Posterior Instability & Posterior Dislocation

Author: Daniel Hatch

Topic updated on 04/18/13 10:02pm

Introduction

Posterior shoulder dislocations are less common than anterior dislocations, but more commonly missed
- 50% of traumatic posterior dislocations seen in the emergency department are undiagnosed
Epidemiology
- incidence
  - 2% to 5% of all unstable shoulders
- risk factors
  - bony abnormality
    - glenoid retroversion or hypoplasia is a less common cause of instability
  - ligamentous laxity
Pathophysiology
- mechanism
  - trauma
    - 50% of cases that present for evaluation
  - microtrauma
    - may lead to a labral tear, incomplete labral avulsion, or erosion of the posterior labrum
    - leads to gradual stretching of capsule
    - common in lineman, weight lifters, overhead athletes
  - seizures and electric shock
    - tetanic muscle contraction pulls the humeral head out
- biomechanical forces
  - flexed, adducted, and internally rotated arm is a high-risk position
Prognosis
- treatment outcomes
  - most dislocations reduce spontaneously

Anatomy

Glenohumeral anatomy
Primary stabilizers of the posterior shoulder
- posterior band of IGHL
  - primary restraint in internal rotation
- subscapularis
  - primary dynamic restraint in external rotation
- coracohumeral ligament
  - primary restraint to inferior translation of the adducted arm and to external rotation
  - primary stabilizer to posterior subluxation with shoulder in flexion, abduction, and internal rotation
Static restraint
- labrum deepens the glenoid

Classification

Acute versus chronic
Voluntary versus involuntary

Associated Lesions

Lesions associated with Posterior Instability
Avulsion of posterior band of IGHL	Associated with acute subluxations
Posterior Bankart lesions	Characterized by detachment of posterior inferior capsulolabral complex
Reverse Hill-Sachs lesions	Associated with nonreducible and difficult to reduce dislocations
Posterior labral cyst	Associated with chronic reverse Bankart lesion
Posterior glenoid rim fracture	Associated with chronic reverse Bankart lesion
Lesser tuberosity fracture	Associated with posterior dislocation
Large capsular pouch	Can see with MRI with contrast

Presentation

History
- trauma with the arm in a flexed, adducated, and internally rotated position
Symptoms
- pain with flexion, adduction, and internal rotation of the arm
Physical exam
- inspection
  - prominent posterior shoulder and coracoid
- motion
  - limited external rotation
  - shoulder locked in an internally rotated position common in undiagnosed posterior dislocations
- provocative tests
  - posterior load & shift test
    - place patient supine with arm in neutral rotation with 40 to 60° abduction and forward flexion, load humeral head and apply anterior and posterior translating forces noting subluxation
  - Jerk test
    - place arm in 90° abduction, internal rotation, elbow bent
    - apply an axial force along axis of humerus and adduct the arm to a forward-flexed position
    - a ‘clunk’ is positive for posterior subluxation
    - 97% sensitive for posterior labral tear when combined with a Kim test
  - posterior stress test
    - stabilize scapula and look for posterior translation with a posterior direct force
    - pain is elicited often, but this is not a specific finding

Posterior Load & Shift Grading
1+	apparent translation but not to rim
2+	translation to glenolabral rim
3+	translation over glenolabral rim
4+	translation with complete dislocation

Imaging

Radiographs
- recommended views
  - AP
    - unreliable
    - may show a 'lightbulb' sign
  - axillary lateral
    - best view to demonstrate a dislocation
- optional
  - Velpeau view if patient is unable to abduct arm for axillary view
CT
- indications
  - analyze the extent and location of bone loss in a chronic dislocation (>2 to 3 weeks)
MRI
- indications
  - evaluate for suspected associated rotator cuff tear

