Traumatic shoulder dislocation in the adolescent athlete: advances in surgical treatment Christopher R. Good and John D.

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1 Traumatic shoulder dislocation in the adolescent athlete: advances in surgical treatment Christopher R. Good and John D. MacGillivray Purpose of review The shoulder joint has the greatest range of motion of any joint in the body and as a result is particularly susceptible to dislocation and subluxation. Recurrent instability is a common complication after traumatic shoulder dislocation in young people, with rates as high as 100% in skeletally immature patients and 96% in for adolescents. Treatment for shoulder dislocation has traditionally involved immobilization followed by a rehabilitation program. Recent studies have reported decreased rates of recurrent instability and improved outcomes in patients treated with surgical stabilization of acute, traumatic shoulder dislocation. The purpose of this review is to review recent publications concerning the treatment of traumatic shoulder dislocations in adolescents. Recent findings Lawton et al. retrospectively reviewed 70 shoulders in 66 patients 16 years old or younger treated for shoulder instability with follow-up more than 2 years. Forty-two shoulders were successfully treated with physical therapy, whereas 28 eventually required surgery. Subsequently, Deitch et al. retrospectively identified 32 patients between 11 and 18 years of age with radiographically documented traumatic anterior shoulder dislocation. Instability recurred in 75% of patients and 50% eventually required surgical stabilization. Bottoni et al. reported results of a prospective randomized trial comparing arthroscopic stabilization to nonoperative treatment of acute, traumatic shoulder dislocations in patients aged 18 to 26 years. Recurrent instability developed in 75% of patients treated conservatively versus 11% in those treated with surgery. DeBerardino et al. prospectively evaluated arthroscopic stabilization of acute shoulder dislocations in 48 young athletes with an average follow-up of 37 months and reported a 12% rate of recurrent instability. All patients with stable shoulders were able to return to their previous levels of activity. Summary Conservative management of traumatic shoulder dislocations in young patients is associated with high rates of recurrent instability. Recent studies have demonstrated improved results and significant reduction in recurrent instability in patients treated with surgical stabilization when compared with nonoperative treatment. Keywords shoulder dislocation, adolescent athletes, surgical stabilization, arthroscopy Curr Opin Pediatr 17: Lippincott Williams & Wilkins. Sports Medicine/Shoulder Service, Hospital for Special Surgery, New York, New York, USA Correspondence to John D. MacGillivray, MD, Sports Medicine/Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA Tel: ; fax: ; macgillivrayj@hss.edu Current Opinion in Pediatrics 2005, 17: Lippincott Williams & Wilkins Introduction The glenohumeral joint is a ball and socket joint with three degrees of freedom of motion. Because of this great range of motion, the shoulder is susceptible to dislocation and subluxation in the setting of trauma and high demand sporting activities. Most studies involving shoulder dislocation in children have reported this injury to be very rare. Shoulder trauma in the skeletally immature child more commonly results in fracture through the proximal humeral physis rather than shoulder dislocation [5,6]. Adolescents, however, are much more commonly affected by instability after similar traumatic episodes. This recurrent instability and dislocation may lead to permanent articular damage and long-term shoulder joint degeneration. Historical treatment has consisted of immobilization followed by a period of rehabilitation; however, recent data suggest that surgical stabilization or acute shoulder dislocations may be more beneficial for some patients. Anatomy The shoulder consists of three bones and four joints. The glenohumeral joint is the ball and socket joint in which the humeral head articulates with the glenoid cavity. The glenoid cavity is a widening of the lateral scapula and is surrounded by a fibrocartilaginous ring called the labrum. This labrum acts to anchor the glenoid to the humeral head as well as to deepen the socket of the shoulder joint. The glenohumeral joint is stabilized by static restraints including the labrum, ligaments, and joint capsule, as well as by dynamic restraints including the rotator cuff muscles and scapular stabilizers. Shoulder dislocation Dislocation of the glenohumeral joint is a complete disassociation between the glenoid cavity and the humeral 25

26 Orthopedics head. The separation is commonly observed after a traumatic event and usually requires manipulation to reduce the humeral head back into the glenoid.

