There are various types of shoulder injuries, including fractures, dislocation, and soft tissue injuries. Fractures commonly involve the clavicle, proximal humerus, and/or the scapula. A shoulder dislocation/separation can involve any of three different joints, with the glenohumeral joint being the most commonly involved. Acromioclavicular joint separations and soft tissue injuries are discussed in other templates and will not be discussed in this publication.1
Anterior dislocations most commonly involve an indirect mechanisms, most often due to a sudden loading of the arm while in abduction, external rotation, and extension; direct injury mechanisms such as a direct blow to the posterior aspect of the shoulder are less frequent. Posterior dislocations are less common and are 2ry to either a forceful and sudden contraction of the shoulder muscles (e.g. seizure or electric shock) or falling on an outstretched arm (flexed, adducted, and internally rotated).2
Shoulder fractures commonly involve the clavicle, proximal humerus, and scapula. A direct blow to the area, collision, or a motor vehicle accident can cause fractures of the clavicle or the proximal humerus. Scapular fractures are rare, but when they occur they are usually secondary to high-energy trauma.1
Epidemiology including risk factors and primary prevention
In the United States, the incidence of shoulder dislocations is 23.9/100,000-person years and approximately 85–98% of initial shoulder dislocations are anterior dislocations. Dislocated shoulders tend to occur more often in males than in females, probably because of association with contact sports. In men, the peak age is 20-30 years and 61-80 years in women (due to increased risk for falls).2
The incidence of proximal humerus fractures increases with age; about 15% per year.3 They are common in the elderly population, with a population-adjusted incidence of 101/100,000 in person years in those over 65 years old.4 Clavicle fractures account for approximately 2.6% of all fractures. The peak incidence occurs in children and young adults. Over one-third of clavicle fractures in males occur between the ages of 13 and 20 years, while 20% of clavicle fractures in women occur in the same age group.5 Scapular fractures on the other hand are uncommon, representing less than 1% of all fractures.1
There are three primary types of shoulder dislocations: anterior, posterior, and inferior. Anterior dislocation accounts for most of the cases, followed by posterior dislocations (mechanism of injury as described above). An inferior dislocation occurs when the arm is forced into hyperabduction, causing the abutment of the acromion against the acromion with subsequent separation of the humeral head from the glenoid.2
Proximal humeral fractures (PHF) are classified using the Neer system, which is based on fracture location relative to the greater tuberosity, lesser tuberosity, head, and shaft. PHF are considered non-displaced if no segment is displaced more than 1 cm or angulated more than 45 degrees, while displaced fractures are classified according to the number of displaced fragments.6 The anatomic site of clavicle fractures are typically described using the Allman classification, which divides the clavicle into thirds (proximal, midshaft, and distal), with midshaft fractures representing approximately 75 to 80% of all clavicle fractures. Lastly, scapular fractures mostly (50% of the times) occur in the body or spine of the scapula.2
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
In patients with a first-time dislocation, the outcome most frequently measured over time is recurrent instability. Patients with a single shoulder dislocation have an estimated 18% risk of developing shoulder arthropathy, while those with recurrent dislocations have a 40% chance. Persistent apprehension, inability to return to sports, and post-traumatic arthritis are other outcomes that may be present in those with history of shoulder dislocation.7
The overall prognosis for PHF’s depends on numerous factors: fracture pattern, patient age, associated comorbidities, and willingness of the patient to undergo lengthy rehabilitation.6 Most clavicle fractures treated non-operatively heal, although with variable amounts of cosmetic deformity.8 In scapular fractures, if no significant associated injury exists, complete or near complete recovery is expected.2
Specific secondary or associated conditions and complications
In young patients with anterior dislocation (<24 years old), anterior inferior labrum disruption is described in the literature to occur in 87-97% of patients, posterolateral humeral cortical compression fracture (Hill-Sachs lesion) in 67-89% of patients, and 10% incidence of Superior Labrum Anterior and Posterior (SLAP) tears. In older individuals (>30 years old), there is a 53% incidence of rotator cuff tears associated with anterior shoulder dislocations. Other complications include axillary nerve and artery injury and brachial plexus injury.7 The “terrible triad” has been described in the literature and includes a shoulder dislocation with a fracture, rotator cuff tear, and brachial plexus injury.2,9
Complications associated with PHF’s include neurovascular injury, avascular necrosis of the humeral head, and adhesive capsulitis. In displaced or comminuted clavicle fractures complications include subclavian vessels injury, hemopneumothorax, brachial plexopathy, nonunion, malunion, posttraumatic arthritis, and recurrent fracture.2
2. ESSENTIALS OF ASSESSMENT
Essential components of the history in a patient with a shoulder injury include time of onset, location, mechanism of injury, associated symptoms (e.g., neurovascular), modifying conditions, history of prior shoulder injuries, and previous interventions. Pain, swelling, loss of function, snapping/cracking sensation, instability (e.g., shoulder feeling loose), and possible deformity over the affected area may be described.
