MSK X-Ray Series:
- Anterior Shoulder Dislocations

Today we discuss the basic steps to consider with your patients following anterior shoulder dislocation.

Hi Reader,

Welcome back to the MSK X-Ray Interpretation series. Below we're discussing why simple knowledge and correct assessment alongside robust management of an anterior shoulder dislocation will not only put your patients' at ease but continue to keep you a step above the rest in terms of clinical proficiency.

The anterior shoulder dislocation accounts for 4-6% of all fractures and is one of the most common fracture patterns seen in the over 65 populations group. This fracture can arise from low trauma especially in the osteoporotic patient (fall from low height) or high energy trauma (road traffic accident).

Now for the purpose of this newsletter, we’re only talking about anterior shoulder dislocations with associated humeral head fractures. This won’t include complex proximal humeral fractures as they carry other potential neurological deficit risk factors. However, as a main takeaway from this newsletter I would encourage you all to revise basic neurological anatomy of the upper limb as a fresher.

Before we discuss anything else lets look at the normal anatomical make up of the shoulder girdle.

Always remember when reviewing your patient's X-ray you're looking at a 2D image of a 3D structure, but following anterior shoulder dislocation, patients are also at significant risk of a brachial plexus injury. So as a reminder let’s think about these few questions first:

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📍 THREE COMMON QUESTIONS TO ALWAYS ASK

• Has the patient’s shoulder been relocated?
• Was there an associated fracture alongside the dislocation?
• Do I now suspect any form of soft tissue or neural injury (rotator cuff tear, axillary nerve disruption or brachial plexus injury)?

Until proven otherwise, how can you be sure they haven’t experienced any of the above? These are three of the most common questions I continue to ask my colleagues with every patient we see following a shoulder dislocation, or history of dislocation.

X-ray imaging should include a complete trauma series of the shoulder an AP, Scapula Y-view and Axillary view, this will cover all three views of the shoulder, but other views are at the consultant's discretion.

A fracture of the humeral head or greater tuberosity with associated Hills Sack lesion is common to see in this particular patient group.

If the suspected fracture has now been ruled out lets focus our attention on ascertaining any neurological deficit in the arm? It is common to find some patients are also at significant risk of a brachial plexus injury following anterior dislocation.

If the sensation is reduced throughout the arm, in what particular area and what would this indicate? Does this mean they have a large peripheral nerve injury or is there a small local loss of sensation at a particular area in the arm. If the axillary nerve has been injured then you may find reduced sensation over the regimented badge area.

Finally, if you've cleared the arm of all of the above its time to assess the integrity of the rotator cuff, reduced forward flexion and abduction with a large shoulder hitch, painful and weak, and it's more than likely there's a large rotator cuff tear. You could consider discussing this with a colleague for a second opinion or if able, immediately referring on for USS or undertaking a point of care ultrasound scan (POCUS) if readily available.

As I like to do, I'll leave you with some thoughtful questions, now you've gathered all of this information about your patient:

• What exactly are your rehabilitation goals, what are theirs and do they align together?
• Have we considered their vocation and putting plans in place to support their eventual return to work?
• How would you rehab this patient 6-weeks after their initial accident if they were conservatively managed?

Next Week! Why compound Tibia and Fibula fractures will have your life on the line!

Lastly, Come on England, we're in to the last 16! Can we finally do it this time - I fricking hope so!
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Warren Caffrey | WLC Physio