CHAPTER 44 • SHOULDER INSTABILITY 265- Computed tomography arthography: This study
allows axial cuts to evaluate glenoid morphology
(amount of excess retroversion or anteversion) with
size and shape of glenoid fracture fragment - Magnetic resonance imaging:The MRI allows
visualization of the articular cartilage and rotator
cuff. It also allows visualization of the glenolabral
structures, capsule, and if there is a humeral avul-
sion of the glenohumeral ligaments (HAGL)
which would predicate a much different operative
course.
METHODS OF REDUCTION
- After a complete history, physical examination and
radiographic evaluation reduction should be com-
pleted as quickly as possible. - Rockwood method:An assistant provides counter-
traction with a sheet draped around the torso stabiliz-
ing the chest. The caregiver then applies counter
traction of the dislocated extremity distally. Slight
internal and external rotation may be used to “free” up
the engaged humeral head. (Neer and Rockwood,
1996) - Stimpson method:The patient is placed in a prone
position with the thorax supported by the table. Five
to 10 lb of weight are applied to the wrist with the arm
straight. In time the muscle will relax and the shoul-
der will be reduced. (Matsen, Thomas, and
Rockwood, Jr, 1998) - Westin method:Stockinette placed around the prox-
imal forearm flexed at 90°and the patient sitting. A
foot is placed in the loop created by the stockinette
and a gentle force applied with internal and external
rotation. (Westin et al, 1995) - Scapula manipulation technique: The patient is
placed prone with the arm flexed, hanging over the
gurney or table and 5 to 15 lb of traction placed at the
elbow. The scapula is rotated medially by pushing
medially on the inferior tip and rotating the superior
aspect of the scapula outward. - Milch Technique:The patient is supine and the arm
is elevated slowly to 90°. It is the abducted with exter-
nal rotation and thumb pressure is used to gently
reduce the shoulder. (Milch, 1938) - Kocher Technique:The arm is flexed to 90°and
traction applied in the line of the humerus. The arm
is then fully externally rotated and then adducted
across the chest. The arm is then internally rotated
until the hand is placed on the opposite shoulder.
This has been associated with proximal humerus
fractures in the elderly. (Neer and Rockwood,
1996)
POST REDUCTION CARE- It is paramount to examine and document neurovas-
cular status after reduction. A sling can be provided
for comfort and pendulum exercises should be taught
to the patient. Follow up evaluation should be in
10–14 days when spasm and pain have subsided.
Rehabilitation can then be employed to establish full
strength and range of motion. (Arciero, 1999) - Rotator cuff injury:In patients over 40 years, tears
of the rotator cuff can occur with an incidence of 15%
(Neviaser, Neviaser, and Neviaser, 1988). In patients
over 50, there is a 63% incidence of rotator cuff
pathology or proximal humerus fractures (Ribbans,
Mitchell, and Taylor, 1990). - Axillary nerve injury:This complication has been
reported to be between 1 and 7%. At 4 weeks postre-
duction if active abduction cannot be established an
electromyogram(EMG) may be necessary to diag-
nose and follow an axillary nerve injury. Full func-
tional and EMG recovery is typically documented 3 to
6 months after this complication (Arciero, 1999). - Proximal humerus fractures: Fractures of the
greater tuberosity have been observed in up to 40% of
patients over the age of 50. Displacement of 1 cm may
require surgical treatment. - Note:associated injuries involving the rotator cuff,
proximal humerus fractures, and axillary nerve
injuries increase with age at time of dislocation.
NATURAL HISTORY AND
NONOPERATIVE TREATMENT- Traumatic anterior:Recurrence rates after primary
dislocation - 65–95% in patients less than 20 years depending on
the author - 60% in patients 20–40 years old
- 10% in patients older than 40
- Both investigators demonstrated that immobilization
had little effect on outcome (Hovelius et al, 1996;
McLaughlin and MacLellan, 1967; Rowe, 1956).
There are new, recent data that arm position with
immobilization may play a role in nonoperative treat-
ment. Immobilization of the arm in 35°of external
rotation better approximates the labrum to the glenoid
than the traditional position of internal rotation (Itoi
et al, 2001). - Posterior:Posterior subluxation patients responded
better to nonoperative treatment than anterior sublux-
ation patients (Burkhead and Rockwood, Jr, 1992). - Multidirectional Instability (MDI):The natural his-
tory of MDI patients involves a much larger spectrum