Clinical: Shoulder problems - part two.(Shoulder dislocation)

 
THE ESSENTIALS 
- The shoulder is the most unstable and commonly dislocated joint. 
- Recurrent shoulder dislocation is a significant disability. 
- Shoulder replacement is not as successful as hip replacement. 
- Epicondylitis usually resolves in six to 12 months. 
- Brachial plexus injury can be devastating. 

The shoulder is by far the most mobile joint in the human body.

To achieve this mobility, stability has been sacrificed, so the shoulder is also the most commonly dislocated joint.

Dislocated shoulders need to be reduced quickly. If a shoulder becomes dislocated and is not reduced, the ligaments around it soon stretch and become ineffective.

After five to seven days, it may become impossible to relocate the humeral head by closed methods. If there is any doubt about dislocation, X-rays in two planes should be taken.

Groups of patients suffering dislocation

There are two groups of patients who suffer shoulder dislocations. These are young patients who receive high-energy injuries, such as rugby players, and an older group with weak rotator cuffs receiving low-energy injuries.

Almost all shoulder dislocations are anterior, with less than 5 per cent being posterior.

When a young man (the patient is usually male) dislocates his shoulder for the first time, it is usually an anterior dislocation following a violent event. He gives a clear-cut history of a sudden force during a contact sport or a fall, with sudden swelling, immobility and pain around the joint.

The joint then has to be relocated, usually under anaesthetic in the A&E department or in theatre. It is left in a sling for three to four weeks, followed by active mobilisation.

Most of these patients recover well, helped along by their youth. Paradoxically, the younger a patient is at first time dislocation, the more likely they are to have a recurrence.

About one in three become recurrent dislocators, that is they repeatedly present with a shoulder dislocation that needs reducing - often after increasingly trivial injuries.

Eventually, there may be a sense of subluxation or dislocation practically all …