior dislocation of the left shoulder.
| pronounce =
| field = Emergency medicine, orthopedics
| symptoms =
| complications = Bankart lesion, Hill-Sachs lesion, rotator cuff tear, axillary nerve injury[1]
| onset =
| duration =
| types = Anterior, posterior, inferior, superior[2][1]
| causes = Fall onto an outstretched arm or the shoulder.[4]
| risks =
| diagnosis = Based on symptoms, X-rays[2]
| differential =
| prevention =
| treatment = Shoulder reduction, arm sling[1][2]
| medication = Procedural sedation and analgesia, intraarticular lidocaine[8]
| prognosis = Recurrence common in young people[4]
| frequency = 24 per 100,000 per year (US)[1]
| deaths =
}}

A dislocated shoulder is when the head of the humerus is out of the shoulder joint.[1] Symptoms include shoulder pain and instability.[1] Complications may include a Bankart lesion, Hill-Sachs lesion, rotator cuff tear, or injury to the axillary nerve.[1]

A shoulder dislocation often occurs as a result of a fall onto an outstretched arm or onto the shoulder.[4] Diagnosis is typically based on symptoms and confirmed by X-rays.[1] They are classified as anterior, posterior, inferior, and superior with most being anterior.[1][1]

Treatment is by shoulder reduction which may be accomplished by a number of techniques including traction-countertraction, external rotation, scapular manipulation, and the Stimson technique.[1] After reduction X-rays are recommended for verification.[1] The arm may than be placed in a sling for a few weeks.[1] Surgery may be recommended in those with recurrent dislocations.[1]

About 1.7% of people have a shoulder dislocation within their lifetime.[2] In the United States this is about 24 per 100,000 people per year.[1] They make up about half of major joint dislocations seen in emergency departments.[1] Males are affected more often than females.[3]

Signs and symptoms

  • Significant pain, sometimes felt along the arm past the shoulder.
  • Sensation that the shoulder is slipping out of the joint during abduction and external rotation.[4]
  • Shoulder and arm held in external rotation (anterior dislocation), or adduction and internal rotation (posterior dislocation).[4] Resistance of all movement.
  • Numbness of the arm.
  • Visibly displaced shoulder. Some dislocations result in the shoulder appearing unusually square.
  • No palpable bone on the side of the shoulder.

Diagnosis

A diagnosis of shoulder dislocation is often suspected based on patient history and physical examination. Radiographs are made to confirm the diagnosis. Most dislocations are apparent on radiographs showing incongruence of the glenohumeral joint. Posterior dislocations may be hard to detect on standard AP radiographs, but are more readily detected on other views. After reduction, radiographs are usually repeated to confirm successful reduction and to detect bony damage. After repeated shoulder dislocations, an MRI scan may be used to assess soft tissue damage. In regards to recurrent dislocations, the apprehension test (anterior instability) and sulcus sign (inferior instability) are useful methods for determining predisposition to future dislocation.

There are three main types of dislocations: anterior, posterior, and inferior.

Anterior (forward)

In over 95% of shoulder dislocations, the humerus is displaced anteriorly.[5] In most of those, the head of the humerus comes to rest under the coracoid process, referred to as sub-coracoid dislocation. Sub-glenoid, subclavicular, and, very rarely, intrathoracic or retroperitoneal dislocations may also occur.[6]

Anterior dislocations are usually caused by a direct blow to, or fall on, an outstretched arm. The patient typically holds his/her arm externally rotated and slightly abducted.

A Hill–Sachs lesion is an impaction of the head of the humerus left by the glenoid rim during dislocation.[4] Hill-Sachs deformities occur in 35–40% of anterior dislocations. They can be seen on a front-facing X-ray when the arm is in internal rotation.[7] Bankart lesions are disruptions of the glenoid labrum with or without an avulsion of bone fragment.

