Shoulder Dislocation Surgery Clinical Presentation

Updated: Nov 15, 2021
  • Author: Brett D Owens, MD; Chief Editor: Mohit N Gilotra, MD, MS, FAAOS, FAOA  more...
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Presentation

History and Physical Examination

The first step in the physical examination is to inspect the shoulder and compare it with the contralateral shoulder, primarily looking at skin, scars, symmetry, swelling, atrophy, and hypertrophy. The next step is to palpate the shoulder and the surrounding muscles and bony prominences. This is followed by range of motion (ROM) evaluation, neurovascular assessment, and provocative tests, depending on the physician’s suspicion of injury and limited by the patient’s pain. Provocative tests help in grading the degree of humeral head translation on a scale from 1+ to 3+, as well as confirming the presence of instability. [13]

Anterior instability tests include the following:

  • Anterior load and shift
  • Apprehension
  • Relocation
  • Anterior release
  • Anterior drawer

Posterior instability tests include the following:

  • Posterior load and shift
  • Jerk test
  • Kim test
  • Posterior drawer
  • Posterior stress test

Multidirectional instability can be diagnosed with a combination of these tests, along with a positive sulcus sign.

Patients with anterior dislocations usually present with the arm in slight abduction and externally rotated. The humeral head can often be palpated in the front of the shoulder. Internal rotation and adduction are limited. Movement is usually very painful as a result of muscle spasms.

Patients with posterior dislocations present with the arm internally rotated and adducted. External rotation is severely limited. A posterior prominence is usually palpable, the anterior shoulder is flattened, and the coracoid process is more prominent. Historically, these dislocations have been missed or misdiagnosed as a frozen shoulder.

Inferior dislocations lead to a condition known as luxatio erecta, which describes a classic presentation of the arm abducted 110-160° with the forearm resting on or behind the patient's head. [14, 15]

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Complications

Associated injuries to assess for during the physical exam include rotator cuff tears and axillary nerve injuries.

The frequency of rotator cuff tears for anterior dislocations across all age groups is between 7% and 32% and increases with advancing age. [16] Approximately 30% of patients older than 40 years who present with an anterior dislocation have an associated cuff tear. About 80% of patients older than 60 years present with a cuff tear.

Nerve injuries are a recognized complication of shoulder dislocations, with axillary nerve injuries being the most prevalent. Reported rates for isolated axillary nerve injuries are between 3.3% and 40%; the risk is increased in older patients. [17]

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