Imaging Studies

Radiography

Conventional radiography should be performed in all patients with suspected shoulder dislocations to confirm the diagnosis and also to exclude associated fractures prior to any attempted reduction.^[18]Routine radiographs should include at least an anteroposterior (AP) view and an axillary view.^[19]

The AP view can be obtained in neutral, internal, or external rotation. In internal rotation, one can easily see a Hill-Sachs lesion of the posterolateral humeral head.

The axillary view nicely shows glenohumeral subluxation or dislocation, as well as anterior or posterior glenoid rim fractures.^[20]A standard axillary view may be difficult in the acute injury setting because it requires 90° of abduction. However, many modifications exist to avoid excessive movement of the painful extremity. For example, the transverse axillary lateral requires the patient to abduct the arm only 10-30°.

Other views that may be useful include the scapular Y view, which is helpful for diagnosing dislocations and scapular fractures. This view, however, should not replace the axillary view, because it does not show subtle subluxations of the glenohumeral joint or fractures of the glenoid rim.

The true AP or Grashey view is helpful in assessing subtle joint incongruity, superior or inferior subluxation, degenerative changes, or glenoid hypoplasia.

The Garth or West Point view is useful in detecting bony Bankart fractures of the anteroinferior glenoid rim as well as Hill-Sachs defects. This view is advantageous in the acute setting because it does not necessitate the patient moving the arm.

The Stryker notch view can also be useful in detecting Hill-Sachs lesions. However, this view is of limited usefulness in detecting subluxations or glenoid fractures.

CT arthrography, MRI, and MR arthrography

Computed tomography (CT) arthrography, magnetic resonance imaging (MRI), or magnetic resonance arthrography may be helpful in assessing some shoulder dislocations.^[21]

CT arthrography was commonly used in the past to evaluate patients with glenohumeral instability either after the initial dislocation or with recurrent instability. Currently, it is used only if MRI is contraindicated or if glenoid version abnormalities are suspected. Multidetector CT (MDCT) with three-dimensional (3D) volume rendering can be helpful in further characterization of osseous abnormalities.^[22]

MRI and magnetic resonance (MR) arthrography have been shown to be more sensitive than other methods in detecting labral and ligamentous pathology, rotator cuff and cartilage tears, capsular abnormalities, and biceps injuries. MR arthrography is more sensitive than MRI alone and is the study of choice after a shoulder dislocation, particularly in cases of recurrent instability. In addition, it is superior to MRI for diagnosing the pathologic lesions mentioned above.

Treatment & Management

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Media Gallery

The rotator cuff interval is closed with a nonabsorbable suture. The T-capsulotomy incision is planned with dotted lines.
Superomedial (SM) and inferomedial (IM) flaps created by T-capsulotomy incision. First, the IM flap will be advanced superiorly and laterally, and then the SM flap will be advanced inferiorly over the top of the IM flap.
The finished repair with the superomedial (SM) flap advanced inferiorly, overlapping the previous inferomedial (IM) flap advancement. Note how the axillary pouch has been eliminated.

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Author

Brett D Owens, MD Director, Sports Medicine Research Lab, Director, Sports Medicine, Department of Orthopedics, The Miriam Hospital, The Warren Alpert Medical School of Brown University; Partner, Director, Cartilage Research Lab, University Orthopedics, Inc; Professor, Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University; Professor, Department of Epidemiology, Brown University School of Public Health; Professor, Department of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

Brett D Owens, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, Herodicus Society, Magellan Society - Orthopaedic Research and Education Foundation, Orthopaedic Trauma Association, Society of Military Orthopaedic Surgeons

Disclosure: Received consulting fee from Musculoskeletal Transplant Foundation/CONMED for consulting; Received consulting fee from Johnson & Johnson (MITEK) for consulting; Received royalty from Elsevier, SLACK Publishing, and Springer for other; Received salary from American Journal of Sports Medicine for employment.

Coauthor(s)

Ozair Meghani, BA MD Candidate, New York Medical College; Research Fellow, Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mohit N Gilotra, MD, MS, FAAOS, FAOA Associate Professor, Department of Orthopaedics, Shoulder and Elbow Service, Associate Residency Program Director, Co-Director of Resident Research, University of Maryland School of Medicine; Chief of Orthopaedics, VA Maryland Healthcare

Mohit N Gilotra, MD, MS, FAAOS, FAOA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Shoulder and Elbow Surgeons, Maryland Orthopaedic Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Tigon<br/>Serve(d) as a speaker or a member of a speakers bureau for: Arthrex<br/>Received research grant from: Orthofix.

Additional Contributors

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Scott Welsh, MD Orthopedic Surgeon, Central Texas Orthopedics

Disclosure: Nothing to disclose.

Mark Veenstra, MD Consulting Staff, K Valley Orthopedics, Southwestern Michigan Sports Medicine Clinic

Disclosure: Nothing to disclose.