Treatment

Nonoperative
- acute reduction and immobilization in external rotation for 4 to 6 weeks
  - indications
    - should be initially attempted for all acute traumatic posterior dislocations
  - technique
    - immobilize in neutral rotation with elbow at side
    - after 6 weeks advance to physical therapy (rotator cuff strengthening and periscapular stabilization) and activity modification (avoid activities that place arm in high-risk position)
Operative
- open or arthroscopic posterior labral repair (Bankart) and capsular shift
  - indications
    - recurrent posterior shoulder instability
    - continued pain with loading of arm in forward flexed position (bench press, football blocking)
  - outcomes
    - 80% to 85% success at 5- to 7-year follow-up after open repair
    - similar outcomes with arthroscopic repair after shorter follow-ups
- open reduction with subscapularis and lesser tuberosity transfer to the defect (McLaughlin)
  - indications
    - chronic dislocation < 6 months old
    - reverse Hill-Sachs defect < 50%
- hemiarthroplasty
  - indications
    - chronic dislocation > 6 months old
    - severe humeral head arthritis
    - collapse of humeral head during reduction
    - reverse Hill-Sachs defect > 50% of articular surface
- total shoulder arthroplasty
  - indications
    - significant glenoid arthritis in addition to one of the hemiarthroplasty indications

Surgical Technqiues

Open or arthroscopic posterior labral repair (Bankart) and capsular shift
- goal is to repair any labral detachment or capsular tears, and/or reduce the posterior capsule volume
- approach
  - arthroscopic approach to shoulder
    - high lateral portal is better than standard portal for posterior labral work
    - lateral decubitus position allows for improved visualization for arthrosocpic stabilization
- posterior capsular shift
  - most common treatmen
  - up to 50% failure rate
- closure of rotator interval
  - augments posterior capsular shift
  - controversial
- thermal shrinkage of capsule
  - contraindicated due to complications
  - mechanism
    - breaks collagen cross links
    - critical temp (65 to 75° C)
- complications
  - recurrence
  - capsular necrosis
  - axillary nerve injury
- postoperative care
  - rigid immobilizer with arm abducted to 30 degrees in neutral internal rotation and elbow posterior to the plane of the body
  - early range of motion and strengthening
  - full heavy labor and contact sports after 6 month
Open reduction with subscapularis and lesser tuberosity transfer to defect (McLaughlin)
- approach
  - deltopectoral approach
- technique to repair defect
  - subscapularis and lesser tuberosity transfer
    - used by most (modified Mclauglin procedure)
  - iliac crest bone graft
    - can be used for any glenoid bone loss
  - disimpaction and bone grafting of the defect
    - if < 3 weeks the surgeon can try disimpaction and bone grafting of the defect
  - opening wedge glenoplasty
    - may be indicated with glenoid hypoplasia
- complications
  - stiffness
  - AVN
  - osteoarthritis

Complications

Recurrence (most common)
- 7% to 50%
Adhesive capsulitis (generalized stiffness)
Overtightening of posterior capsule
- may lead to anterior subluxation or coracoid impingement
Nerve injury
- axillary or suprascapular

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Qbank (9 Questions)

TAG

(OBQ11.164) Which of the following patients may benefit from a lesser tuberosity transfer (modified McLaughlin procedure)? Topic

Review Topic

1. A kidney transplant recipient with AVN of the humeral head
2. A patient with severe rheumatoid arthritis
3. A young man with a locked posterior dislocation following an electrocution injury at work
4. A patient with a history of previous shoulder surgery that now has subscapularis insufficiency
5. A patient with a large Hill-Sachs defect following an anterior shoulder dislocation

PREFERRED RESPONSE ▶

DISCUSSION: Forceful posterior glenohumeral dislocations such as those resulting from seizures or electrocution may sustain a large reverse Hill-Sachs defect resulting in persistent instability in internal rotation or a locked posterior dislocation. These patients may benefit from having the lesser tuberosity along with the subscapularis advanced into the bony defect on the anterior humeral head (modified McLaughlin procedure). The original description by McLaughlin involved transferring the subscapularis tendon into the defect, and was later modified and popularized by Neer who recommended transferring the lesser tuberosity with the subscapularis.

