Updated: 11/29/2021

Posterior Shoulder Instability & Dislocation

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  • Summary
    • Posterior shoulder instability and dislocations are less common than anterior shoulder instability and dislocations, but are much more commonly missed.
    • Diagnosis is made radiographically in the setting of acute dislocations. Chronic instability can be diagnosed with presence of positive posterior instability provocative tests and confirmed with MRI studies showing posterior labral pathology.
    • Treatment may be nonoperative or operative depending on chronicity of symptoms, recurrence of instability, and the severity of labrum and/or glenoid defects.
  • Epidemiology
    • Incidence
      • 2% to 5% of all unstable shoulders
      • 50% of traumatic posterior dislocations seen in the emergency department are undiagnosed
    • Risk factors
      • bony abnormality
        • glenoid retroversion or hypoplasia is a less common cause of instability
      • ligamentous laxity
  • Etiology
    • Pathophysiology
      • mechanism
        • trauma (posterior dislocation)
          • 50% of cases that present for evaluation
          • usually dramatic presentation
        • microtrauma (posterior instability)
          • may lead to a labral tear, incomplete labral avulsion, or erosion of the posterior labrum
          • may lead to gradual stretching of capsule and patulous posterior capsule
          • common in lineman, weight lifters, overhead athletes
          • usually insidious onset and presentation
        • seizures and electric shock
          • tetanic muscle contraction pulls the humeral head out
          • anterior instability and dislocations are still more common with seizures
          • however, posterior dislocations are unlikely to occur without significant trauma (ie. seizures)
      • biomechanical forces
        • flexed, adducted, and internally rotated arm is a high-risk position
    • Associated conditions
      • see table below
        • 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 locked 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 acute posterior dislocation
        • Large capsular pouch
        • Can see with MRI with contrast, often with chronic posterior instabiltiy
  • 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
        • primary dynamic restraint against posterior subluxation
      • superior glenohumeral ligament and coracohumeral ligament
        • primary restraint to inferior translation of the adducted arm and to external rotation
        • primary static stabilizer to posterior subluxation with shoulder in flexion, adduction, and internal rotation
    • Static restraint
      • labrum deepens the glenoid by 50%
  • Classification
    • Acute versus chronic
      • Acute = trauma, seizure, electric shock with dramatic presentation
      • Chronic = microtrauma from repetition such as offense football lineman with insidious onset and presentation
    • Voluntary versus involuntary
  • Presentation
    • History
      • trauma or microtrauma with the arm in a flexed, adducted, and internally rotated position
      • chronic instability often presents with insidious onset, and vague symptoms (usually pain and not instability as opposed to anterior instability)
        • often in sporting or occupational activities that require repetitive pushing with the arm in forward flexed position foot ball lineman, weight lifters, etc
    • Symptoms
      • pain with flexion, adduction, and internal rotation of the arm
    • Physical exam
      • inspection
        • prominent posterior shoulder and coracoid for acute posterior dislocation
        • may be normal from chronic posterior instability from microtrauma
      • motion
        • limited external rotation for acute posterior dislocation
        • shoulder locked in an internally rotated position common in undiagnosed posterior dislocations
        • pain on flexion, adduction and internal rotation for posterior instability
      • provocative tests - performed in the setting of chronic posterior instability
        • 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
        • Kim test
          • 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.
          • test is positive when pain is present
        • 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 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
            • 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
        • chronic posterior instability without history of acute posterior dislocation
        • evaluate for suspected posterior labral tear, reverse Hill-Sach's lesion, or associated rotator cuff tear
        • may show Kim lesion (concealed avulsion of the deep posteroinferior labrum, with apparently intact superficial labrum)
  • 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
        • most dislocations reduce spontaneously
        • technique
          • immobilize in 10-20 degrees of external 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)
      • physical therapy
        • may be a first line treatment for chronic posterior instability with rotator cuff strengthening, periscapular stabilizers may be considered for the in-season athlete
    • Operative
      • open or arthroscopic posterior labral repair (Bankart)
        • indications
          • recurrent posterior shoulder instability despite appropriate course of physical therapy
          • continued pain with loading of arm in forward flexed position (bench press, football blocking)
          • negative Beighton score
        • outcomes
          • 80% to 85% success at 5- to 7-year follow-up after open repair
          • similar outcomes with arthroscopic repair after shorter follow-ups
          • avoidance of excessive shoulder flexion, adduction, and internal rotation in the immediate post-operative period  
      • open or arthroscopic posterior capsular shift and rotator interval closure
        • indications
          • positive Beighton score
      • posterior glenoid opening wedge osteotomy
        • indications
          • excessive congenital glenoid retroversion
          • limited studies assessing outcomes with this approach
      • open reduction with subscapularis transfer (McLaughlin) or lesser tuberosity transfer to the defect (Modified McLaughlin)
        • indications
          • chronic dislocation < 6 months old
          • reverse Hill-Sachs defect < 40%
      • hemiarthroplasty
        • indications
          • chronic dislocation > 6 months old
          • severe humeral head arthritis
          • collapse of humeral head during reduction
          • reverse Hill-Sachs defect > 40% of articular surface
      • total shoulder arthroplasty
        • indications
          • significant glenoid arthritis in addition to one of the hemiarthroplasty indications
  • Techniques
    • Open or arthroscopic posterior labral repair 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 may be better than standard portal for posterior labral work (ie drilling trajectory for suture anchors)
          • lateral decubitus position may allow for improved visualization for arthroscopic stabilization
      • posterior capsular shift
        • may be performed in addition to labral repair, capsular shift may be less desirable in throwing athletes
      • closure of rotator interval
        • augments posterior capsular shift
        • controversial
      • thermal shrinkage of capsule (historical)
        • contraindicated due to complications
        • mechanism
          • breaks collagen cross links
          • critical temp (65 to 75° C)
      • complications
        • recurrence
        • capsular necrosis
        • axillary nerve injury
      • postoperative care
        • immobilizer with arm in neutral position (external rotation sling) or standard sling
        • early range of motion and strengthening
        • full heavy labor and contact sports after 6 month
    • Open reduction with subscapularis with or without tuberosity transfer to defect
      • approach
        • deltopectoral approach
      • technique to repair defect
        • subscapularis transfer (McLaughlin procedure)
        • subscapularis with 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 congenital glenoid retroversion
      • complications
        • stiffness
        • AVN
        • osteoarthritis
  • Complications
    • Stiffness
      • most common complication after labral repair
    • Recurrence
      • 2nd most common (7% to 50%)
    • Degenerative joint disease
      • 3rd most common
    • Adhesive capsulitis
    • Overtightening of posterior capsule
      • may lead to anterior subluxation or coracoid impingement
    • Nerve injury
      • axillary or suprascapular
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Questions (34)
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(OBQ19.68) A 23-year-old football player presents with acute shoulder pain after a recent football game. Imaging studies are obtained and depicted in Figures A-C. Which of the following is the likely physical examination finding observed in this patient?