Damage to the axillary artery[8] and axillary nerve (C5,C6) may result. The axillary nerve is injured in 37% making it the most commonly injured structure with this type of injury.[9] Other common, associated, nerve injuries include injury to the suprascapular nerve (29%) and the radial nerve (22%).[9] Axillary nerve damage results in a weakened or paralyzed deltoid muscle and as the deltoid atrophies unilaterally, the normal rounded contour of the shoulder is lost. A patient with injury to the axillary nerve will have difficulty in abducting the arm from approximately 15° away from the body. The supraspinatus muscle initiates abduction from a fully adducted position.

Posterior (backward)

Posterior dislocations are uncommon, and are typically due to the muscle contraction from electric shock or seizure.[4] They may be caused by strength imbalance of the rotator cuff muscles. Patients typically present holding their arm internally rotated and adducted, and exhibiting flattening of the anterior shoulder with a prominent coracoid process.

Posterior dislocations may go unrecognized, especially in an elderly patient[10] and in the unconscious trauma patient.[11] An average interval of 1 year was noted between injury and diagnosis in a series of 40 patients.[12]

Inferior (downward)

Inferior dislocation is the least likely, occurring in less than 1%. This condition is also called luxatio erecta because the arm appears to be permanently held upward or behind the head.[13] It is caused by a hyper abduction of the arm that forces the humeral head against the acromion.[14] Such injuries have a high complication rate as many vascular, neurological, tendon, and ligament injuries are likely to occur from this mechanism of injury.

Treatment

Prompt medical treatment should be sought for suspected dislocation.

Usually, the shoulder is kept in its current position by use of a splint or sling. A pillow between the arm and torso may provide support and increase comfort. Strong analgesics are needed to allay the pain of a dislocation and the distress associated with it.

Reduction

{{Main|Shoulder reduction}}Shoulder reduction may be accomplished with a number of techniques including traction-countertraction, external rotation, scapular manipulation, Stimson technique, Cunningham technique, or Milch technique.[3][2] Pain can be managed during the procedures either by procedural sedation and analgesia or injected lidocaine into the shoulder joint.[15] Injecting lidocaine into the joint may be less expensive and faster.[16] If a shoulder cannot be relocated in the emergency room, relocation in the operating room may be required.[3] This situation occurs in about 7% of cases.[3]

Post-reduction

There does not appear to be any difference in outcomes when the arm is immobilized in internal versus external rotation following an anterior shoulder dislocation.[17][18] A 2008 study of 300 people for almost six years found that conventional shoulder immobilisation in a sling offered no benefit.[19]

Surgery

In young adults engaged in highly demanding activities shoulder surgery may be considered.[20] Arthroscopic surgery techniques may be used to repair the glenoidal labrum, capsular ligaments, biceps long head anchor or SLAP lesion or to tighten the shoulder capsule.[21]

Arthroscopic stabilization surgery has evolved from the Bankart repair, a time-honored surgical treatment for recurrent anterior instability of the shoulder.[22] However, the failure rate following Bankart repair has been shown to increase markedly in patients with significant bone loss from the glenoid (socket).[23] In such cases, improved results have been reported with some form of bone augmentation of the glenoid such as the Latarjet operation.[24][25][26]

Although posterior dislocation is much less common, instability following it is no less challenging and, again, some form of bone augmentation may be required to control instability.[27]

There remains those situations characterized by multidirectional instability, which have failed to respond satisfactorily to rehabilitation, falling under the AMBRI classification previously noted. This is usually due to an overstretched and redundant capsule which no longer offers stability or support. Traditionally, this has responded well to a 'reefing' procedure known as an open inferior capsular shift.[28] More recently, the procedure has been carried out as an arthroscopic procedure, rather than open surgery, again with comparable results.[28] Most recently, the procedure has been carried out using radio frequency technology to shrink the redundant shoulder capsule (thermal capsular shrinkage);[29] while long-term results of this development are currently unproven, recent studies show thermal capsular shrinkage have higher failure rates with the highest incidence of instability recurrence and re-operation.[26]

Prognosis

After an anterior shoulder dislocation, the risk of a future dislocation is about 20%. This risk is greater in males than females.[30]

