Hawkins, J Bone Joint Surg Am 1987 - Locked Posterior Dislocation of the Shoulder - Article Summary

Locked Posterior Dislocation of the Shoulder

Hawkins, Mendoza, et al.·J Bone Joint Surg Am·1987·488 citations·Retrospective cohort

Hawkins and colleagues reviewed how locked posterior shoulder dislocations came to be diagnosed and how each treatment option performed.

Series of 41 shoulders in 40 patients, mean follow‑up 5.5 years.

Methods

Design: Case series
Two centers: New York and London, Ontario
Patients: 40 patients with 41 locked posterior dislocations
Caused by motor‑vehicle accident, seizure, alcohol‑related injury or electroshock therapy
Treatment: Deformity accepted in 7 shoulders
Closed reduction
Subscapularis tendon or lesser tuberosity transfer
Hemiarthroplasty or total arthroplasty
Follow-up: Mean 5.5 years (range 2 to 17)
Outcomes: Pain
Range of motion
Strength
Function

Key Findings

The first physician missed the diagnosis in most of the 41 dislocations, and diagnosis came a mean of 1 year after injury, with 25 of the 40 patients diagnosed within 6 months.
No shoulder had a displaced humeral fracture, but 20 had an undisplaced fracture of the proximal humerus.
Closed reduction succeeded in only 3 of the 12 shoulders seen within 6 weeks, each with a defect under 20% of the articular surface and reduced 1, 3 or 4 weeks after injury.
Lesser tuberosity transfer appeared to do better than the McLaughlin subscapularis transfer, but every failed subscapularis transfer had been done elsewhere, and all 4 done by the authors succeeded.
All 3 failed hemiarthroplasties had glenoid surface involvement noted at the index operation, and all 3 patients had good pain relief after conversion to total shoulder replacement.
Humeral components went in at about neutral version for dislocations older than 6 months and about 20° of retroversion for younger ones, and the one shoulder that redislocated had 20° of retroversion after a 3‑year dislocation.

Board pearl

In the 9 shoulders filmed at the time of injury, AP views with the beam in the sagittal plane and transthoracic laterals missed the dislocation, while an axillary view confirmed it in all 41 shoulders.

Authors' treatment plan for locked posterior dislocationHawkins, J Bone Joint Surg Am 1987

Situation	Recommended treatment
The patient is inactive and a poor surgical risk	No treatment
The dislocation is under 6 weeks old and the defect is under 20% of the articular surface	Closed reduction, then 6 weeks with the arm at the side in 20° of external rotation. Lesser tuberosity transfer if reduction fails.
The dislocation is 6 weeks to 6 months old and the defect is 20% to 45%	Lesser tuberosity transfer, then 6 weeks with the arm at the side in 20° of external rotation
The dislocation is over 6 months old or the defect is over 45%, and the glenoid is normal	Hemiarthroplasty with immediate rehabilitation
The dislocation is over 6 months old or the defect is over 45%, and the glenoid is destroyed	Total shoulder replacement, with a bone graft if needed, and immediate rehabilitation

Defect size is measured on the axillary radiograph.

Authors' conclusion

Once the diagnosis is established, the majority of patients with this lesion can be successfully managed.

Core

Locked Posterior Dislocation of the Shoulder.

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Locked Posterior Dislocation of the Shoulder

Hawkins, Mendoza, et al.·J Bone Joint Surg Am·1987·488 citations·Retrospective cohort

DOI·PubMed

Hawkins and colleagues reviewed how locked posterior shoulder dislocations came to be diagnosed and how each treatment option performed.

Series of 41 shoulders in 40 patients, mean follow‑up 5.5 years.

Methods

Design: Case series
Two centers: New York and London, Ontario
Patients: 40 patients with 41 locked posterior dislocations
Caused by motor‑vehicle accident, seizure, alcohol‑related injury or electroshock therapy
Treatment: Deformity accepted in 7 shoulders
Closed reduction
Subscapularis tendon or lesser tuberosity transfer
Hemiarthroplasty or total arthroplasty
Follow-up: Mean 5.5 years (range 2 to 17)
Outcomes: Pain
Range of motion
Strength
Function

Key Findings

The first physician missed the diagnosis in most of the 41 dislocations, and diagnosis came a mean of 1 year after injury, with 25 of the 40 patients diagnosed within 6 months.
No shoulder had a displaced humeral fracture, but 20 had an undisplaced fracture of the proximal humerus.
Closed reduction succeeded in only 3 of the 12 shoulders seen within 6 weeks, each with a defect under 20% of the articular surface and reduced 1, 3 or 4 weeks after injury.
Lesser tuberosity transfer appeared to do better than the McLaughlin subscapularis transfer, but every failed subscapularis transfer had been done elsewhere, and all 4 done by the authors succeeded.
All 3 failed hemiarthroplasties had glenoid surface involvement noted at the index operation, and all 3 patients had good pain relief after conversion to total shoulder replacement.
Humeral components went in at about neutral version for dislocations older than 6 months and about 20° of retroversion for younger ones, and the one shoulder that redislocated had 20° of retroversion after a 3‑year dislocation.

Board pearl

Authors' treatment plan for locked posterior dislocationHawkins, J Bone Joint Surg Am 1987

Situation	Recommended treatment
The patient is inactive and a poor surgical risk	No treatment
The dislocation is under 6 weeks old and the defect is under 20% of the articular surface	Closed reduction, then 6 weeks with the arm at the side in 20° of external rotation. Lesser tuberosity transfer if reduction fails.
The dislocation is 6 weeks to 6 months old and the defect is 20% to 45%	Lesser tuberosity transfer, then 6 weeks with the arm at the side in 20° of external rotation
The dislocation is over 6 months old or the defect is over 45%, and the glenoid is normal	Hemiarthroplasty with immediate rehabilitation
The dislocation is over 6 months old or the defect is over 45%, and the glenoid is destroyed	Total shoulder replacement, with a bone graft if needed, and immediate rehabilitation

Defect size is measured on the axillary radiograph.

Authors' conclusion

Once the diagnosis is established, the majority of patients with this lesion can be successfully managed.