The Journal of Bone and Joint Surgery (American). 2005;87:639-650.
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Current Concepts Review

Posterior Shoulder Dislocations and Fracture-Dislocations

C. Michael Robinson, BMedSci, FRCSEd(Orth)1 and Joseph Aderinto, FRCSEd1

1 The Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh EH16 4SU, United Kingdom. E-mail address for C.M. Robinson: c.mike.robinson{at}ed.ac.uk

Investigation performed at The Shoulder Injury Clinic, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.


   Abstract
Top
 Abstract
Introduction
 Spectrum of Posterior Shoulder...
 Epidemiology
 Pathogenesis
 Classification
 Assessment and Diagnosis
 Treatment
 Outcome and Complications of...
 References
 
Posterior shoulder dislocations and fracture-dislocations are uncommon injuries that most often occur during seizures or as a result of high-energy trauma. Despite advances in imaging, they are frequently diagnosed late. Detection is facilitated by heightened clinical suspicion of the injury in high-risk individuals together with appropriate radiographic investigation.

A wide variety of operative techniques, ranging from simple closed reduction to soft-tissue and bone stabilization procedures to prosthetic arthroplasty, are available to treat these injuries. Selection of the most appropriate treatment option is complex and multifactorial. Because of the rarity of these injuries, evidence-based treatment protocols are difficult to devise.

Good functional outcomes are associated with early detection and treatment of isolated posterior dislocations that are associated with a small osseous defect and are stable following closed reduction. Poor prognostic factors include late diagnosis, a large anterior defect in the humeral head, deformity or arthrosis of the humeral head, an associated fracture of the proximal part of the humerus, and the need for an arthroplasty.


   Introduction
Top
 Abstract
 Introduction
Spectrum of Posterior Shoulder...
 Epidemiology
 Pathogenesis
 Classification
 Assessment and Diagnosis
 Treatment
 Outcome and Complications of...
 References
 
Posterior shoulder instability comprises a spectrum of disorders, which include first-time traumatic dislocation (complete dissociation of the humeral head from the glenoid) and recurrent dislocation or subluxation (symptomatic, excessive translation of the humeral head on the glenoid). These conditions are uncommon but are more challenging to treat than are their anterior counterparts, and few surgeons encounter them with sufficient frequency in their clinical practice to be confident about their assessment and treatment. As a consequence, delays in diagnosis, errors in treatment, and protracted morbidity frequently occur. Their rarity makes it difficult to devise evidence-based management strategies or to obtain substantive proof of the benefits of newer treatment methods. This review provides an overview of the current knowledge regarding the diagnosis, classification, assessment, and treatment of posterior shoulder dislocations and fracture-dislocations.


   Spectrum of Posterior Shoulder Instability
Top
 Abstract
 Introduction
 Spectrum of Posterior Shoulder...
Epidemiology
 Pathogenesis
 Classification
 Assessment and Diagnosis
 Treatment
 Outcome and Complications of...
 References
 
First-time traumatic posterior dislocations include so-called simple dislocations, which are usually accompanied by an anterior osteochondral impression fracture of the humeral head, and true fracture-dislocations, which are accompanied by more complex fractures of the tuberosities and/or proximal part of the humerus. Recurrent episodes of posterior shoulder subluxation or dislocation may occur following reduction of a first-time traumatic posterior dislocation. However, symptomatic recurrent posterior instability most commonly presents with repeated episodes of subluxation, with or without a history of shoulder injury. The etiology of recurrent posterior instability is complex and multifactorial and currently defies rigid classification. This condition is the subject of a review that is to be published in the next issue of The Journal.


   Epidemiology
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 Abstract
 Introduction
 Spectrum of Posterior Shoulder...
 Epidemiology
Pathogenesis
 Classification
 Assessment and Diagnosis
 Treatment
 Outcome and Complications of...
 References
 
Although traumatic posterior dislocations account for <3% of all shoulder dislocations (forty-one of 1491 dislocations in four series1-4), it is difficult to assess their prevalence accurately because many cases remain clinically undetected. Many of these injuries are fracture-dislocations1,5,6, but only a small minority of fractures of the proximal part of the humerus have a concomitant posterior dislocation7,8.

