Shoulder Instability (Recurrent Dislocation)

MBBS, MRCS(UK) FRCS (Tr &Ortho), FEBOT(France), Fellow European Board Orthopaedics and Trauma., 

D Ortho,Dip SICOT(Honk Kong).

Consultant Orthopaedic Surgeon

ApolloHospitals Ayanambakkam , Chennai, India

For appointments and queries contact us on  Ph 9566222533/ [email protected]

The shoulder joint is a ball and socket joint. The round end of the upper arm

bone (humerus) fits into the shallow socket (glenoid) on the shoulder blade

(scapula) much like a golf ball rests on a tee. The anatomy of the shoulder

joint makes it the most mobile joint in the body.

While this gives us the ability to move it in many directions it also makes it an easy joint to dislocate.  A complete dislocation means that the ball (humeral head) has come all the way out of the socket. When the ball comes out of the socket incompletely, it is called a partial dislocation or subluxation. When the shoulder dislocates or subluxes repeatedly it is known as shoulder instability. The shoulder joint can dislocate forward, backward  or downward. The most common type is when the shoulder slips forward (anterior).

                                       

A ring of cartilage surrounds the shallow socket of the shoulder joint (glenoid).

This ring is called the labrum. The glenoid labrum increases the depth of the

socket making the shoulder joint more stable. A tough, but thin elastic tissue

(capsule) further surrounds the shoulder like a bag. The capsule contains a

series of ligaments or bands, which connect the humerus to the glenoid. 

                                                    

The most common cause for shoulder dislocation is a forceful injury like falling

on an outstretched hand (sports injuries, falls) or a hard blow to the shoulder

(a cricket injury or a road traffic accident). This is called a traumatic

dislocation.

                                                     

The force that causes this injury can cause the labrum to be torn

from the socket making it shallow. This lesion is known as a Bankart’s lesion

and it can lead to further episodes of subluxation or dislocation. 

Sometimes a relatively minor force may dislocate the shoulder for the first

time and the patient may feel a pop as it reduces by itself. This will occur in

people who have normal but lax joints. This is referred to as an atraumatic

dislocation.

A very small group of patients can dislocate their  shoulders without any

trauma. These type of dislocations / subluxations occur because of abnormal

working of the muscles around the shoulder. Such a condition is referred to as

‘positional instability of the shoulder’.

  

When the shoulder dislocates the first time after an injury, the patient will

immediately complain of pain, deformity and weakness in the shoulder. The

patient may develop bruising and complain of numbness or tingling if any of

the nerves around the shoulder have stretched.  

The symptoms of shoulder instability will range from obvious repeated

dislocations, to just pain with certain activities or shoulder positions. Patients

may complain of clicking or popping of the shoulder, the arm suddenly ‘feeling

dead’ or the shoulder been generally weak. 

                                            

                                     .

After appropriate clinical assessment, an x-ray of  the shoulder is

recommended. When the shoulder is dislocated the first time an x-ray will

reveal any broken bone.   In some situations after the first injury, or if the first injury progresses to  instability, a MR Arthrogram is advised. A dye is injected into the shoulder  and a magnetic field is used to create cross sectional images of the shoulder.

Sometimes a CT scan may be recommended to assess the bony defects. 

Electrical tests may also be necessary if the patient has tingling, numbness or

an altered sensation, to assess for any nerve damage.

                                       

                             

1. After the first dislocation the shoulder will need to be reduced usually in

the Accident & Emergency department. This will be carried out using a

muscle relaxant, sedative or rarely a general anaesthetic. Following

reduction of the shoulder you will be put in a sling or external brace for a

period of time. Physiotherapy is not always needed but may be advised. 

2. If the patient goes on to develop shoulder instability, further investigations

and treatment may be necessary. Further treatment will depend on the

type of instability and the kind of soft tissue or bony injuries.  

3. Physiotherapy is the initial line of management in  patients who have

developed atraumatic type shoulder instability, due to muscle imbalance or

abnormal patterns of muscle activity. Some of these cases may not

respond to physiotherapy and may need surgical intervention.

4. Surgery is the treatment of choice in patients with traumatic shoulder

instability. These patients will demonstrate soft tissue injuries (Bankart’s

lesion) or bony defects on the MR Arthrogram. Physiotherapy is unlikely to

help in such situations. The aim of surgery is to reconstruct the torn labrum or capsule.

 If there is a bony defect it will have to be filled.

 The surgery is most often done arthroscopically (key hole surgery)

 in our centre although open surgery may be needed depending upon patient factors.

Arthroscopic (keyhole) stabilisation surgery: About 3-4 small incisions of

5mm each are needed. A telescope is passed into the shoulder through

one of these incisions and special surgical instruments are passed through

the other incisions to reconstruct the labrum and capsule. The advantage

of keyhole surgery is that it is less traumatic and so recovery is quicker. It

is usually carried out as a day procedure. Loss of  movement of the

shoulder is rare after arthroscopic repair. 

Open surgery for bony defects: If there is a significant bone loss, keyhole

surgery is not advised. In such circumstances an open

operation (Laterjet Procedure) is performed. This procedure involves transfer of a small  bone (tip of corocoid process) with its muscle attachments, to the front of the shoulder socket. The transferred bone is fixed with 1or 2 screws.

person, the higher the chance of re-dislocation.

If the above conditions are not treated it is likely that the symptoms will

persist. It may be that the shoulder will become less troublesome if activities

that cause the problems are stopped. It is possible that an unstable shoulder

may cause arthritis in the long term but there are  no convincing long term

studies that conclude this. 

Surgical treatment for traumatic shoulder instability, when the shoulder

repeatedly dislocates forward, has a more than 90% success rate. 

1. Infection of the wound is possible and can usually be successfully treated

with antibiotics. 

2. Loss of movement is possible especially after open surgery.

3. Damage to the nerve or blood vessels is possible.

4. The operation may fail in about 5-8 % of the patients. 

5. If the repair is too tight, osteoarthritis of the shoulder may result in the

long term. 

6. When bone is transferred to address the bony defects (Latarjet

procedure), the bone may not heal.  

7. Any surgical intervention has the risk of developing complications that are

unpredicted. These complications may have the potential to leave the

patient worse than before surgery.

Keep the wounds dry and clean until they have healed.

It is important to remember that during the operation, ligaments were

reconstructed. The shoulder will be protected in a sling after the operation and

the physiotherapist will supervise rehabilitation of the shoulder after the

operation. It is very important that the instructions are followed. 

Return to work depends on many factors including the nature of the job and

hand dominance. Generally you will be able to return to a desk job within 4

weeks of the operation and perform reasonable tasks with the limb within 4-6

weeks. You will be unable to drive for a period of 6-8 weeks and activities like

cricket and  racquet sports are best avoided for at least 3 months. Contact sports

can be resumed after 4-6 months. 

These recommendations will vary from patient to patient.