ABSTRACT

Approximately 20% of all shoulder dislocations occur in patients aged >60 years.
Older patients who sustain a primary shoulder dislocation are much less likely than younger
patients to suffer from recurrence. However, older patients are more likely than younger
patients to sustain injuries to the rotator cuff, axillary nerve, or brachial plexus. Rotator cuff
tears are significantly more common than nerve palsies, and rotator cuff tears can be
mistaken for nerve palsies. Older patients with persistent shoulder pain and dysfunction after
dislocation should be carefully evaluated for rotator cuff pathology. Although dislocation is a
common injury in the older population, these concomitant injuries—especially of the rotator
cuff—are often missed

Although the incidence of shoulder dislocation is similar between young and elderly
persons, most of the literature has traditionally focused on young patients because of the high
rate of recurrent dislocations in this population. Shoulder dislocations in older patients tend to
occur as the result of low-energy mechanisms and are associated with less risk of recurrent
dislocation; however, pain and disability can persist for years as a result of associated rotator
cuff tears and nerve injuries. Careful patient evaluation and treatment selection are important
to provide adequate care to older patients with shoulder dislocation.

Mechanism of Injury and Pathoanatomy

Approximately 20% of shoulder dislocations occur in patients aged ≥60 years. The
rate of recurrent shoulder dislocation is reportedly as high as 90% in patients in their 20s and
30s, but it is <10% in patients aged ≥40 years. Differences in mechanism of injury are largely
responsible for the increased incidence of instability in younger patients and the increased
likelihood of rotator cuff tear in patients aged ≥40 years.
In young patients, McLaughlin and MacLellan describe an anterior mechanism of
injury in the dislocated shoulder. In younger patients with strong, healthy rotator cuff tissue, a
high-energy insult results in failure of the weaker anterior static restraints (ie, labrum,
capsule). McLaughlin speculated that, in older patients, the posterior mechanism constraints,
composed of the rotator cuff, are more susceptible to injury as the result of weakening of the
cuff tendons caused by degeneration associated with aging. As a consequence, young
patients present with Bankart tears, that is, displaced tears of the anterior-inferior labrum and
inferior glenohumeral ligaments, whereas older patients typically present with rotator cuff
tears (Figure 1).
FIGURE 1.
A and B, Illustrations of the posterior mechanism of injury in shoulder dislocation in
an elderly patient. A low-velocity fall on the outstretched hand causes the humeral head to
subluxate anteriorly. The force created (large arrows) results in stretching of the anterior
capsule and subscapularis tendon and tearing of the weaker posterior rotator cuff or
supraspinatus tendon.

This difference in injury mechanisms explains the different recurrence rates between
the two populations. In the young, Bankart tears render the shoulder inherently unstable with
the loss of the static restraints. In patients aged ≥40 years, the rotator cuff usually tears.
However, the rotator cuff plays a lesser role in shoulder stability, and, in general, only
massive tears result in recurrent instability. Therefore, older patients tend to redislocate at a
much lower rate than do their younger counterparts. Hence, surgical management of
shoulder dislocation in older patients should focus on reconstruction of the rotator cuff rather
than on capsulolabral reconstruction.

Patient Evaluation and Physical Examination

Careful physical examination is crucial because shoulder dislocation can be missed on
initial presentation. Upon arrival to an emergency department or physician’s office, a patient
with a suspected shoulder dislocation should receive a standard radiographic trauma series
consisting of a true AP view of the shoulder in the scapular plane (ie, Grashey), an axillary
lateral view, and a true scapulolateral view. Images should be critically evaluated for
evidence of glenohumeral joint reduction and for subtle signs of previous dislocation (ie,
glenoid rim fractures, erosions), such as a Hill-Sachs lesion or a bony Bankart lesion. The
greater tuberosity of the humerus should also be closely evaluated because subtle fractures
may be missed on overpenetrated radiographs.
Physical examination is done with the goal of measuring joint stability and diagnosing
associated injuries. Inspection may reveal muscular atrophy, which may be an indicator of a
chronic problem such as chronic rotator cuff tear or nerve palsy. Obvious deformity, such as
loss of the contour of the coracoid, indicates an anterior dislocation, whereas a prominent
coracoid may suggest posterior shoulder dislocation.
Examination of shoulder passive range of motion is crucial. Loss of passive range of
motion may be suggestive of fracture, shoulder subluxation/dislocation, or glenohumeral joint
stiffness, such as arthritis or adhesive capsulitis. Inability to externally rotate the arm may
suggest posterior shoulder dislocation in which the dislocated humeral head is mechanically
blocked by the glenoid. Isolated loss of active range of motion may suggest rotator cuff tear
rather than nerve palsy. The acromioclavicular joint, greater tuberosity, biceps groove, and
coracoid are potential sources of shoulder pain and should be palpated.
The rotator cuff should be thoroughly examined. Resisted thumb down shoulder
abduction in the scapular plane suggests supraspinatus pathology. Similarly, weakness on
resisted external rotation in adduction and at 90° of abduction is suggestive of infraspinatus
and teres minor pathology, respectively. Several physical examination tests have been
described to assess for subscapularis tears, but the most commonly used tests are the belly
press and modified lift-off. Provocative testing is completed with testing for shoulder
apprehension/relocation signs to obtain evidence of existing shoulder instability.
Finally, a thorough neurovascular examination is performed, with special attention
paid to the axillary nerve. Axillary nerve palsy usually presents as a painless loss of shoulder
abduction and loss of sensation in the proximal-lateral aspect of the arm. The arm is
evaluated for brachial plexus injury, which usually manifests as sensory and/or motor
weakness distally in the arm. Vascular injury is assessed by inspecting for evidence of
expanding hematoma, which may indicate arterial/venous injury after a recent dislocation.
Distal radial and ulnar pulses should be evaluated and compared with those of the
contralateral side.