2 26 Orthopedics head. The separation is commonly observed after a traumatic event and usually requires manipulation to reduce the humeral head back into the glenoid. Subluxation, on the other hand, involves instability and translation across the glenohumeral joint without complete dislocation. Instability may involve the humeral head traveling in an anterior, posterior, or inferior direction in relation to the glenoid cavity. Instability may also occur in multiple directions within the same patient and has been associated with generalized joint laxity in young patients [7]. Shoulder dislocation may or may not occur in the setting of trauma. Traumatic dislocations occur with an acute onset and an appropriate mechanism of injury is present. Conversely, atraumatic dislocations may present with a questionable onset and may lack an appropriate mechanism of injury. Atraumatic dislocations are seen in patients with multidirectional instability and ligamentous laxity, and the presence of these factors should be recognized to maximize further treatment. Traumatic anterior dislocation Anterior dislocation represents more than 90% of traumatic dislocations. These injuries are commonly seen in adolescents participating in contact sports. The dislocation occurs after a high-energy injury, commonly involving a fall on the outstretched hand. This mechanism of injury abducts and externally rotates the shoulder, pushing the humeral head out the front of the glenoid cavity, with resultant injury to the anterior glenohumeral ligaments. The anteriorly dislocating humeral head and joint capsule may tear the labrum from the rim of the glenoid as it dislocates, and this common injury is termed a Bankart lesion (Fig. 1). After the dislocation, the posterior humeral head is snapped back against the anterior glenoid rim. This impaction may lead to a fracture on the Figure 1. Arthroscopic photograph of a Bankart lesion Arthroscopic photograph of a Bankart lesion demonstrating the separation of the glenoid labrum (right) from the rim of the glenoid cavity. posterior superior humeral head (called a Hill-Sachs lesion) and may be visible on plain radiographs. Traumatic posterior dislocation Traumatic posterior shoulder dislocation is an uncommon injury representing less than 5% of all traumatic shoulder dislocations [8,9]. Most cases of posterior dislocation in young patients are associated with multidirectional instability. Few statistics are available for children and adolescents, but some authors have estimated the incidence of posterior dislocations to be nearer to 10% in this group because of the increased ligamentous laxity associated with youth. Posterior dislocation may occur as the result of a fall on the outstretched hand with the shoulder in adduction and internal rotation, which may force the humeral head out the back of the glenoid cavity. Posterior dislocations may also result from a direct anterior blow to the shoulder, which pushes the humeral head posteriorly out of the glenoid. Finally, it is important to remember that posterior dislocations may occur as the result of an electrical shock or seizure. The mechanism of dislocation in these cases is sustained contraction of the internal rotator musculature, which may lever the humeral head out of the glenoid cavity posteriorly. Clinical evaluation Patients with traumatic shoulder dislocation often present with obvious deformity and pain with range of motion. The humeral head may be visible with an obvious deformity. The acromion may be prominent with a cavity inferiorly where the humeral head usually sits. Patients commonly present with the arm internally rotated and supported by their other hand. Initial evaluation should also include a careful neurovascular examination. Radial and ulnar pulses should be documented in addition to individual nerve testing. The axillary nerve is the most commonly injured structure and has been reported in 5 to 35% of traumatic anterior shoulder dislocations. Radiographic evaluation Plain radiographs are the best routine imaging studies for the evaluation of acute shoulder dislocation and should include three specific views: the anteroposterior view, axillary view, and scapular Y view. These views allow the location of the humeral head to be visualized in threedimensional space in relation to the glenoid cavity. Single anteroposterior views and oblique views are commonly obtained secondary to patient discomfort, but are not sufficient to determine the location and nature of dislocation and should never be accepted. These same three views should also be obtained to confirm shoulder reduction after manipulation. Postreduction views commonly reveal the posterolateral humeral head impaction fracture (or Hill-Sachs lesion) mentioned earlier. Although of little use in the emergency room, MRI scans have the ability to provide very specific details regarding soft tissue injuries after shoulder dislocation. MRI is the modality of choice for evaluating capsular and labral in-