QID: 213970
FIGURES:

The arm falls into internal rotation when asked to hold his right arm in 90 degrees of abduction and external rotation

1%

(16/1189)

Pain is elicited in the bicipital groove when he attempts to forward elevate his shoulder with forearm extended and in supination

5%

(58/1189)

While upright, there is pain and occasional clunk when an axial load to the humerus is applied with his shoulder flexed and internally rotated to 90 degrees

76%

(901/1189)

While supine, he experiences a sense of instability when his arm is abducted at 90 degrees and fully externally rotated

14%

(162/1189)

There is tenderness in the shoulder joint while the forearm is pronated against resistance, but not when the forearm is supinated

3%

(33/1189)

L 2 E

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(SBQ16SM.11) A 19-year-old collegiate pitcher presents to your clinic with a right shoulder injury he sustained 6 weeks prior while sliding into a base. He endorses pain and weakness of the right shoulder, especially while bench pressing. Physical examination reveals a positive Kim's test, a negative O'Brien's test, and normal rotator cuff strength. Radiographs are unremarkable. MRI confirms the suspected injury without any evidence of bony abnormalities. The patient would like to proceed with surgical treatment. What is the most likely complication after the appropriate surgical treatment for this patient?

QID: 211227

Posterior instability

12%

(232/1933)

Anterior instability

3%

(54/1933)

Suprascapular neuropraxia

6%

(122/1933)

Decreased internal rotation

76%

(1471/1933)

Glenohumeral joint arthritis.

2%

(39/1933)

L 4 B

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(SBQ16SM.9) An 18-year-old football linebacker reports persistent left shoulder pain for the past 3 months. He complains of a feeling of instability and an inability to perform a bench-press or push-up. He has a positive posterior jerk and Kim test. Radiographs show no fracture and the shoulder is shown to be well-located on the axillary view. Which of the following acts as the primary restraint to posterior displacement of the shoulder in the position of flexion and internal rotation?

QID: 211205
FIGURES:

Anterior band of the inferior glenohumeral ligament

12%

(230/1980)

Middle glenohumeral ligament

7%

(131/1980)

Anterior labrum

0%

(7/1980)

Posterior band of the inferior glenohumeral ligament

75%

(1487/1980)

Superior labrum

6%

(110/1980)

N/A B

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(SBQ16SM.10) A 17-year-old offensive lineman presents with acute on chronic right shoulder pain. His season is nearly complete but the pain began months prior as he increased his pre-season weightlifting regimen, emphasizing the bench press and similar lifts. Pain has persisted since then and now bothers him constantly, and is exacerbated when blocking oncoming defenders. On exam, his right shoulder pain is easily reproduced and now with a palpable clunk. What finding would you expect to see on his MRI and what is the best surgical procedure to address this?

