The Injury Clinic - The Harris Injury

Cary Harris' dislocated shoulder is a more significant injury than Chauncey Washington's AC Joint separation.

A shoulder dislocation is often confused with a shoulder separation, but these are two very different injuries! It is important to distinguish between these two problems because the issues with management, treatment, and rehabilitation are different. A shoulder dislocation injury affects the capsule that surrounds the actual glenohumeral joint, as explained below.

The capsule that surrounds the shoulder joint is a very strong ligament that helps to keep the shoulder in the joint and functioning normally. In most people it is very difficult to tear the ligaments of the capsule or pull the shoulder out of joint. These injuries usually occur only when a lot of force has been applied to the shoulder or the arm - like in a football game. If the shoulder slips partially out of joint, this is called "subluxation". A dislocated shoulder occurs when the shoulder comes completely out of joint.

A simple definition of the shoulder joint is an inverted golf ball on the tee. More below:

Anatomy of the Injury


The Shoulder
Photo Credit: Image and Text from About.com
The shoulder joint is made of three bones which come together at one place. The arm bone or humerus, the shoulder blade or scapula, and the collarbone or clavicle all meet up at the top of the shoulder. A shoulder separation occurs when there is an injury to the joint between the scapula and clavicle--this is called an acromioclavicular or an A-C separation, as discussed here. A shoulder dislocation occurs when there is an injury to the joint between the humerus and scapula.

The joint between the humerus and scapula, also called the glenohumeral joint, is a ball-and-socket joint- the ball is on the top of the humerus, and this fits into a socket of the shoulder blade called the glenoid. This joint is incredible because it allows us to move our shoulder though an amazing arc of motion- no joint in the body allows more motion than the glenohumeral joint. Unfortunately, by allowing this wide range of motion, the shoulder is not as stable as other joints. Because of this, shoulder dislocations are not uncommon injuries.

Symptoms

Patients with a shoulder dislocation are usually in significant pain. They know something is wrong, but may not know they have sustained a shoulder dislocation. Symptoms of shoulder dislocation include:

  • Shoulder pain
  • Arm held at the side, usually slightly away from the body with the forearm turned outward
  • Loss of the normal rounded contour of the deltoid muscle
Diagnosis and Treatment
Diagnosis

The Dislocated Shoulder
Photo Credit: C. Thomas Vangsness, Jr., MD
The diagnosis of a dislocated shoulder is made by the combination of the history of injury, signs and symptoms on physical exam, and by x-rays that show that the humeral head is out of the socket. The diagnosis of subluxation is made the same way, but the humeral head will still be in the socket because it has not completely dislocated. Occasionally, an MRI is used to look at these injured soft tissues.

After the shoulder has been put back in the socket, the severe pain will stop almost immediately. The structures such as the labrum, bone, nerves, or ligaments were injured must be evaluated. The treatment that follows depends on what structures were injured, how many dislocations you have had, how unstable the shoulder is and how much pain you have. Immobilizization of the shoulder in a sling or sling and side pillow is done for a few weeks while the injury heals.

TREATMENT

Conservative nonoperative treatment including physical therapy to strengthen the muscles around the shoulder (rotator cuff) is best after the first dislocation. If you have had multiple dislocations or subluxations, surgery is suggested to repair or tighten the capsule and ligaments that hold the shoulder in place. If the labrum has been injured, it will need to be trimmed or sutured. The surgery is usually done arthoscopically, which is less invasive and offers quicker return to full activity. The surgery is performed with an arthroscope and small instruments introduced into the shoulder joint through hollow cannulas. Miniature anchors or screws with suture attached are inserted precisely into the socket edge of the shoulder, and the torn ligaments and labrum are reattached to the socket. Complete healing from this procedure takes approximately 4-6 months.

The older a patient is at the time of dislocation the lower the chances are for developing recurrent dislocations. Patients over 35-40 can tear the rotator cuff with a dislocation. Patients under the age of 25 with traumatic dislocations have a substantially higher rate of recurrence (greater than 80-90%).

From C. Thomas Vangsness, Jr., MD
Chief, Sports Medicine Service, LAC/USC Medical Center
Team Physician, USC Department of Athletics

X-ray images of the shoulder


The normal, anatomic shoulder - after being relocated or popped back into place


The dislocated shoulder

Images from Leiden University Medical Center, the Netherlands

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