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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Postarthroscopic Glenohumeral Chondrolysis PAGCL JAAOS

The February 2012 JAAOS published an article on Postarthroscopic Glenohumeral Chondrolysis. This article points out, once again, that glenohumeral chondrolysis is the devastating and irreversible destruction of the articular cartilage of the shoulder joint, often in young (average age in the late 20's) active individuals having shoulder arthroscopy for the treatment of non-degenerative conditions, such as instability or 'SLAP' tears. In that once it has been initiated, the destruction of cartilage cannot be stopped or reversed, it is essential that the causes of chondrolysis be identified so that the condition can be prevented by avoiding each of the causational factors. As we have described in a previous post the evidence linking pain pumps to the irreversible destruction of articular cartilage from chondroysis is clear.

Against this background it is curious that the authors state that 'no cause of PAGCL has been confirmed and the associations are mostly speculative'. We note that one of the authors of this article discloses that he or an immediate family member serves as a paid consultant to Styker, a manufacturer of pain pumps used for the post arthroscopic infusion of local anesthetics.

The authors borrow photographs from a recent article, Risk Factors for Chondrolysis of the Glenohumeral Joint, A study of 375 shoulder arthroscopic procedures in the practice of an individual community surgeon. This article clearly demonstrates the role of post-arthroscopic infusion of local anesthetics via pain pumps in the causation of glenohumeral chondrolysis, yet they omit this article from their discussion of the causes of this condition.

The causation of chondrolysis is now clearly established as shown in this post.

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Brachial Plexus Blocks for Upper Extremity Surgery - JAAOS

The January issue of JAAOS publishes an article on brachial plexus blocks by Andrew Green and co-authors. This is a comprehensive review of the relevant anatomy, possible applications, technical considerations.  The authors quote the article by UW shoulder fellow Lenters et al. pointing to a substantial complication rate which, although lower in the hands of anesthesiologists experienced in the technique, was still significant for those who had performed many of them.

As we have discussed in a previous post, we avoid plexus blocks in most cases because of the potential for serious and possibly long term complications that are not seen with general anesthesia. As the authors state, "permanent <nerve> injury can result in substantial disability."  Even though the rate of these injuries is low, we are aware of a number of cases where career-ending neuropathies have occurred in surgeons and engineers and where previously independent individuals became dependent because of irreversible loss of function.

The authors also mention phrenic nerve palsy 'in almost all patients with interscalene block'. Our observations are similar and note that for many individuals with sleep apnea, COPD, or other respiratory conditions, even the transient loss of half of their pulmonary function can be critical.

The authors also describe other systemic complications, pneumothorax, vascular puncture, and the risks of indwelling catheters.

The proponents of blocks point to the value of postoperative analgesia. Our experience is that with shoulder arthritis surgery the use of blocks only delays the onset of pain until the block wears off in the evening or the wee hours of the morning when the nurse/patient ratio is lower.

So, again, after a rather prolonged use of blocks, we no longer find that the advantages outweigh the disadvantages and have discontinued their routine use.

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You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.