QID: 211216

Antero-inferior labral tear; arthroscopic labral repair

4%

(72/1923)

Posterior labral tear; arthroscopic labral repair

81%

(1563/1923)

Posterior labral tear; arthroscopic thermal capsulorraphy

2%

(44/1923)

Superior labral tear from 12 o'clock to 2 o'clock; arthroscopic labral debridement versus repair

9%

(182/1923)

Superior labral tear from 12 o'clock to 2 o'clock; arthroscopic biceps tenodesis

3%

(50/1923)

L 2 A

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(OBQ12.267) A 27-year-old right hand dominant construction worker falls off a scaffold onto his outstretched arm. Figure A exhibits the radiograph taken at a local emergency room. Following treatment, he is placed in a sling and follows up at your office two weeks later. He complains of a feeling that his arm is going to 'pop out'. Which specific physical examination finding is likely to be present?

QID: 4627
FIGURES:

Hornblower's Test

2%

(69/3939)

Jobe's Test

2%

(70/3939)

Apprehension Sign with shoulder abducted and externally rotated

35%

(1391/3939)

Speed's Test

1%

(24/3939)

Kim's Test

57%

(2264/3939)

L 4 B

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

QID: 3587

A kidney transplant recipient with AVN of the humeral head

0%

(17/4848)

A patient with severe rheumatoid arthritis

0%

(22/4848)

A young man with a locked posterior dislocation following an electric shock injury at work

58%

(2821/4848)

A patient with a history of previous shoulder surgery that now has subscapularis insufficiency

25%

(1231/4848)

A patient with a large Hill-Sachs defect following an anterior shoulder dislocation

15%

(716/4848)

L 4 B

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(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?

QID: 3196

SLAP tear

6%

(260/4484)

ALPSA lesion

2%

(99/4484)

Hill-Sachs lesion

2%

(74/4484)

Posterior labral tear

88%

(3961/4484)

PASTA tear

1%

(60/4484)

L 1 C

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

QID: 2820

Internal rotation

88%

(2033/2313)

External rotation

8%

(192/2313)

Forward elevation

1%

(30/2313)

Abduction

1%

(24/2313)

Retraction

1%

(17/2313)

L 1 C

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

QID: 2919

Bankart lesion

11%

(289/2534)

Kim lesion

80%

(2024/2534)

Hill-Sachs lesion

4%

(104/2534)

Glenohumeral internal rotation deficit

3%

(72/2534)

Acromioclavicular separation

1%

(24/2534)

L 2 C

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(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?

QID: 656

Bankart lesion

2%

(31/1439)

Posterior labral tear

89%

(1281/1439)

Superior labral tear

4%

(57/1439)

Humeral avulsion of the glenohumeral ligament (HAGL)

4%

(55/1439)

Acromioclavicular separatation

1%

(8/1439)

L 1 C

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(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?

QID: 547
FIGURES:

Physical therapy for range of motion followed by rotator cuff and deltoid strengthening exercises

8%

(125/1585)

Axillary radiograph of the shoulder

77%

(1227/1585)

EMG to evaluate the suprascapular and axillary nerves

12%

(189/1585)

Arthroscopic rotator cuff repair

2%

(27/1585)

Open subacromial decompression and latissimus dorsi transfer for massive cuff tear

0%

(6/1585)

L 2 C

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(OBQ08.117) Posterior glenohumeral dislocations are as common as anterior dislocations in which of the following patient groups?

QID: 503

Football players

5%

(88/1641)

Marfan's syndrome patients

11%

(175/1641)

Renal failure patients

0%

(6/1641)

Epilepsy patients

83%

(1362/1641)

Women

0%

(5/1641)

L 2 C

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(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?

QID: 26
FIGURES:

Physical therapy for adhesive capsulitis secondary to chronic 2-part humeral head fracture

19%

(524/2827)

Proximal humeral arthroplasty

1%

(32/2827)

Obtain further radiographic studies

78%

(2195/2827)

Open reduction and internal fixation of the chronic 2-part humeral head fracture

1%

(25/2827)

Sling immobilization for 10-14 days then begin physical therapy for chronic 2-part humeral head fracture

1%

(36/2827)

L 2 C

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(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 radiograph 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 step in management?

QID: 342
FIGURES:

Sling use for comfort and follow-up in 2 weeks

2%

(21/1211)

Repeat True AP radiograph

2%

(19/1211)

Axillary lateral radiograph

91%

(1099/1211)

MRI of the shoulder

5%

(61/1211)

Intra-articular cortisone injection with range of motion exercises

0%

(6/1211)

L 1 C

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