3 Shoulder dislocation in teen athlete Good and MacGillivray 27 jures including the previously described Bankart lesion (Fig. 2). MRI also allows visualization of the ligaments and muscles responsible for shoulder stabilization and motion. The anatomic detail provided by an MRI scan provides much information in regard to surgical planning and rehabilitation. Initial management of shoulder dislocation After physical examination and standard radiography, closed reduction is the initial treatment for shoulder dislocation. A number of effective techniques have been described, and the reduction of an acute shoulder dislocation can commonly be accomplished without the use of anesthesia. Shoulders that have been dislocated for a number of hours or patients experiencing significant pain and muscle spasm may require anesthesia, including intraarticular injection and intravenous sedation. Once reduction is achieved, repeat neurologic examination and postreduction radiographs must be performed. After reduction, the shoulder is immobilized in a sling for protection. Nonoperative management after shoulder dislocation Patients with acute, traumatic shoulder dislocation have traditionally been treated with conservative means, including a brief period of immobilization followed by a rehabilitation program with a delayed return to full activities. The duration of immobilization and the type and length of rehabilitation after shoulder dislocation are Figure 2. Arthroscopic photograph of a Bankart lesionmri of the shoulder revealing the presence of a bony Bankart lesion (arrow) This bony avulsion fracture is created as the anteriorly dislocating humeral head and joint capsule tear the labrum from the rim of the glenoid. controversial. As has previously been stated, recurrent dislocation is the most common complication after traumatic shoulder dislocation. Rehabilitation after immobilization includes muscle strengthening including the rotator cuff, deltoid, and shoulder stabilizers. Historical studies Historically, a large number of studies examining shoulder instability have been conducted; however, details specific to children and adolescents have been sparse. In 1956, Rowe et al. [10,11] published a review of 500 shoulder dislocations. Of these patients, only eight patients were younger than 10 years old, whereas 99 were between the ages of 10 and 20. Rowe reported a recurrence rate of 100% in patients younger than 10 and a 94% recurrence rate in patients between 10 and 20 years of age. More recent studies have focused on the younger population in particular. In 1983, Wagner et al. [12] presented the first series with data specific to shoulder dislocation in children, taken from a large series of traumatic anterior shoulder dislocations. Nine cases of dislocation reportedly occurred in children with open physes (4.7% incidence); all of them were treated with immobilization and physical therapy. Among these nine patients, a recurrence rate of 80% was reported, with all recurrences requiring operative intervention. In 1992, Marans et al. [13] reviewed the outcomes of 21 patients with traumatic anterior shoulder dislocation treated with sling and swathe immobilization and reported a recurrence rate of 100%. Hovelius et al. [14,15] have also published 2, 5, and 10-year follow-up data for patients between 12 and 40 years of age after anterior shoulder dislocation. Seventy percent of patients from 12 to 16 years old had recurrent dislocations at the time of final follow-up (this includes patients treated with conservative therapy and those treated with surgery). Recent publications addressing incidence and recurrence Recent data have also supported the high rates of shoulder instability reported after traumatic shoulder dislocation in children and adolescents. Lawton et al. [2] retrospectively reviewed 70 shoulders in 66 patients 16 years old or younger with a history of shoulder instability. They associated trauma with the initial episode of instability in 86% of patients, with 50% of patients actually experiencing a dislocation with this primary event. Instability was associated with male sex, adolescence, and a history of trauma. Sixty-seven percent of patients were treated with therapy and 40% eventually underwent surgery. At more than 2-year follow-up, 70% described their shoulders as better and 90% were performing at preinjury levels at sports and work. Surgically treated patients were less likely to have recurrent stability or report limitations, and factor analysis found that older boys with traumatic onset, no history of voluntary instability, and who were