Traditionally, most posterior dislocations have been associated with epileptic seizures, high-energy trauma, electrocution, or electroconvulsive therapy6,9,10 (although the latter two causes are now extremely rare11). In the absence of trauma, posterior fracture-dislocation (unilateral or bilateral) is virtually pathognomonic of a seizure12,13. The rising prevalence of diabetes mellitus and of alcohol and drug dependency has led to a greater proportion of dislocations occurring during seizures as a result of hypoglycemia14 or drug withdrawal15.

The majority of posterior dislocations occur in men between thirty-five and fifty-five years of age, and 15% are bilateral (twenty-four of 164 patients with posterior dislocation in five series had the condition bilaterally1,6,16-18). The reason for the higher prevalence in men is unclear, although they are more commonly injured in motor-vehicle accidents and when playing sports. Furthermore, their more muscular habitus may increase their risk of shoulder injury during a seizure.


   Pathogenesis
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 Abstract
 Introduction
 Spectrum of Posterior Shoulder...
 Epidemiology
 Pathogenesis
Classification
 Assessment and Diagnosis
 Treatment
 Outcome and Complications of...
 References
 
Although the humeral head and, to a lesser extent, the glenoid are both normally retroverted with respect to their long axes, the scapula is protracted on the chest wall19. Consequently, in its normal position of function, the shoulder is protected from posterior dislocation by the strong buttressing action of the posterior aspect of the glenoid20,21. Additional static stabilization is provided by the posterior capsulolabral complex and the posterior band of the inferior glenohumeral ligament22, while dynamic stability is provided by the rotator cuff and the shoulder girdle muscles.

Excessive posterior translation is also prevented by anterior constraints that contribute to capsuloligamentous stability23-25. These include the rotator interval capsule26, the superior and middle glenohumeral and coracohumeral ligaments, and the subscapularis tendon23,24,27,28. The relative contribution of these structures to stability varies with the position of the shoulder25,27. Stability also depends on coordinated glenohumeral and scapulothoracic movements29.

Traumatic posterior dislocation is possible during a high-energy injury if an axial force is applied with the shoulder in the unstable position of internal rotation, forward elevation, and adduction (Fig. 1)21. Traumatic dislocation may also be sustained as a result of sustained contraction of the internal rotators during a seizure that occurs with the arm at the side30,31. During posterior dislocation, an osteochondral impression fracture (also termed an encoche fracture or a reverse Hill-Sachs lesion)2 is produced as the anterior aspect of the humeral head impacts on the posterior aspect of the glenoid (Fig. 2-A)32. If the shoulder is not relocated at an early stage, the head defect enlarges and becomes corticated as a result of the grinding effect of rotational movements. With prolonged dislocation, secondary deformity of the articular cartilage of the humeral head may develop. This "ping-pong-ball" effect33,34 is due to resorption of the subchondral bone of the humeral head when it is not subjected to physiologic loading, which eventually progresses to secondary osteoarthrosis6,18,33,35.



Fig. 1 The shoulder is most at risk for posterior dislocation when it is axially loaded with the arm in forward elevation, adduction, and internal rotation during a high-energy injury. That position is also the one in which patients with recurrent subluxation of the shoulder characteristically experience instability symptoms. (Printed with permission of Jennifer Fairman, Fairman Studios, Waltham, Massachusetts.)

 



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  		Fig. 2A and Fig. 2B Three-dimensional computerized tomography reconstructions of a simple posterior dislocation (Fig. 2-A) and a posterior fracture-dislocation (Fig. 2-B) with an anatomic neck (HH) fracture and combined greater (GT) and lesser (LT) tuberosity "shield" fragments. G = glenoid.