The examination should begin with inspection of the affected arm in the resting position (e.g. extremity held in adduction) looking for evidence of atrophy, bruising, abrasion (may suggest direct trauma), asymmetry, muscle contraction, or deformity. Palpation of the affected and surroundings areas is performed assessing for tenderness, crepitance, or bony abnormalities. An assessment of active and passive range of motion (ROM), muscle tone, strength, and neurovascular status is then performed. Cervical spine examination may be needed.
Special testing should include evaluation for rotator cuff strength (e.g., Empty Can, External Rotation, Belly/Lift-off), impingement testing (e.g., Hawkin’s sign and Neer’s test), long head of biceps tendon testing (e.g., Yergason’s and Speed’s Tests), laxity/instability testing (e.g., load and shift, apprehension/relocation, and sulcus sign), and labral testing (e.g., O’Brien’s and Biceps Loading). Important to note that passive ROM may be limited due to pain and shoulder should not be passively moved beyond 90 degrees in any direction due to risk of re-dislocation.
Shoulder functional assessment can be evaluated through active and passive ROM and muscle length, strength, and joint mobility assessment. The American Shoulder and Elbow Surgeons have adopted a standardized form that contains visual analog scales for pain and instability and activities of daily living questionnaire to measure shoulder function and outcome.10
Laboratory studies are not considered routine in subluxation or dislocation events. PHF are often associated with diabetes, rheumatological conditions, or osteoporosis and calcium deficiency. Recommended initial laboratory studies include 25-hydroxycalciferol, calcium, parathyroid hormone, thyroid stimulating hormone, alkaline phosphatase, phosphorus, and creatinine. Bone mineral density may be assessed by dual-energy x-ray absorptiometry (DEXA).
Radiographs are the preferred initial test to detect dislocations and fractures. Suggested views include an anterior-posterior (A/P), axillary, true A/P in scapular plane (Grashey view), A/P in internal rotation, and Stryker view. Depending on the location of the fracture (e.g., scapula or clavicle) and findings in the initial radiographs, specific views may be warranted. The need for advanced imaging (e.g., CT or MRI) is mainly dependent in part on initial radiographic findings and in those who are surgical candidates.2
Supplemental assessment tools
Multiple assessment tools are utilized as a standard method to determine shoulder functionality in patients with shoulder injuries. Outcome measures include evaluation of pain, functionality, ROM, symptomatology, level of independence, and treatment satisfaction. Multiple questionnaires are currently available: Quick DASH scores, Constant Scores, Visual Analog Scale scores, Simple Shoulder Test, Short Form-36, and the Oxford Shoulder Scores.11 Results from these allow the clinician to evaluate effectiveness of treatment and the degree of limitation secondary to shoulder pathology.
Early predictions of outcomes
Younger age is a significant predictor for shoulder dislocation recurrence. A number of studies have found the recurrence rate to be as high as 90% over two years in patients < 25 years old. Associated risk factors include number of prior dislocations, activity level, male sex, and prior history of bony defects, capsular deformation, or ligamentous injuries/laxity. Conversely, recurrence is < 10% in older populations, largely due to the predominance of concomitant rotator cuff injuries as opposed to bony or ligamentous injuries as with younger populations.12-14 Outcomes in shoulder fractures are dependent mostly on patient’s age, comorbidities, associated complications, and location and nature of the fracture.
Social role and social support system
Treatment outcomes involve the cooperation of the patient, the parents (in the young patient), and the athletic trainers and coaches in those involved in sports injuries. Sport psychologists can address coping with the natural process of the disease, the timing of recovery, and the treatment expectations.