Finkelstein et al reported good functional results using this procedure acutely in 7 patients who were unstable in internal rotation and had an anteromedial impaction fracture occupying 25-40% of the articular surface.

Hawkins et al descibe various treaments for locked posterior dislocations. All 4 of their patients with a lesser tuberosity transfer did well and they suggest using it when closed reduction fails for smaller defects and for moderate defects with head involvement of 20-45%.

A CT scan showing a posterior dislocation with large reverse Hill-Sachs lesion in shown in Illustration A. The post-op CT scan after open reduction and lesser tuberosity transfer into the defect is seen in Illustration B.

Incorrect Responses:
None of the other patients meet the accepted indications for this stability procedure.
1. & 2. May benefit from other procedures such as a shoulder arthroplasty.
4. May benefit from subscapularis repair or pectoralis tendon transfer to restore function.
5. A Hill-Sachs defect is on the posterior superior aspect of the humeral head and may benefit from bone grafting or remplissage, but not a lesser tuberosity transfer.

Illustrations: A

REFERENCES:

1. Finkelstein JA, Waddell JP, O'Driscoll SW, Vincent G. Acute posterior fracture dislocations of the shoulder treated with the Neer modification of the McLaughlin procedure. J Orthop Trauma. 1995 Jun;9(3):190-3. 7623169. PMID:7623169 (Link to Abstract)

2. Hawkins RJ, Neer CS 2nd, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am. 1987 Jan;69(1):9-18. PMID:3805075 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Ben Taylor MD, Michael Hughes MD,

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TAG

(OBQ10.102) A 26-year-old football offensive lineman presents with shoulder pain which is affecting his ability to block effectively. On exam, he has a positive jerk test and a positive Kim test. What is his most likely diagnosis? Topic

Review Topic

1. SLAP tear
2. ALPSA lesion
3. Hill-Sachs lesion
4. Posterior labral tear
5. PASTA tear

PREFERRED RESPONSE ▶

DISCUSSION: The posterior jerk test is a sensitive exam for ascertaining the presence of posterior glenoid labral tears in the mid-range of the glenoid. The Kim test is more sensitive for posterior-inferior labral tears. This is performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45 forward flexion while simultaneously applying axial load on the elbow & posterior-inferior force on the upper humerus. The test is positive when pain is present. When the jerk test and Kim test are combined, there is 97% sensitivity in detecting a posterior labral tear.

Escobedo et al performed a retrospective study of 166 shoulder MRI arthrograms from patients who had presented with shoulder pain and/or instability. They selected out 20 competitive football players and 20 age-matched controls. 55% of the football players had at least one posterior labral tear, while only 10% of the matched non-football players had a posterior labral tear, which was statistically significant.

Acronyms are commonly used to describe injuries in sports medicine and may be tested with either the short or long name: SLAP=superior labrum anterior-posterior; ALPSA=anterior labral periosteal sleeve avulsion; PASTA=partial articular-sided supraspinatus tendon avulsion.

Illustration A demonstrates the Kim test.

Illustrations: A

REFERENCES:

1. Wright RW, Brophy RH, McCarty EC, Bishop JY. Acute shoulder injuries. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:3-17.

2. Escobedo EM, Richardson ML, Schulz YB, Hunter JC, Green JR 3rd, Messick KJ. Increased risk of posterior glenoid labrum tears in football players. AJR Am J Roentgenol. 2007 Jan;188(1):193-7. PMID:17179364 (Link to Abstract)

Question Authors:

Aaron Bott MD, Patrick McCulloch MD, Michael Hughes MD,

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Related Videos

Reverse Bankart

Sports - Educational Presentation - Posterior Instability & Posterior Dislocation

Arthroscopic treatment of reverse Bankart tear for posterior instability.