 

Acute dislocation may produce an injury to the posterior stabilizers, which can present as capsulolabral tears or avulsions22,27,36-38, glenoid rim fractures39,40, or rotator cuff tears22,27,41. There is some evidence to suggest that posterior capsular tears will heal spontaneously following relocation of the shoulder40,42.

If the force producing a posterior dislocation is severe or if the proximal part of the humerus is osteoporotic, the impression fracture may propagate to produce fractures of the tuberosities and/or proximal part of the humerus, most commonly through the anatomic neck (Fig. 2-B). The humeral head has a segmental blood supply, mainly derived from the ascending branch of the anterior circumflex humeral artery43,44. There is consequently a risk of osteonecrosis after fractures of the anatomic neck, although if the fracture extends below the articular surface medially, the head may be perfused by intact posteromedial vessels45.


   Classification
Top
 Abstract
 Introduction
 Spectrum of Posterior Shoulder...
 Epidemiology
 Pathogenesis
 Classification
Assessment and Diagnosis
 Treatment
 Outcome and Complications of...
 References
 
Because of the rarity of posterior dislocation and the complexity and unpredictable outcome of its treatment, a satisfactory classification of this injury has not been devised. Dislocations with a concomitant fracture of the anatomic neck or tuberosities (fracture-dislocations) should be considered separately from simple dislocations, which should include those associated with an impression fracture of the humeral head (Figs. 2-A and 2-B).

Simple Dislocations (without Associated Fracture of the Tuberosities or the Proximal Part of the Humerus)
These injuries have usually been classified according to the timing of the diagnosis, with those diagnosed immediately or within the first six weeks after the injury traditionally classified separately from those that are detected later2,16,33,46. Dislocations that present late have previously been termed "chronic"33,47, "neglected"48, or "locked"6, although these terms are misleading and probably best avoided.

In reality, the temporal delay in diagnosis is a continuum, during which the humeral head defect becomes progressively larger and the shoulder becomes more difficult to reduce, until it eventually becomes deformed and arthritic. As these factors most commonly influence treatment, it is preferable to use them for subclassification rather than basing the classification solely on the timing of the diagnosis. The treatment and prognosis of dislocations with a head defect measuring <40% to 50% of the articular surface is usually considered to be different from those with a larger defect and those with deformity or arthritic change in the remainder of the humeral head6,17,18,49. The subclassification used in this review is based on this distinction.

Fracture-Dislocations (Dislocations with Fractures of the Tuberosities and/or Proximal Part of the Humerus)
Posterior fracture-dislocations are included in most shoulder fracture classifications7,32,50. The three most commonly encountered fracture patterns are two-part fractures of the lesser tuberosity (Group V in the Neer system and not classified in the AO system)48,51-53, two-part fractures of the anatomic neck (Group VI in the Neer system and Type C3.1 in the AO system)53,54, and complex three-part and four-part fractures (Group VI in the Neer system and Types B3.3, C3.2, and C3.3 in the AO system)7,49,54-58 (Fig. 2-B).

The important distinction between fracture-dislocations, in which the humeral head is locked on the posterior aspect of the glenoid, and fracture-subluxations is unclear in most classification systems59. The latter are typically osteoporotic, multipart fractures in the elderly, with the humeral head subluxated posteriorly but not locked on the glenoid rim or extruded60,61. Fracture-subluxations should be considered with other Neer Group-III and IV, three and four-part fractures. These injuries are not discussed in detail in this review.


   Assessment and Diagnosis
Top
 Abstract
 Introduction
 Spectrum of Posterior Shoulder...
 Epidemiology
 Pathogenesis
 Classification
 Assessment and Diagnosis
Treatment
 Outcome and Complications of...
 References
 
Delays in the diagnosis of posterior dislocations are common: it is estimated that up to 50% are missed when the patient first seeks medical consultation40,46,62. Common causes for delay include late presentation by the patient, the physician's failure to suspect the diagnosis on examination, and inadequate radiographic investigation63. Dislocations are more commonly missed in the elderly5, in patients with concomitant fractures64,65, and in those with multiple injuries or other injuries in the same limb1. The key to diagnosis lies in maintaining a high index of clinical suspicion and performing appropriate radiographic investigations.

