Monday, October 22, 2012

Shoulder dislocation in the older patient. JAAOS

JAAOS  has recently published an article on Shoulder dislocation in the older patient.  This article is important in that it reminds us that as we age, the features of a dislocation change. Young patients (i.e. 25 years of age and younger) almost always sustain a Bankart lesion (tearing of the glenoid labrum from the anteroinferior glenoid bone) and frequently a Hill-Sachs defect (an impaction fracture of the posteriorlateral humeral head). With advancing age, the trend shifts away from these pathologies and toward rotator cuff defects and fractures of the greater tuberosity. Dislocations in older individuals are more commonly associated with axillary nerve, brachial plexus or axillary artery injuries as well - a thorough neurovascular examination is indicated before and after reduction. 

As this article points out, it is all too easy to overlook a cuff tear in an older patient with a shoulder dislocation. Post reduction dysfunction of the shoulder may be related to other causes such as pain or neurological injury. Specific testing of cuff function is necessary and a prompt MRI or shoulder ultrasound indicated if there is any question regarding cuff integrity. Of course the question arises "did the cuff tear precede the dislocation or was it a result of it?" While some patients may have had prior imaging, information regarding the possible pre-existance of a cuff tear may be only available from historical information about the pre-dislocation shoulder function. Knowledge of the chronicity of a cuff defect is important: large, chronic tears in older individuals are often not reparable. 

Two final caveats: (1) older individuals may have chronic dislocations - a careful history is needed to assure that the injury is acute, in that long standing dislocations may be difficult and risky to reduce and (2) in that older individuals often have weakened bone, a shoulder dislocation in such a patient needs to be done with great care and often with complete muscle relaxation under anesthesia to minimize the risk of fracture. 


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