See also

  • Shoulder problems

References

1. ^1 2 3 4 5 6 7 8 {{cite web|title=Dislocated Shoulder|url=http://orthoinfo.aaos.org/topic.cfm?topic=A00035|website=OrthoInfo - AAOS|accessdate=13 October 2017|date=October 2007|deadurl=no|archiveurl=https://web.archive.org/web/20170617231641/http://orthoinfo.aaos.org/topic.cfm?topic=A00035|archivedate=17 June 2017|df=}}
2. ^1 2 3 4 {{cite journal|last1=Cunningham|first1=NJ|title=Techniques for reduction of anteroinferior shoulder dislocation.|journal=Emergency Medicine Australasia : EMA|date=2005|volume=17|issue=5–6|pages=463–71|doi=10.1111/j.1742-6723.2005.00778.x|pmid=16302939}}
3. ^1 2 3 4 5 6 7 8 9 10 11 12 13 {{cite journal|last1=Bonz|first1=J|last2=Tinloy|first2=B|title=Emergency department evaluation and treatment of the shoulder and humerus.|journal=Emergency Medicine Clinics of North America|date=May 2015|volume=33|issue=2|pages=297–310|doi=10.1016/j.emc.2014.12.004|pmid=25892723}}
4. ^1 2 3 {{Cite book|title=Essentials of musculoskeletal care|date=2010|publisher=American Academy of Orthopaedic Surgeons|others=Sarwark, John F.|isbn=978-0892035793|location=Rosemont, Ill.|oclc=706805938}}
5. ^{{Cite book|title=Current medical diagnosis & treatment 2018|others=Papadakis, Maxine A., McPhee, Stephen J., Rabow, Michael W.|isbn=9781259861482|edition=Fifty-seventh|location=New York|oclc=959649794|last1 = Rabow|first1 = Michael W.|last2=McPhee|first2=Stephen J.|last3=Papadakis|first3=Maxine A.|date=2017-09-02}}
6. ^{{EMedicine|orthoped|440|Shoulder Dislocations}}
7. ^{{Cite journal|last=Riebel|first=G. D.|last2=McCabe|first2=J. B.|date=March 1991|title=Anterior shoulder dislocation: a review of reduction techniques|journal=The American Journal of Emergency Medicine|volume=9|issue=2|pages=180–88|issn=0735-6757|pmid=1994950|doi=10.1016/0735-6757(91)90187-o}}
8. ^{{cite journal |last1=Kelley |first1= SP |last2= Hinsche |first2= AF |last3= Hossain |first3= JF |title=Axillary artery transection following anterior shoulder dislocation: Classical presentation and current concepts |journal=Injury |volume=35 |issue=11 |pages=1128–32 |date=November 2004 |pmid=15488503 |doi=10.1016/j.injury.2003.08.009 }}
9. ^1 {{cite journal |last1=Malik |first1= S |last2= Chiampas |first2= G |last3= Leonard |first3= H|title=Emergent evaluation of injuries to the shoulder, clavicle, and humerus|journal=Emerg Med Clin North Am|volume=28|issue=4|pages=739–63 |date=November 2010|pmid=20971390|doi=10.1016/j.emc.2010.06.006}}
10. ^{{EMedicine|emerg|148|Dislocations, Shoulder}}
11. ^Life in the Fast Lane Posterior Shoulder Dislocation {{webarchive |url=https://web.archive.org/web/20100106011232/http://lifeinthefastlane.com/2009/06/posterior-shoulder-dislocation/ |date=January 6, 2010 }}
12. ^{{cite journal |last1=Hawkins |first1=RJ |last2=Neer |first2=CS |last3=Pianta |first3=RM |last4=Mendoza |first4=FX |title=Locked posterior dislocation of the shoulder |journal=J Bone Joint Surg Am |volume=69 |issue=1 |pages=9–18 |date=January 1987 |pmid=3805075 |url=http://www.medscape.com/medline/abstract/3805075?src=emed_ckb_ref_0 |deadurl=no |archiveurl=https://web.archive.org/web/20071013084735/http://www.medscape.com/medline/abstract/3805075?src=emed_ckb_ref_0 |archivedate=2007-10-13 |df= |doi=10.2106/00004623-198769010-00003 }}