4/21/2013

23 views

TAG

(OBQ09.7) An acute posterior shoulder dislocation should be suspected in a patient with pain and the shoulder locked in what position? Topic

Review Topic

1. internal rotation
2. external rotation
3. forward elevation
4. abduction
5. retraction

PREFERRED RESPONSE ▶

DISCUSSION: Patients with posterior shoulder dislocations are often overlooked. They present with the shoulder locked in internal rotation and adduction and lack external rotation. Orthogonal radiographs (anterior-posterior and axillary lateral) are absolutely necessary for proper diagnosis. Posterior dislocation patients often have reverse Bankart and reverse Hill-Sachs lesions. Ivkovic et al reported a case of bilateral posterior dislocations successfully treated with hemiarthroplasty and osteochondral allograft.

REFERENCES:

2. Ivkovic A, Boric I, Cicak N: One-stage operation for locked bilateral posterior dislocation of the shoulder. J Bone Joint Surg Br 2007;89:825-828 PMID:17613513 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD,

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3.0

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TAG

(OBQ09.106) A football player subluxes his shoulder while blocking with his arm forward flexed and internally rotated. The “Jerk” test is positive. What is his most likely pathology? Topic

Review Topic

1. Bankart lesion
2. Kim lesion
3. Hill-Sachs lesion
4. Glenohumeral internal rotation deficit
5. Acromioclavicular separation

PREFERRED RESPONSE ▶

DISCUSSION: This football player likely suffered a posterior inferior labral tear, also known as a Kim lesion, or a Reverse Bankart lesion. The Jerk test is where a posterior force is applied along the axis of the humerus with the arm in forward flexion and internal rotation. This will cause the humeral head to subluxate posteriorly out of the glenoid socket. As the arm is brought into extension, a clunk will be felt as the humerus reduces into the glenoid cavity. A Hill-Sachs lesion is a bony humeral impaction lesion from an anterior dislocation, glenohumeral internal rotation deficit (GIRD) is found in thowers who have a tight posterior-inferior capsule and lack internal rotation, an acromioclavicular separation has pain over the AC joint and may have a positive piano key sign when the clavicle “pops” up with arm depression. The review by Millett describes the history, exam, and radiologic findings of posterior shoulder instability. The Kim paper describes the injury which bears his name.

REFERENCES:

1. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 53-77

2. Millett PJ, Clavert P, Hatch GF 3rd, Warner JJ. Recurrent posterior shoulder instability. J Am Acad Orthop Surg 2006;14:464-467 PMID:16885478 (Link to Abstract)

3. Kim SH, Ha KI, Yoo JC, Noh KC. Kim's lesion: an incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthroscopy. 2004 Sep;20(7):712-20. Review. PMID:15346113 (Link to Abstract)

Question Authors:

Charles Jobin MD, Patrick McCulloch MD,

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TAG

(OBQ08.117) Posterior gleno-humeral dislocations are as common as anterior dislocations in which of the following patient groups? Topic

Review Topic

1. Football players
2. Marfan's syndrome patients
3. Renal failure patients
4. Epilepsy patients
5. Women

PREFERRED RESPONSE ▶

DISCUSSION: Millett et al and Robinson et al provide review articles on posterior shoulder dislocations, which are rare clinical entities that occur during seizures and electrocution (due to tetantic muscle contraction) or as a result of high energy trauma. Robinson et al noted that poor prognostic factors associated with posterior shoulder dislocation include late diagnosis, large bony defect of humeral head, associated proximal humerus fracture, and need for arthroplasty. In Gerber's series, posterior dislocations were occurred with equal frequency to anterior in a cohort of epilepsy patients.

