– the most common cause of shoulder abduction weakness after dislocation in a middle-aged person (50-60) is a rotator cuff tear. Certainly, older people are at higher risk of axillary nerve palsy too, but the risk of rotator cuff tear in a 60 year old is nearly 80%!
– axillary nerve palsy – increases with age, time that shoulder remains dislocated, and amount of initial trauma
– for the older patient with OA on both sides (humeral and glenoid) – try to do a total shoulder replacement rather than a hemiarthroplasty. Check to make sure their rotator cuff is intact – look at the x-rays to make sure they have no superior migration of their head to indicate that the cuff is gone.
– “glenoid resurfacing in patients with OA or RA has yielded a higher percentage of patients with satisfactory pain relief than hemiarthroplasty” – but note that glenoid loosening is much higher in patients with rotator cuff deficiency
– beware the elderly patient with a dislocated shoulder and expanding axillary mass – they’ve torn their axillary artery; usually tears at the junction of the 2nd and 3rd part. (1st part – superior thoracic; 2nd part – thoracoacromial artery and the lateral thoracic; 3rd part – anterior and posterior circumflex and subscapular – from which comes the circumflex scapular and thoracodorsal)
– factors that influence outcome in rotator cuff surgery are:
– adequacy of acromioplasty
– size of rotator cuff tear
– patient age
– premorbid activity level
– quality of deltoid function
– factors that relate to cuff tear size – quality of tissue, degree of retraction, intactness of biceps tendon
– for the 40 year old with impingement – do an acromioplasty; DO NOT take down their coracoacromial ligament – this supposedly has a role in preventing superior migration.
– for arthroscopic shoulder repairs for instability – staples and screws are now out of favor – they migrate into the joint and lead to abrasive arthritis.
– with respect to anterior dislocation with GT fracture – the injury should be treated as per usual (as long as the GT doesn’t need to be fixed after reduction). There is not a higher rate of recurrent dislocation with this injury.
– the incidence of recurrent dislocation in a skeletally immature patient is near 90-100%
– in an elderly patient with missed locked posterior dislocation – if over 3 months – hemiarthroplasty!
– manage the acute anterior SC dislocation with one try at reduction; if unsuccessful – sling. DO NOT OPERATE!
– a young patient who has sudden SC subluxation – no treatment; especially if atraumatic. Just make sure it’s not a septic arthritis.
– after reducing an anterior dislocation, the head may be abit inferiorly subluxated on x-ray – management? Physio? Is this sign of a rotator cuff tear?
– with luxatio erecta, the humerus is hyperabducted and often is associated with axillary artery injury; the reduction is done in inline traction. The humeral head is usually NOT held irreducible by the biceps tendon. If it is irreducible, it is more likely because the head has buttonholed out through the inferior capsule
– the posterior dislocation presents with a fullness in the posterior shoulder, in fixed adduction and internal rotation, with limited or no external rotation, limited elevation, flattening of the anterior shoulder, and prominence of the coracoid.
– recurrent posterior subluxation is often not felt as a sensation of instability – they will more likely have pain. Their dislocations are less painful than the anteriors though I think.
– do not be fooled into doing a closed reduction on a elderly patient with a longstanding dislocation.
– multi-directional instability – PHYSIO PHYSIO PHYSIO
– treat most of the elderly patients with longstanding missed dislocations with hemiarthroplasties.
– the most influential factor in recurrent dislocation is AGE at time of primary dislocation.
– for the younger patient (40ish) with a rotator cuff tear – you might be leaning towards fixing these.