Clinical Assessment
An acute posterior dislocation is characteristically painful, but affected patients may have reduced nociception following a seizure, especially in instances of drug or alcohol intoxication. Although the absolute risk of dislocation during a seizure is small13,31, the diagnosis must be excluded if shoulder pain is present following such an episode. In the absence of a history of epilepsy, investigation is required to exclude underlying causes, such as an intracranial mass lesion or metabolic abnormality66,67.

The dislocated shoulder is typically held in internal rotation, and the most consistent finding is a mechanical block to external rotation, caused by engagement of the anterior humeral head defect on the posterior aspect of the glenoid2. The absence of pain on rotational shoulder movements is suggestive of a chronic dislocation, but the exact age of a dislocation may be difficult to define, particularly if a patient with unstable epilepsy has had shoulder pain for some time. Concomitant tears of the rotator cuff and neurovascular injury are uncommon, but those diagnoses should be excluded39-41.

Patients who sustain a posterior dislocation during a seizure often have medical and psychosocial problems, which may be related to the conditions that caused the seizure, such as alcoholism or drug dependency, or to noncompliance with their treatment with anticonvulsant medication68,69. Treatment of unstable medical problems may be appropriate prior to operative intervention. A psychological assessment may also be useful in determining the patient's likely receptivity and compliance with treatment.

Imaging Studies
Many radiographic signs of posterior dislocation on standard anteroposterior radiographs have been described70,71. However, these signs are unreliable, and an axillary radiograph is essential to confirm the diagnosis. Standard axial radiographs are difficult to make because the patient usually cannot abduct the arm. Apical oblique72, Velpeau73, or modified axial radiographs74 are therefore preferable, as they can be made with the arm in a sling (Figs. 3-A, 3-B, and 3-C). Ultrasound has been used to detect posterior dislocation, but it requires specialist training and cannot accurately demonstrate the extent of osseous pathology75.



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  		Fig. 3-A The configuration of the x-ray gantry and cassette used to make a modified axial radiograph of the shoulder.

 



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  		Fig. 3-B Conventional anteroposterior radiograph of a shoulder with a posterior dislocation, which is not evident on this view. Fig. 3-C The posterior dislocation is clearly evident on the modified axial radiograph of the same shoulder.

 

Additional imaging is essential in the evaluation of posterior dislocations prior to treatment. Computerized tomography provides good definition of the osseous lesions that determine treatment48,68. It can detect radiographically occult anatomical neck fractures76, and it enables an accurate assessment of the size of the humeral head defect and the shape and degree of degenerative change in the remainder of the humeral head48,68,75. Occasionally, assessment of the size and degree of cortication of the humeral head defect can help to determine whether a dislocation occurred recently or has been present for a longer period of time. Three-dimensional reconstructions are available with modern spiral scanners, which can be useful in planning operative reconstruction (Figs. 2-A and 2-B). Magnetic resonance imaging may also provide useful information regarding the condition of the rotator cuff and the ligamentous soft-tissue restraints of the shoulder.


   Treatment
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 Abstract
 Introduction
 Spectrum of Posterior Shoulder...
 Epidemiology
 Pathogenesis
 Classification
 Assessment and Diagnosis
 Treatment
Outcome and Complications of...
 References
 
If the interval between the dislocation and the diagnosis has been prolonged, it is sometimes preferable not to treat the dislocation. This is particularly true if the patient is frail, elderly, or demented; has unstable epilepsy; or has only minor functional disability2,6,75. After physiotherapy, the final degree of functional incapacity is often minimal, given such patients' limited functional expectations77. Active treatment is indicated for all remaining patients, with the aim of achieving a congruously relocated, stable, functional, and pain-free shoulder. A wide variety of reconstructive techniques, ranging from simple closed reduction to the more complex humeral head salvage and head-replacement procedures, may be required to treat these complex injuries.