REFERENCES:

1. MILLETT PJ, CLAVERT P, HATCH GF III, ET AL: RECURRENT POSTERIOR SHOULDER INSTABILITY. J AM ACAD ORTHOP SURG 2006;14:464-476. PMID:16885478 (Link to Abstract)

2. ROBINSON CM, ADERINTO J: POSTERIOR SHOULDER DISLOCATIONS AND FRACTURE DISLOCATIONS. J BONE JOINT SURG AM 2005;87:639-650. PMID:15805222 (Link to Abstract)

3. Bühler M, Gerber C. Shoulder instability related to epileptic seizures. J Shoulder Elbow Surg. 2002 Jul-Aug;11(4):339-44. PMID:12195251 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Guillem Lomas MD,

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TAG

(OBQ08.161) A 35-year-old man awoke following a night of heavy drinking with severe right shoulder pain and inability to raise his arm above his head. A radiograph from the emergency room is provided in Figure A. He was treated with a sling for a diagnosis of rotator cuff tear. Six weeks later, he complains of continued pain and difficulty using the arm. Which of the following is the next best step in management? Topic

Review Topic

FIGURES: A

1. Physical therapy for range of motion followed by rotator cuff and deltoid strengthening exercises
2. Axillary radiograph of the shoulder
3. EMG to evaluate the suprascapular and axillary nerves
4. Arthroscopic rotator cuff repair
5. Open subacromial decompression and latissimus dorsi transfer for massive cuff tear

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph demonstrates overlap of the humeral head and glenoid suggesting shoulder dislocation. An Axillary radiograph is necessary to evaluate concentric reduction vs. dislocation of the shoulder. An example is provided in illustration A. Posterior shoulder dislocations can be easily be missed without the proper orthogonal views of the shoulder. Perron reviews the proper identification and emergency room care of posterior shoulder dislocation. Richardson found apical oblique(axillary) radiographs to be more sensitive than trans-scapular radiographs for identifying posterior shoulder dislocations.

Illustrations: A

REFERENCES:

1. Perron AD, Jones RL. Posterior shoulder dislocation: Avoiding a missed diagnosis. Am J Emerg Med 2000; 18: 189-191 PMID:10750929 (Link to Abstract)

2. Richardson JB, Ramsay A, Davidson JK, Kelly IG. Radiographs in shoulder trauma. J Bone Joint Surg Br 1988; 70: 457-460 PMID:3372570 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Eric Shirley MD,

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TAG

(OBQ08.270) A football linemen has posterior shoulder pain after making a block with his arm in forward flexion and internal rotation. What is the most likely diagnosis? Topic

Review Topic

1. Bankart lesion
2. Posterior labral tear
3. Superior labral tear
4. Scapular fracture
5. AC sprain

PREFERRED RESPONSE ▶

DISCUSSION: This is the most common shoulder position for posterior instability. Compared with anterior shoulder instability, posterior instability is relatively uncommon with an overall reported incidence rate between 2% and 12% of all cases of shoulder instability. The majority of patients will complain primarily of pain, with instability as a secondary concern. Symptoms are caused by an abnormal posterior translation of the humeral head relative to the glenoid surface. Symptoms may be reproduced by performing the posterior load and shift test. The examiner stands at the side of the patient while stabilizing the scapula, the affected arm is flexed forward to 90 degrees and internally rotated and then a posteriorly directed force is applied. This can also be done with the patient supine with the medial scapula stabilized by the edge of the table.

REFERENCES:

1. Bradley JP, Baker CL III, Kline AJ, et al: Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: A prospective study of 100 shoulders. Am J of Sports Med 2006;34:1061-1071. PMID:16567458 (Link to Abstract)

2. Wiliams RJ III, Strickland S, Cohen M, et al: Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209. PMID:12642253 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore,

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TAG

(OBQ06.15) A 63-year-old diabetic female complains of left shoulder pain and decreased range of motion 7 months after a fall onto her left side. On physical examination she has marked decrease in external rotation. A radiograph obtained earlier that day at her primary care office is displayed in Figure A. What is the next step in management? Topic

Review Topic

FIGURES: A

1. Physical therapy for adhesive capsulitis secondary to chronic 2-part humeral head fracture
2. Proximal humeral arthroplasty
3. Obtain further radiographic studies
4. Open reduction and internal fixation of the chronic 2-part humeral head fracture
5. Sling immobilization for 10-14 days then begin physical therapy for chronic 2-part humeral head fracture

PREFERRED RESPONSE ▶

DISCUSSION: Further radiographic studies are required including an axillary view. The humeral head resembles a "light bulb", indicating a possible posterior shoulder dislocation. Illustration A is an axillary view of this patient confirming chronic two-part fracture-dislocation of the anatomical neck of the humerus.