Imaging Studies
Radiographs play a limited role in direct evaluation of rotator cuff pathology.
However, they can identify associated pathologies, such as tuberosity excrescences. A high-
riding humeral head may also suggest underlying chronic rotator cuff pathology. MRI has
become the preferred modality to evaluate rotator cuff tears and assess associated shoulder
injuries (Figure 2).

FIGURE 2.
AP (A) and scapular Y (B) radiographs of a 70-year-old man with anterior shoulder
dislocation. (C) T2-weighted coronal magnetic resonance image of the same patient
demonstrating a massive, retracted supraspinatus tear (arrow).

Ultrasonography is a cost-effective and noninvasive imaging modality for evaluating

rotator cuff tears. In one study, ultrasonography correctly identified 45 of 46 full-thickness
rotator cuff tears and predicted the degree of retraction and width of rotator cuff tears with
accuracy similar to that of MRI. Ultrasonography allows for dynamic evaluation of the
rotator cuff and may be especially helpful in patients in whom MRI findings are equivocal.
Results are operator dependent, however, and ultrasonography does not provide adequate
information regarding glenohumeral bone loss and arthritis, which can influence treatment
decisions in persons with rotator cuff tears.
In patients in whom medical comorbidities or indwelling metallic implants preclude
MRI, CT arthrography is a reasonable modality to assess rotator cuff and labral integrity and
can be used to evaluate muscle atrophy. In a study of 33 patients assessed 4 to 6 weeks
following primary shoulder dislocation, Ribbans et al visualized labral tears in 100% of the
young patients (aged <50 years) and in 75% of the older patients (aged ≥50 years) with
dislocation. Rotator cuff tear was found in 63% of older patients and none of the younger
patients.

Associated Injuries
 Concomitant rotator cuff tear with anterior dislocation of the shoulder is well
documented in older patients.
The incidence of rotator cuff tear in conjunction with shoulder dislocation in patients
aged ≥40 years ranges from 35% to 86%. In older patients, a posterior mechanism of failure
is observed with weakening and disruption of the rotator cuff, but the anterior
capsuloligamentous complex remains intact. Tearing of these structures is more prevalent in
the older patient because rotator cuff degeneration is correlated with increasing age. In fact,
Yamaguchi et al demonstrated a 50% chance of bilateral rotator cuff tear in patients aged ≥66
years. As a result, in older patients, the degenerative cuff is more likely to tear than are the
much stronger capsular attachments. A study by Porcellini et al supports this hypothesis.
They found a strong correlation between dislocation and supraspinatus tear in 150 patients
between 40 and 60 years of age who underwent arthroscopy for rotator cuff tears, instability,
or both. No correlation was observed between dislocation and capsular or Bankart lesions.
Although older patients with anterior shoulder injuries are at higher risk of nerve
injury than are younger patients, care must be taken not to misdiagnose rotator cuff tears as
nerve palsies in older patients. In a study of 31 patients (average age, 57.5 years) who were
unable to abduct their arms following reduction of an anterior glenohumeral dislocation, 29
were presumed to have an axillary nerve injury; however, this was actually the case for only
4 patients. All 31 patients underwent single-contrast arthrography of the shoulder, and each
study showed extravasation of the contrast material, confirming a rotator cuff tear. Rotator
cuff injury should be ruled out in all patients older than age 40 years who present with signs
and symptoms of nerve palsy after shoulder dislocation.
Many older patients have age-related attritional tears that were asymptomatic prior to
shoulder dislocation. Therefore, it is crucial to obtain a careful history of any preexisting
symptoms of rotator cuff dysfunction. It is important to obtain a thorough history of preinjury
pain and disability to elucidate whether the patient had a symptomatic rotator cuff. Once
adequate assessment is made of past and current disabilities attributable to the rotator cuff, a
treatment decision can be made. In our practice, older patients who have minimal pain and
intact strength are treated nonsurgically. Only tears that cause significant pain and/or
disability are managed surgically.