Dislocations with Involvement of Less Than Forty to Fifty Percent of the Humeral Head Articular Surface and No Deformity or Degenerative Changes
This pattern of injury is usually recognized in dislocations diagnosed immediately or within the first six weeks postinjury. A posterior dislocation may occasionally reduce spontaneously or, rarely, the patient may have relocated the shoulder prior to seeking medical advice. However, this scenario is much less common than it is following anterior dislocation, and most first-time posterior dislocations require reduction under medical supervision.

Treatment consists of closed relocation of the shoulder followed by assessment of its stability. This is difficult in a conscious, sedated patient, so posterior dislocations should be reduced with the patient under general anesthesia. Ancillary stabilization techniques may be required if the reduction is unstable.

Attempted closed reduction is indicated for dislocations with a small humeral head defect that are diagnosed immediately or within the first six weeks after the injury15,46. The impression fracture is disimpacted and is cleared from the posterior glenoid lip with use of gentle manipulation while the arm is flexed 90° and adducted1. External rotation at this stage will relocate the shoulder, but it should not be attempted before the defect has been fully disengaged, as there is a risk of fracturing the humerus.

Open reduction is indicated if attempted closed relocation is unsuccessful, which is typical if the diagnosis has been delayed and/or there is a large humeral head defect. The deltopectoral approach is most commonly used2,6, but it provides limited access to the posterior aspect of the glenoid for relocation of the humeral head78. A separate posterior approach is sometimes required if the head is irreducible79.

The deltoid-splitting, superior subacromial approach is an alternative favored by some authors78,80 as it provides more direct access to the dislocated humeral head. Most reconstructive procedures can be performed through this approach61, although there is a risk of postoperative detachment of the deltoid from the acromion and injury to the axillary nerve if the split is continued too distally. Irrespective of the approach that is used, following arthrotomy at the rotator interval and prior to relocation, the impression fracture should be disengaged from the glenoid rim under direct vision.

Following reduction, stability is assessed by internal rotation of the shoulder to establish the point at which redislocation occurs. The degree of instability is usually determined by the size of the anterior humeral head defect, as it reengages with the posterior aspect of the glenoid rim, although instability can also be produced by posterior capsular injury. If the reduction is stable throughout a functional range of rotation (usually in a patient with a dislocation accompanied by a small humeral head defect occupying <25% of the articular surface18,40), immobilization of the shoulder in neutral or external rotation for four weeks is recommended (Fig. 4)40.



Fig. 4 Following reduction of a posterior dislocation, the shoulder is in its most stable position when it is in neutral forward elevation and external rotation because the anterior humeral head defect is prevented from reengaging with the posterior aspect of the glenoid. This is the generally preferred position of immobilization following relocation of the shoulder to prevent acute redislocation. (Printed with permission of Jennifer Fairman, Fairman Studios, Waltham, Massachusetts.)

 

If the shoulder redislocates as it is internally rotated, there are two choices for treatment: an adjunctive stabilization procedure or immobilization in a more stable position of external rotation (Fig. 4), which moves the area of the anterior humeral head defect away from the posterior aspect of the glenoid rim75,81. Although these two options have not been directly compared, operative stabilization is being increasingly recommended because of the shortcomings of immobilization, which include shoulder stiffness, acute redislocation, and recurrent instability2,81,82. Furthermore, splinting of the arm in external rotation is difficult to maintain, unless a permanent shoulder spica is applied20,81.