The Level 4 study by Hawkins and Neer describe their experiences with 41 locked posterior dislocations of the shoulder with 50% having an associated fracture. Twenty of the dislocations were missed diagnoses by treating physicians and the average time from injury to diagnosis was 1 year. Hawkins and Neer conclude treatment is determined by the duration of time the shoulder has been dislocated and the size of the humeral head defect, (reverse Hill-Sachs lesion).If the dislocation is less than 6 weeks old AND the defect involves less than 20% of the articular surface, then closed reduction should be attempted. If the dislocation is 6 weeks to 6 months old AND the defect involves 20 to 45% of the articular surface, transfer of the lesser tuberosity (McLaughlin procedure) should be done. If the glenoid is normal and the dislocation is more than 6 months old OR the defect involves more than 45% of the articular surface, or both, a hemiarthroplasty should be done. A hemiarthroplasty is indicated as treatment in this patient's case after obtaining full radiographs. It should be noted that adhesive capsulitis (option 1) does cause pain and loss of range of motion, especially with external rotation.

Illustrations: A

REFERENCES:

1. Hawkins RJ, Neer CS 2nd, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am. 1987 Jan;69(1):9-18. PMID:3805075 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD,

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TAG

(OBQ06.156) A 25-year old female with a seizure disorder complains of persistent left shoulder pain after sustaining a seizure 1 week ago. She was placed in a sling in the ER and is following up in your office. Figure A shows the xray taken in the ER. On examination, her range of motion is limited and is only able to externally rotate to neutral. What is the next test to order? Topic

Review Topic

FIGURES: A

1. CT scan of the shoulder
2. Repeat True AP radiograph
3. Axillary lateral radiograph
4. MRI of the shoulder
5. EMG with nerve conduction study

PREFERRED RESPONSE ▶

DISCUSSION: This question tests the concept that posterior shoulder dislocation is frequently missed due to inadequate imaging. Trauma shoulder radiographs (which include an AP, axillary, and scapular Y view) must be obtained in all suspected shoulder dislocations. Posterior dislocations are more common following a seizure. The posteriorly dislocated shoulder is typically held in IR and most consistent finding is a mechanical block to ER caused by the anterior humeral head defect on the posterior aspect of the glenoid. According to the reference by Robinson et al, good functional outcomes are associated with early detection and treatment of isolated posterior dislocations that are associated with a small osseous defect and are stable following closed reduction.

REFERENCES:

1. Robinson CM, Aderinto J: Posterior shoulder dislocations and fracture-dislocations. J Bone Joint Surg Am 2005;87:639-650. PMID:15741636 (Link to Abstract)

2. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 71-81.

Question Authors:

Patrick McCulloch MD, Eric Shirley MD,

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Cases

http://upload.orthobullets.com/cases/1114/img_1326.jpg

http://upload.orthobullets.com/cases/1114/img_1327.jpg

Chronic posterior shoulder dislocation (C1114)

Sports - - Posterior Instability & Posterior Dislocation

HPI - 65 yo M alcoholic complains of multiple shoulder dislocations. Most recent disl...

Treatment for this chronic posterior shoulder dislocation?