13. ^{{EMedicine|emerg|148|Dislocations, Shoulder|clinical}}
14. ^{{Cite journal|last=Yamamoto|first=Tetsuji|last2=Yoshiya|first2=Shinichi|last3=Kurosaka|first3=Masahiro|last4=Nagira|first4=Keiko|last5=Nabeshima|first5=Yuji|date=December 2003|title=Luxatio erecta (inferior dislocation of the shoulder): a report of 5 cases and a review of the literature|journal=American Journal of Orthopedics (Belle Mead, N.J.)|volume=32|issue=12|pages=601–03|issn=1078-4519|pmid=14713067}}
15. ^{{cite journal|last1=Fitch|first1=RW|last2=Kuhn|first2=JE|title=Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review.|journal=Academic Emergency Medicine|date=August 2008|volume=15|issue=8|pages=703–08|doi=10.1111/j.1553-2712.2008.00164.x|pmid=18783486}}
16. ^1 {{cite journal|last1=Wakai|first1=A|last2=O'Sullivan|first2=R|last3=McCabe|first3=A|title=Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults.|journal=The Cochrane Database of Systematic Reviews|date=13 April 2011|issue=4|pages=CD004919|doi=10.1002/14651858.CD004919.pub2|pmid=21491392}}
17. ^{{cite journal|last1=Whelan|first1=DB|last2=Kletke|first2=SN|last3=Schemitsch|first3=G|last4=Chahal|first4=J|title=Immobilization in External Rotation Versus Internal Rotation After Primary Anterior Shoulder Dislocation: A Meta-analysis of Randomized Controlled Trials.|journal=The American Journal of Sports Medicine|date=26 June 2015|pmid=26116355|doi=10.1177/0363546515585119|volume=44|issue=2|pages=521–32}}
18. ^{{cite journal|last1=Hanchard|first1=NC|last2=Goodchild|first2=LM|last3=Kottam|first3=L|title=Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.|journal=The Cochrane Database of Systematic Reviews|date=30 April 2014|volume=4|issue=4|pages=CD004962|pmid=24782346|doi=10.1002/14651858.CD004962.pub3}}
19. ^{{cite journal |vauthors=Chalidis B, Sachinis N, Dimitriou C, Papadopoulos P, Samoladas E, Pournaras J |title=Has the management of shoulder dislocation changed over time? |journal=Int Orthop |volume=31 |issue=3 |pages=385–89 |date=June 2007 |pmid=16909255 |pmc=2267594 |doi=10.1007/s00264-006-0183-y }}
20. ^{{cite journal |vauthors=Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V | title=Management of Primary Acute Anterior Shoulder Dislocation: Systematic Review and Quantitative Synthesis of the Literature |journal=Arthroscopy | date=Apr 2014 | volume=30 | issue = 4 | pages=506–22| pmid=24680311 | doi=10.1016/j.arthro.2014.01.003}}
21. ^{{cite web|title=Shoulder Scope|url=http://www.orthop.washington.edu/?q=patient-care/articles/sports/shoulder-scope.html|website=UW Orthopaedics and Sports Medicine, Seattle|accessdate=14 October 2017|language=en|date=3 August 2012|deadurl=no|archiveurl=https://web.archive.org/web/20131619041300/http://www.orthop.washington.edu/?q=patient-care%2Farticles%2Fsports%2Fshoulder-scope.html|archivedate=5 November 2017|df=}}
22. ^{{cite web | url=http://www.orthop.washington.edu/openbankart | title=Bankart repair for unstable dislocating shoulders | publisher=University of Washington: Orthopaedics and Sports Medicine | deadurl=no | archiveurl=https://web.archive.org/web/20080115171413/http://www.orthop.washington.edu/openbankart | archivedate=2008-01-15 | df= }}