4 28 Orthopedics treated surgically did better than patients with other factors. Deitch et al. [5] recently reported on 32 patients from 8 to 11 years of age with radiographically documented anterior shoulder dislocation. Follow-up at an average of 4 years via telephone revealed that 23 (71%) experienced at least one episode of recurrence and 16 were treated with surgery for recurrent dislocation. Outcomes analysis performed with the data from these interviews found no significant differences in outcomes between patients treated nonoperatively compared with those who underwent surgical stabilization. Surgical treatment A number of surgical alternatives have been investigated for the treatment of acute traumatic shoulder dislocation in young patients [1,2 4,16,17,18]. Operative management may consist of formal open surgery, arthroscopic surgery, or arthroscopically assisted open surgery. Arthroscopic findings have documented the presence of hemarthrosis and Bankart repair after acute traumatic anterior shoulder dislocation. Repair of a Bankart lesion is of paramount importance when surgically addressing traumatic anterior shoulder instability. Formal open repair has been the gold standard for performing this repair and is commonly carried out via an incision lying in the axillary crease lateral to the coracoid process. Arthroscopic repair has previously been associated with higher rates of postoperative stability, but the use of newer techniques, sutures, and anchors has produced promising results. In addition, the presence of hemarthrosis in the setting of the healing response may provide a favorable setting in which to perform arthroscopic stabilization. Recent publications concerning surgery In 2000, Bottoni et al. [3] published a prospective randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic first-time shoulder dislocations. This study included 24 US active duty military personnel between 18 and 26 years of age. Patients were randomized to nonoperative management consisting of 4 weeks immobilization followed by physical therapy versus arthroscopic stabilization using a bioabsorbable tack. At average follow-up of 36 months, the recurrence rate in the nonoperative group was 75% versus 11% in the surgical group. The data supporting arthroscopic stabilization is also supported by the work of DeBerardino et al. in 2001 [4], who performed a prospective evaluation of arthroscopic stabilization for treatment of acute, initial shoulder dislocations in young athletes at the US military academy. Forty-nine patients were treated with arthroscopic stabilization using bioabsorbable tacks. Eighty-eight shoulders were found to remain stable after stabilization with all of these patients returning to their preinjury level of functioning at 5-year follow-up. Outcomes assessment performed at follow-up revealed significantly better results than patients treated nonoperatively. Additional support was recently published by Swung-Ho et al. [17 ], who published results evaluating arthroscopic Bankart repair with suture anchors and nonabsorbable sutures in 167 patients with a mean age of 25 years. All shoulder scores improved significantly after surgery, and the incidence of postoperative instability was only 4% at mean follow-up of 44 months. Conclusion Patients with acute, traumatic shoulder dislocation have traditionally been treated with conservative therapy including immobilization, therapy, and restricted activities. The most common complication of nonoperative therapy after traumatic shoulder dislocation is recurrent instability. This is a particular concern in the adolescent and pediatric population because the single greatest prognostic factor determining rate of recurrence is patient age at time of initial injury. Recent studies have shown rates of recurrence to be between 70 and 100% in the adolescent population, with a great number of patients eventually requiring surgery for unacceptable instability. The patients at greatest risk of recurrence are commonly males with a history of traumatic dislocations who are involved in high demand sporting activities. Recent studies have shown that in this patient population, acute, primary arthroscopic stabilization is an effective treatment that may decrease recurrence rates, rehabilitation time, and improve overall outcomes. It is currently our practice to offer acute stabilization to young athletes after acute traumatic shoulder dislocation. Further followup data are necessary to compare results of open stabilization to that performed arthroscopically and to better predict which patients will succeed with different surgical techniques. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: Of special interest Of outstanding interest 1 Deitch J, Mehlman CT, Foad SL, et al. Traumatic anterior shoulder dislocation in adolescents. Am J Sports Med 2003; 31: A retrospective cohort study documenting instability rates and functional outcome in adolescents after dislocation. 2 Lawton RL, Choudhury S, Mansat P, et al. Pediatric shoulder instability: presentation, findings, treatment, and outcomes. J Pediatr Orthop 2002; 22: Bottoni CR, Wilckens JH, DeBardino TM, et al. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations. Am J Sports Med 2000; 30: DeBerardino TM, Arciero RA, Taylor DC, et al. Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Am J Sports Med 2001; 29:

5 Shoulder dislocation in teen athlete Good and MacGillivray 29 5 Dameron TB, Reibel DB: Fractures involving the proximal humeral epiphyseal plate. J Bone Joint Surg 1969; 51: Gregg-Smith SJ, White SH: Salter-Harris III fracture-dislocation of the proximal humeral epiphysis. Injury 1992; 23: Mallon WJ, Speer KP: Multidirectional instability: current concepts. J Shoulder Elbow Surg 1995; 4: Boyd HB, Sisk TD: Recurrent posterior dislocation of the shoulder. J Bone Joint Surg 1972; 54A: Kawam M, Sinclair J, Letts M: Recurrent posterior shoulder dislocation in children: the results of surgical management. J Pediatr Orthop 1997; 17: Rowe C: Prognosis in dislocation of the shoulder. J Bone Joint Surg [Am] 1956; 38: Rowe C, Sakellarides H: Factors related to recurrences of anterior dislocations of the shoulder. Clin Orthop 1961; 20: Wagner KT, Lyne ED: Adolescent traumatic dislocations of the shoulder with open epiphyses. J Pediatr Orthop 1983; 3: Marans HJ, Angel KR, Schemitsch EH, Wedge JH: The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg 1992; 74A: Hovelius L: Gavle: anterior dislocation of the shoulder in teen-agers and young adults. J Bone Joint Surg 1987; 69A: Hovelius L: The natural history of primary anterior dislocation of the shoulder in the young. J Orthop Sci 1999; 4: Pagnani MJ, Dome DC: Surgical treatment of traumatic anterior shoulder instability in American football players. J Bone Joint Surg 2002; 84A: Seung-Ho K, Kwon-Ick H, Yang-Bum C, et al. Arthroscopic anterior stabilization of the shoulder. J Bone Joint Surg 85A: A report demonstrating satisfactory outcomes after arthroscopic stabilization with suture anchors. 18 Warner JJP, Warren RF: Arthroscopic Bankart repair using a cannulated, absorbable fixation device. Oper Tech Orthop 1991; 1:

SHOULDER INSTABILITY

SHOULDER INSTABILITY Your shoulder is the most flexible joint in your body, allowing you to throw fastballs, lift a heavy suitcase, scratch your back, and reach in almost any direction. Your shoulder joint