12/18/2011

59 responses

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Videos

	Reverse Bankart Sports - Educational Presentation - Posterior Instability & Posterior Dislocation Arthroscopic treatment of reverse Bankart tear for posterior instability.	4/21/2013 23 views 5
	Arthroscopic Posterior Shoulder Stabilization - Dr. Peter Millett Sports - Surgical Approaches - Posterior Instability & Posterior Dislocation Video demonstrating arthroscopic posterior shoulder stabilization	4/15/2013 40 views 5
	Treatment of Posterior Shoulder Instability - Dr. Don Buford Sports - Surgical Techniques - Posterior Instability & Posterior Dislocation video of Dr. Don Buford's surgical technique for posterior shoulder instability...	4/15/2013 30 views 0

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Groups

ABOS II: Posterior Instability & Posterior Dislocation

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7/29/2011

0 responses

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Finkelstein JA, Waddell JP, O'Driscoll SW, Vincent G. Acute posterior fracture dislocations of the shoulder treated with the Neer modification of the McLaughlin procedure. J Orthop Trauma. 1995 Jun;9(3):190-3. 7623169. PMID:7623169 (Link to Abstract)
Hawkins RJ, Neer CS 2nd, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am. 1987 Jan;69(1):9-18. PMID:3805075 (Link to Abstract)
Escobedo EM, Richardson ML, Schulz YB, Hunter JC, Green JR 3rd, Messick KJ. Increased risk of posterior glenoid labrum tears in football players. AJR Am J Roentgenol. 2007 Jan;188(1):193-7. PMID:17179364 (Link to Abstract)
Millett PJ, Clavert P, Hatch GF 3rd, Warner JJ. Recurrent posterior shoulder instability. J Am Acad Orthop Surg 2006;14:464-467 PMID:16885478 (Link to Abstract)
Kim SH, Ha KI, Yoo JC, Noh KC. Kim's lesion: an incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthroscopy. 2004 Sep;20(7):712-20. Review. PMID:15346113 (Link to Abstract)
Hawkins RJ, Neer CS 2nd, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am. 1987 Jan;69(1):9-18. PMID:3805075 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Wright RW, Brophy RH, McCarty EC, Bishop JY. Acute shoulder injuries. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:3-17.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 53-77

Undefined

Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008
Ivkovic A, Boric I, Cicak N: One-stage operation for locked bilateral posterior dislocation of the shoulder. J Bone Joint Surg Br 2007;89:825-828 PMID:17613513 (Link to Abstract)
Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008
MILLETT PJ, CLAVERT P, HATCH GF III, ET AL: RECURRENT POSTERIOR SHOULDER INSTABILITY. J AM ACAD ORTHOP SURG 2006;14:464-476. PMID:16885478 (Link to Abstract)
ROBINSON CM, ADERINTO J: POSTERIOR SHOULDER DISLOCATIONS AND FRACTURE DISLOCATIONS. J BONE JOINT SURG AM 2005;87:639-650. PMID:15805222 (Link to Abstract)
Bühler M, Gerber C. Shoulder instability related to epileptic seizures. J Shoulder Elbow Surg. 2002 Jul-Aug;11(4):339-44. PMID:12195251 (Link to Abstract)
Perron AD, Jones RL. Posterior shoulder dislocation: Avoiding a missed diagnosis. Am J Emerg Med 2000; 18: 189-191 PMID:10750929 (Link to Abstract)
Richardson JB, Ramsay A, Davidson JK, Kelly IG. Radiographs in shoulder trauma. J Bone Joint Surg Br 1988; 70: 457-460 PMID:3372570 (Link to Abstract)
Bradley JP, Baker CL III, Kline AJ, et al: Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: A prospective study of 100 shoulders. Am J of Sports Med 2006;34:1061-1071. PMID:16567458 (Link to Abstract)
Wiliams RJ III, Strickland S, Cohen M, et al: Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209. PMID:12642253 (Link to Abstract)
Robinson CM, Aderinto J: Posterior shoulder dislocations and fracture-dislocations. J Bone Joint Surg Am 2005;87:639-650. PMID:15741636 (Link to Abstract)
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 71-81.

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Posterior Instability & Posterior Dislocation

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