The return to premorbid activities, such as the return to play in athletes and return to work in professional individuals are important aspects in the management of shoulder injuries. There should be a multidisciplinary approach, with discussion of the natural process of the injury, treatment options, and patient’s goals in order to make an informed decision.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Acute management of shoulder dislocation typically includes closed reduction. There are several techniques, but consensus states that the physician should perform the techniques he or she is most proficient. After reduction, the arm is placed on a sling and immobilized for at least 1 week, after which early gentle ROM is recommended to minimize capsular contraction. Restrictions for the first 4-6 weeks include no abduction and external rotation at 90° to prevent re-dislocation. Scapular strengthening will be introduced at the 6-week mark.15,16
Management of fractures depends on patient’s age, activity level, location, and nature (displaced, non-displaced, comminuted) of the fracture. Non-operative management remains the most common approach for non-displaced fractures. ROM pendulum and stretching exercises can be started as soon as pain allows, with gradual progression to active ROM and strengthening exercises over 4-6 weeks. For clavicle fractures, a sling, figure-of-eight splint, or a combination of both may be used; currently there is no consensus on the optimal duration of immobilization (~ 2-6 weeks).6,8,11
Displaced fractures causing neurovascular or hemodynamic instability, or those that have high rate of non-union or sequel may require operative treatment. Post-operative rehabilitation after surgical management for a clavicle fracture generally includes sling immobilization for 2-4 weeks, with immediate ROM exercises as tolerated.10 Patients with PHF treated with Open Reduction and Internal Fixation (ORIF) are placed in a sling for 6 weeks and started in gentle ROM exercises 2 weeks postoperatively with gradual progression, adding strengthening exercise at 3 months postoperatively.6,8,11
Return to sport (RTS) in patients treated conservatively following a shoulder dislocation or fracture will be allowed once full ROM and strength have been regained (~3 months). RTS after a shoulder fracture, treated surgically, may take an average of 3-6 months, but readiness will be influenced by multiple factors (e.g., age, associated complications, nature and location of fracture, ROM, strength, and surgical technique).6,11
At different disease stages
The patient should be referred to an orthopaedic surgeon if the following conditions are diagnosed: glenoid osseous defect >25%, humeral head articular surface osseous defect >25%, proximal humerus fracture requiring surgery, irreducible dislocation, failed trial of rehabilitation, inability to tolerate shoulder restrictions, and inability to perform sport-specific drills without instability. While not absolute, orthopaedic referral should be considered in young patients with >2 shoulder dislocations during a season, overhead or throwing athletes, contact sport athletes, and injury near the end of a season.15,16
Coordination of care
Improved outcomes are obtained when patients are managed in a multidisciplinary manner. Communication between the patient, family members, coaches, orthopedic surgeon, physiatrist, physical and occupational therapist, nursing staff, case manager, and others is essential to obtain good outcomes.
Patient & family education
The patient, parents, coaches, and trainers should be fully involved in care. They should be educated about the findings, expectations, and recommendations. Patients should be educated on the various operative and non-operative treatment options, possible complications, and the recovery timeline for their injury.
Reverse shoulder arthroplasty (RSA) has gained wide acceptance for treating PHF’s in the elderly. Excellent results have been observed and have demonstrated more reliable outcomes when compared to hemiarthroplasty, for which RSA is currently being favored in the elderly population.17
Recent studies suggest that conservative interventions for shoulder dislocations reveal unsatisfactory results, primarily in the young and athletic patients. Early arthroscopic remplissage has demonstrated to be an effective technique with respect to recurrence rate, ROM, and shoulder function.18
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
When deciding the optimal treatment intervention in patients with a shoulder fracture or dislocation multiple factors must be taken into consideration (e.g., patient’s age, activity level, dominant side, possible associated complications, and location of the fracture). Independent of selected treatment option (surgical vs. non-surgical), early motion is crucial in obtaining adequate functional outcomes.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
Ultrasound has the potential to save time, radiation exposure, healthcare costs, and possible need for re-sedation in patients that present to the emergency room with a shoulder dislocation. A systematic review compared the diagnostic accuracy of ultrasound compared with plain radiography and observed that ultrasound may be considered as an alternative diagnostic method for the detection of shoulder dislocation and reduction.19
As described above, non-operative management remains the most common approach for non-displaced fractures, but recent studies have demonstrated that in the elderly population RSA is a reliable treatment option, as better outcomes have been proven when compared to hemiarthroplasty.17
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
There is still no consensus in the literature about the management of patients presenting with first-time traumatic anterior dislocation of the shoulder. The traditional standard approach of immobilization as a definitive treatment after the reduction is being challenged due to the high rate of recurrence. A Cochrane review found insufficient evidence to inform choice of immobilization and recommended more good-quality trials on the subject.20
Although the majority of fractures are treated non-operatively, the most appropriate form of management (surgical vs. conservative) is currently less clear when it comes to elderly patients. In addition, few guidelines are currently available as to staging physical therapy interventions to maximize ROM, strength, and optimize activities of daily living in these patients.6
- Pavlov, H and Freiberger, H. Fractures and Dislocations About the Shoulder. Seminars in Roentgenology. 1978.12(2):85-96.
