History

Children presenting with a dislocated shoulder may relate a couple of possible mechanisms. These mechanisms occur in a number of ways and are similar to those in adults. Most commonly, the child falls on the outstretched hand, forcing the arm into abduction and external rotation, levering the humeral head out of the glenoid cavity. Activities promoting this injury include contact sports, falls from heights, fights, and motor vehicle accidents. Other mechanisms have been described, including elevation with external rotation and direct blows.

A history of prior dislocations suggests a high likelihood of anterior glenohumeral instability. Studies have shown a 70-100% recurrence rate in various population groups of patients younger than 20 years.

Physical Examination

As with physical examinations of any joint, beginning by observing the shoulder is important. Note any atrophy of the biceps, supraspinatus, or infraspinatus. Gross deformities can also suggest the direction of a dislocation.

Range of motion (ROM) of the shoulder must be tested for restriction or hypermobility. Atraumatic instability generally manifests with hypermobility of the shoulder, whereas traumatic instability typically results in bilaterally symmetric motion. Generalized joint laxity is demonstrated by extending the elbow, wrist, metacarpophalangeal (MCP), and distal interphalangeal (DIP) joints. External rotation can be increased as much as 28° or decreased as much as 14° after dislocation.

Next, the examiner manually assesses translation of the humeral head in the glenoid fossa. The humeral head is grasped in one hand, and the clavicle and scapula are stabilized in the other as the examiner pushes anteriorly and posteriorly. This is known as a shoulder drawer sign. Compared with the unaffected shoulder, the affected shoulder often demonstrates increased laxity. Remember that as much as 50% of posterior translation may be normal.

A sulcus sign is demonstrated by pulling inferiorly on the relaxed shoulder. A sulcus observed between the acromion and proximal humeral head is considered a positive finding. This finding indicates that the shoulder has multidirectional instability.

The key finding in anterior glenohumeral instability is a positive apprehension test. The arm is placed in abduction, extension, and external rotation while being stressed in anterior translation. If the patient becomes apprehensive and reports pain, this is considered a positive finding. It is important to note that pain alone does not constitute a positive apprehension test: The patient must report apprehension.

The relocation test involves placing the shoulder in the position of apprehension and applying a posteriorly directed force on the humeral head. The result is considered positive if this relieves the patient's apprehension.

The anterior release or surprise test is sensitive and specific for clinically diagnosing anterior shoulder instability.^[16]

Impingement signs must also be evaluated because as many as 10% of patients experience impingement after dislocation. Evaluate for the Hawkins sign, and perform the Neer impingement test.

Workup

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Media Gallery

Y-view radiograph of the right shoulder shows anterior dislocation of the humeral head relative to the glenoid fossa
Upper - Type I superior labrum anterior posterior lesion. Lower - Type II superior labrum anterior posterior lesion.
Upper - Type III superior labrum anterior posterior lesion. Lower - Type IV superior labrum anterior posterior lesion.

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Author

Amin H Afsari, DO General Orthopedic and Hand/Upper Extremity Surgeon, Lakeshore Medical Clinic

Amin H Afsari, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Osteopathic Association, American Society for Surgery of the Hand, American Osteopathic Academy of Orthopedics

Disclosure: Nothing to disclose.

Coauthor(s)

Alexander W Nielsen Medical College of Wisconsin

Disclosure: Nothing to disclose.

Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association

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

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

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.

Sections Anterior Glenohumeral Instability
Overview
Presentation
Workup
Treatment
Media Gallery
References

Anterior Glenohumeral Instability Clinical Presentation

History

Physical Examination

References

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