The aim of adjunctive stabilization procedures is to restore stability throughout a functional range of movement, thereby preventing an acute redislocation. Transposition of the subscapularis tendon into the humeral head defect, either alone (the McLaughlin procedure, Fig. 5)2 or in continuity with the osteotomized lesser tuberosity when there is a larger defect (the Neer modification of the McLaughlin technique)6,83, has been widely used48,75,84. Of the two variations, the latter is preferable when there is an associated fracture of the lesser tuberosity52. Rotational osteotomy of the proximal part of the humerus has also been described85, but it is not widely used because of its technical difficulty and the risk of devascularizing the humeral head17.



Fig. 5 Schematic drawing of the McLaughlin procedure. (Printed with permission of Jennifer Fairman, Fairman Studios, Waltham, Massachusetts.)

 

These nonanatomic techniques restore stability when they are used to treat smaller impression fractures, but they are less successful when the head defect occupies 33% to 50% of the articular surface6,18,40,52,68,86. Additionally, there is a risk of subscapularis dysfunction, leading to weakness of internal rotation or contracture, which may complicate later joint replacement40.

Disimpaction, elevation, and autogenous bone-grafting of the depressed osteochondral humeral head fracture has more recently been used to treat residual instability in patients in whom the dislocation had been diagnosed within the first two weeks after the injury (Fig. 6)40,68,87,88. When the remaining articular surface is not osteoporotic, deformed, or arthritic, a sculpted osteochondral humeral or femoral head allograft may be preferable for larger defects, occupying up to half of the articular surface (Fig. 7)40,47,68. Only brief reports of these newer anatomic techniques are available40,68, although the functional results of allografting are considered to be similar to those of subscapularis transfer40.



Fig. 6 Schematic representation of acute elevation, bone-grafting, and internal fixation of a small anterior osteochondral fracture of the humeral head. A channel is created through the humeral head to gain access to the impaction fracture cavity. The cavity is then filled with bone graft, which is impacted to elevate the depressed segment of articular cartilage. (Printed with permission of Jennifer Fairman, Fairman Studios, Waltham, Massachusetts.)

 


 Fig. 7 Schematic diagram of the use of a solid osteochondral allograft to fill a larger anterior humeral head defect. (Printed with permission of Jennifer Fairman, Fairman Studios, Waltham, Massachusetts.)

 

Although there are no evidence-based guidelines for treatment, we currently recommend disimpaction and bonegrafting for small defects (<25% of the humeral head surface) that are recognized within the first two weeks after injury. Subscapularis transfer is used for smaller defects diagnosed more than two weeks after injury. Larger lesions, occupying up to 40% to 50% of the articular surface, are filled with a structural allograft, irrespective of the duration of the dislocation. Stability should be reassessed after the adjunctive procedure. Inadequate restoration of stability may be due to a posterior capsulolabral disruption or a displaced posterior glenoid fracture69, which may require stabilization68.

Dislocations with Involvement of More Than Forty to Fifty Percent of the Humeral Head Surface or with Deformity or Secondary Osteoarthrosis of the Humeral Head
This pattern of injury is most commonly present in patients for whom the diagnosis had been delayed or in older patients who have substantial softening of the humeral head due to osteoporosis. Open reduction and allograft stabilization of the humeral head has been used to treat carefully selected, younger patients with a defect of >50% of the head surface and preserved sphericity of the humeral head40. However, arthroplasty is more commonly used to treat dislocations associated with a large humeral head defect6,18 or those associated with deformity (a "ping-pong-ball" head) or secondary osteoarthrosis of the articular surface18,33. Both hemiarthroplasty and total shoulder replacement18,40,46,79,89 have been used, although they have never been directly compared, to our knowledge. Some authors have recommended use of total shoulder replacement only when there is reciprocal arthritic change in the glenoid6,18,46, whereas others use it routinely, claiming that it provides better pain relief and restoration of the anatomy40,79.

A recognized technical problem of arthroplasty is the predisposition to posterior subluxation or dislocation of the prosthesis due to anterior-inferior capsular and subscapularis contractures. The prosthesis has been inserted in a neutral or relatively anteverted orientation to reduce this risk6,46,89, but capsular release together with normal prosthetic retroversion is now favored by many authors18,40,75.