- Sheenan, S et al. Traumatic Shoulder Injuries: A Force Mechanism Analysis-Glenohumeral Dislocation and Instability. AJR. 2013; 201:378–393.
- Roux, A. Epidemiology of proximal humerus fractures managed in a trauma center. Orthopedics & Traumatology: Surgery & Research.2012;98: 715-719.
- Lee SH, Dargent-Molina P, Breart G. Risk Factors for Fractues of the Proximal Humerus: Results From the EPIDOS Prospective Study. Journal of Bone and Mineral Research. 2002(17);817-25.
- Hatch, R et al. (2017) Clavicle fracture. UpToDate. Retrieved from https://www.uptodate.com/contents/clavicle-fractures.
- Singleton, E. Rehabilitation After Proximal Humeral Fractures. Techniques in Shoulder & Elbow Surgery.2014:15(1):46-40.
- Boone J, Arciero R. First-time anterior shoulder dislocations: has the standard changed? Br J Sports Med. 2010; 44: 355-360.
- Paladini, P. Treatment of Clavicle Fractures. Transl Med UniSa.2012;2:47–58.
- Groh GI, Rockwood CA. The terrible triad: Anterior dislocation of the shoulder associated with rupture of the rotator cuff and injury to the brachial plexus.J Shoulder Elbow Surg.1995;4(1):51-53.
- Schmidt, Stefanie, et al. Evaluation of Shoulder-Specific Patient-Reported Outcome Measures: a Systematic and Standardized Comparison of Available Evidence. Journal of Shoulder and Elbow Surgery, vol. 23, no. 3, 2014, pp. 434–444.
- Robertson, G and Wood, A. Return to sport following clavicle fractures: a systematic review British Medical Bulletin.2016;119(1):111–128.
- Pevny T, Hunter RE, Freeman JR. Primary traumatic anterior shoulder dislocation in patients 40 years of age and older.Arthroscop. 1998;14(3):289-294.
- McLaughlin HL, MacLellan DI. Recurrent anterior dislocation of the shoulder: II, a comparative study. J Trauma. 1967;7(2):191-201. 18. Stayner LR, Cummings J, Andersen J, Jobe CM. Shoulder dislocations in patients older than 40 years of age.Orthop Clin North Am. 2000;31(2):231- 239.
- Burns TC, Owens BD. Management of shoulder instability in in-season athletes.Phys Sportsmed.2010;38(3):55-60.
- Owens BD, Dickens JF, Kilcoyne KG, Rue JP. Management of mid-season traumatic anterior shoulder instability in athletes.J Am Acad Orthop Surg.2012;20(8):518-526.
- Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States.J Bone Joint Surg Am. 2010;92:542-549.
- Chuinard, C.Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture. Techniques in Shoulder & Elbow Surgery.2016;17(3):122-130.
- Haviv, B., Mayo,L.,and Biggs, D. Outcomes of arthroscopic “Remplissage”: capsulotenodesis of the engaging large Hill-Sachs lesion. Journal of Orthopaedic Surgery and Research.2011;6:29.
- Gottlieb, M. and Russell, F. Diagnostic Accuracy of Ultrasound for Identifying Shoulder Dislocations and Reductions: A Systematic Review of the Literature. Western Journal of Emergency Medicine.2017;18(5):937-942.
- Handoll HH, Almaiyah MA, Rangan A. Surgical versus non-surgical treatment for acute anterior shoulder dislocation.Cochrane Database Syst Rev.2004;(1):CD004325.
Original Version of the Topic
Jason L. Zaremski, MD, Daniel C. Herman, MD, PhD, Kevin Vincent, MD. Shoulder fractures, separation-dislocation, and other soft tissue injuries. Original publication date: 09/20/2014.
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William Micheo, MD
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Brenda Castillo, MD
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Jose R. Vives, MD
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Javier González, MD
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