23. ^{{cite journal |last1=Burkhart |first1= SS |last2= De Beer |first2= JF | title=Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion | journal=Arthroscopy | date=Oct 2000 | volume=16 | pages=677–94 | pmid= 11027751 | issue=7 | doi=10.1053/jars.2000.17715 }}
24. ^{{cite journal |vauthors=Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C, Richards DP | title=Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss | journal=Arthroscopy | date=Oct 2007 | volume=23 | issue = 10 | pages=1033–41| pmid=17916467 | doi=10.1016/j.arthro.2007.08.009}}
25. ^{{cite journal | title=Comparison of reconstructive procedures for glenoid bone loss associated with recurrent anterior shoulder instability |vauthors=Noonan B, Hollister SJ, Sekiya JK, Bedi A | date=Aug 2014 | journal=J Shoulder Elbow Sur | volume=23 | issue = 8 | pages=1113–19 | pmid=24561175 | doi= 10.1016/j.jse.2013.11.011 }}
26. ^1 {{Cite journal|last=Barmare|first=Arshad|last2=Critchley|first2=Ian|last3=Herald|first3=Jonathan|last4=Goldberg|first4=Jerome|last5=Chen|first5=Dong|date=2016-02-01|title=Effects of surgical management on multidirectional instability of the shoulder: a meta-analysis|journal=Knee Surgery, Sports Traumatology, Arthroscopy|language=en|volume=24|issue=2|pages=630–639|doi=10.1007/s00167-015-3901-4|pmid=26658564|issn=1433-7347}}
27. ^{{cite journal | title=Reconstruction of posterior glenoid deficiency using distal tibial osteoarticular allograft |vauthors=Millett PJ, Schoenahl JY, Register B, Gaskill TR, van Deurzen DF, Martetschläger F | date=Feb 2013 | journal=Knee Surg Sports Traumatol Arthrosc | volume=21 | pages=445–49 | pmid=23114865 | doi=10.1007/s00167-012-2254-5 | issue=2}}
28. ^1 {{cite journal | title=Arthroscopic inferior capsular shift: long-term follow-up | last1= Fleega |first1= BA |last2= El Shewy |first2= MT | date=May 2012 | journal=Am J Sports Med | volume=40 | issue = 5 | pages=1126–32 | pmid=22437281 | doi= 10.1177/0363546512438509 }}
29. ^{{cite journal | title=Electrothermal arthroscopic capsulorrhaphy: old technology, new evidence. A multicenter randomized clinical trial |vauthors=Mohtadi NG, Kirkley A, Hollinshead RM, McCormack R, MacDonald PB, Chan DS, Sasyniuk TM, Fick GH, Paolucci EO | date=Aug 2014 | journal=J Shoulder Elbow Surg | volume=23 | issue = 8 | pages=1171–80 | pmid=24939380 | doi=10.1016/j.jse.2014.02.022 }}
30. ^1 {{cite journal|last1=Wasserstein|first1=DN|last2=Sheth|first2=U|last3=Colbenson|first3=K|last4=Henry|first4=PD|last5=Chahal|first5=J|last6=Dwyer|first6=T|last7=Kuhn|first7=JE|title=The True Recurrence Rate and Factors Predicting Recurrent Instability After Nonsurgical Management of Traumatic Primary Anterior Shoulder Dislocation: A Systematic Review.|journal=Arthroscopy|date=December 2016|volume=32|issue=12|pages=2616–25|pmid=27487737|doi=10.1016/j.arthro.2016.05.039}}

External links

{{Medical resources
| DiseasesDB = 31231
| ICD10 = {{ICD10|S|43|0|s|40}}
| ICD9 = {{ICD9|831}}
| OMIM =
| MedlinePlus =
| ICDO =
| eMedicineSubj = orthoped
| eMedicineTopic = 440
| eMedicine_mult = {{eMedicine2|radio|630}} {{eMedicine2|sports|152}}
| MeshID = D012783
}}{{Dislocations, sprains and strains}}{{DEFAULTSORT:Dislocated Shoulder}}

4 : Injuries of shoulder and upper arm|Shoulder|Dislocations, sprains and strains|RTT
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