Rarely, when there is severe humeral head deformity, an arthroplasty, arthrodesis, or excision of the humeral head (Jones procedure) may be considered16,17,33. There is no evidence with which to delineate the relative indications for these procedures, but an arthroplasty is usually preferable if it is technically feasible, as the functional outcome is likely to be better.

Fracture-Dislocations
Dislocations with an undisplaced lesser tuberosity fracture can be treated in the same manner as simple dislocations57, but open reduction and internal fixation is recommended if there is displacement. The tuberosity may be fixed either anatomically or into the base of the humeral head defect if the shoulder is unstable. Two, three, and four-part fractures involving the anatomic neck are treated either with reduction and internal fixation or with arthroplasty. The treatment is determined by the age and medical status of the patient and the degree of devascularization and fragmentation of the humeral head and tuberosities57.

Arthroplasty is generally favored for multipart fractures in the elderly18,57,79. In addition to the technical problems encountered when an arthroplasty is used to treat a simple dislocation, it may be difficult to judge the appropriate prosthetic soft-tissue tensioning and to obtain stable fixation of the fractured tuberosities (Fig. 8-A)57,90,91.




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  		Fig. 8-A Severely comminuted multipart posterior fracture-dislocations in the elderly are usually treated with hemiarthroplasty. In this patient, the prosthesis was well centered on the glenoid (with the center of the humeral head prosthesis displaced only 3 mm from the center of the glenoid) and the tuberosities healed without migration, leading to a satisfactory functional outcome. Fig. 8-B In younger individuals with a posterior fracture-dislocation, head salvage, typically with open reduction and plate fixation, is attempted whenever possible.

 

Head-salvaging reconstruction is usually attempted in younger adults with good bone stock. While closed reduction techniques have been described1,54,92, open reduction and internal fixation is usually preferred because it reduces the risk of iatrogenic fracture displacement93. Temporary transfixation wires may prevent displacement of undisplaced neck fractures during open relocation93.

The type of internal fixation used is determined by the complexity of the fracture. Two-part fractures may be stabilized by simple interfragmentary screws34, whereas multipart fractures require more complex reconstruction with use of buttress plates, tension bands, or intramedullary fixation (Fig. 8-B)8,94-96. Stability should be assessed following internal fixation, as adjunctive procedures may be required if there is residual instability.

Neglected fracture-dislocations may be difficult to reduce operatively, and malunion of the proximal part of the humerus makes reconstructive procedures technically demanding. If an arthroplasty is attempted, it is best to avoid osteotomy and realignment of the tuberosities, as this can be associated with nonunion, secondary displacement, and a poor functional outcome40,75,97. In many cases, a joint excision or fusion may be the only technically feasible option18,33.


   Outcome and Complications of Posterior Dislocation
Top
 Abstract
 Introduction
 Spectrum of Posterior Shoulder...
 Epidemiology
 Pathogenesis
 Classification
 Assessment and Diagnosis
 Treatment
 Outcome and Complications of...
References
 
As a result of the rarity of posterior dislocations, most of the published literature consists of Level-IV (case-series) and Level-V (expert opinion) studies, often compiled retrospectively over many years. Comparative studies of different treatment methods, which would help to resolve areas of controversy, are lacking. Furthermore, because a wide variety of subjective and objective methods has been used to assess functional outcome, it is impossible to compare different studies. The most consistently recorded outcome measure is the occurrence of complications. Although it is generally accepted that the risk of complications is high, their exact prevalence is often difficult to quantify because of variable recording and differences in both case-mix and treatment philosophies in published studies.

In general, a less favorable functional outcome is anticipated and the risk of all complications is higher when the dislocation is diagnosed late1,2,5,18,86, when the humeral head impression defect is large6, when secondary humeral head deformity and osteoarthrosis are present2,6, or when there is a concomitant proximal humeral fracture17,18. Outcomes have also been reported to be less satisfactory when closed reduction alone is not possible5,6,18 or when an arthroplasty is required to treat the dislocation18,33. The following complications have been specifically associated with posterior dislocation.

Acute Redislocation
This complication may occur following closed relocation or be due to failure of an adjunctive surgical stabilization procedure. Reported redislocation rates following nonoperative treatment have varied widely. Detenbeck51 treated ten shoulders and reported no redislocations, whereas Wilson and McKeever1, Dimon82, and Roberts and Wickstrom39 reported redislocations in four of eleven shoulders, one of three shoulders, and nine of twenty-four shoulders, respectively. Redislocations following nonoperative treatment have often been recognized late and have been treated nonoperatively, with open reduction and adjunctive surgical stabilization, or with an arthroplasty.

Redislocation following adjunctive stabilization with the McLaughlin procedure was reported in five patients6. All of those patients were referred from outside the authors' institution, and it appeared that the procedure had been used to treat dislocations associated with larger humeral head defects. The patients were subsequently treated either nonoperatively or with an arthroplasty.

Recurrent episodes of posterior instability may occur following an initial dislocation and are best considered within the spectrum of recurrent posterior instability. These will be discussed in the subsequent review concerning recurrent posterior shoulder instability.

Osteonecrosis
Osteonecrosis of the humeral head has been reported following simple dislocation47, but it is more frequently encountered following internal fixation of an anatomic neck fracture-dislocation17,93. The risk of osteonecrosis increases with the degree of fracture displacement and the extent of involvement of the tuberosities57. However, following anatomic reconstruction, the head may continue to be perfused by intact posteromedial vessels45 or, alternatively, revascularization by creeping substitution may occur98,99. Osteonecrosis may be associated with satisfactory function if an anatomic reconstruction was previously achieved95,100. Symptomatic patients are usually treated with an arthroplasty57.

Posttraumatic Osteoarthrosis
Posttraumatic degeneration of the glenohumeral joint is relatively uncommon after posterior dislocation, but when it occurs the severity of the arthrosis is usually worse than that following anterior dislocation35. If symptoms are severe enough to warrant treatment, a shoulder arthroplasty is usually performed.

Joint Stiffness and Functional Incapacity
Persistent shoulder stiffness and functional incapacity after a simple dislocation are associated with a delay in the diagnosis; deformity, osteoarthrosis, or osteonecrosis of the humeral head; a tear of the rotator cuff41; a complication of an ancillary stabilization procedure6; or treatment with an arthroplasty, excision, or arthrodesis6,18. The treatment of stiffness in these patients should be directed toward the underlying cause. However, the cause of stiffness is often obscure and is assumed to be due to periarticular fibrosis and capsular contracture. This may respond to manipulation and an intensive physical therapy regimen57, but it tends to be refractory to treatment in most patients.

The functional results of reduction and internal fixation of a fracture-dislocation are satisfactory in patients in whom complications do not develop18,95. However, joint stiffness may occur if a nonunion or malunion of the humeral head develops57,98,100. Closed manipulation is not advised for the treatment of persistent stiffness, as there is an unacceptable risk of refracture57; treatment should be directed toward correcting the underlying cause.

Stiffness and a poor functional outcome are also common when an arthroplasty is used to treat a fracture-dislocation79,90,91,101,102. The outcome is often comparable with that of an arthrodesis, with the patient having pain-free scapulothoracic movement only91. An arthroplasty is more likely to result in poor function in the elderly and in patients with malunion or nonunion of the tuberosities90, glenoid arthrosis6,18, or subluxation of the prosthesis18,91. The joint stiffness is often refractory to treatment, and there have been no reports of the use of revision arthroplasty to treat this complication, to our knowledge.


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 Abstract
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 Spectrum of Posterior Shoulder...
 Epidemiology
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