Associated Fractures
Bony injuries associated with shoulder dislocations include compression fractures of
the humeral head (ie, Hill-Sachs lesion), anterior glenoid rim fractures, and greater tuberosity
fractures. Older patients, especially elderly patients with osteoporosis, may sustain large Hill-
Sachs lesions from even lowvelocity falls. These lesions may predispose them to increased
instability and to the need for shoulder arthroplasty to address loss of articular congruity and
relatively easy engagement during forward elevation and external rotation, which leads to
anterior shoulder subluxation or dislocation.
The Hill-Sachs posterolateral humeral head defect is a compression fracture caused by
the anterior glenoid rim as the humeral head dislocates from the glenoid fossa. This lesion is
seen in most anterior inferior shoulder dislocations and is largest in recurrent and chronic
dislocations. Special radiographic views, such as the AP in internal rotation view and the
Stryker notch view, are useful to identify humeral head defects. MRI can show bony
pathology, but CT, with or without threedimensional reconstruction, is best to determine the
extent of the lesion.
Greater tuberosity fractures are the most common fractures associated with anterior
shoulder dislocation, and occurrence increases with increasing age. Several authors have
found that patients with isolated greater tuberosity fracture have a better prognosis than do
patients with rotator cuff tear. There is a decrease in the incidence of recurrent shoulder
dislocation in older patients with greater tuberosity fracture because the rotator cuff
mechanism is effectively repaired when the fracture unites. Hovelius et al observed no
recurrence in patients with a greater tuberosity fracture compared with a 32% recurrence rate
in patients without a fracture.
It is our current standard practice to manage nondisplaced fractures nonsurgically and
to operate on fractures displaced >5 mm, especially those displaced into the subacromial
space. However, the decision for surgical versus nonsurgical treatment should take into
account the activity level of the patient. Special attention should be paid to the individual
patient’s preoperative function as well as his or her postinjury goals. Patients who are poor
surgical candidates and those with low postinjury functional goals should be treated
nonsurgically.
Glenoid fractures associated with humeral head dislocations are typically avulsion
fractures that occur when the humeral head impacts the anterior capsule and labrum. In older
patients, the glenoid fractures because the bone is weaker and osteoporotic. If fracture is
suspected or if there is evidence of potential instability, an axillary radiograph and/or CT scan
may reveal the glenoid lesion, which can be associated with recurrent instability.

Peripheal Nerve Injury

 Nerve injury associated with anterior shoulder dislocations is more common in older
persons than in their younger counterparts. The axillary nerve is the most commonly affected,
with a reported incidence of 9.3% to 63%, followed by the suprascapular nerve (29%),
musculocutaneous nerve (19%), radial nerve (22%), and ulnar nerve (8%). The increased
incidence in older patients may be attributable to age-related degenerative changes in neural
tissue, which render the nerve more susceptible to injury in closed trauma.
Clinical features of axillary nerve palsy include deltoid weakness or wasting that may
be accompanied by sensory deficit on the lateral shoulder. Although suggestive, these
features are not diagnostic in older patients. It is critical to rule out massive rotator cuff tear
before diagnosing a nerve palsy. For patients with persistent symptoms 3 to 4 weeks after
dislocation and with MRI findings that are negative for rotator cuff tear, it is reasonable to
obtain electrodiagnostic studies to evaluate the axillary nerve. Gumina and Postacchini used
electrophysiologic studies to evaluate nerve palsies in patients with shoulder dislocations. Of
the 545 patients with anterior shoulder dislocations, 108 were aged ≥60 years. Of these 108
patients, 9.3% experienced weakness on shoulder abduction and decreased sensation in the
deltoid region. Electrophysiologic studies established that seven patients (6.5%) had
neurapraxia of the axillary nerve, whereas three (2.8%) had axonotmesis. All recovered
completely within 1 year without further intervention.
Formal management of these lesions is usually unnecessary. Most patients with nerve
dysfunction spontaneously recover without intervention.

Brachial Plexus Injury

The brachial plexus lies immediately anterior, inferior, and medial to the
glenohumeral joint. This anatomic relationship places the brachial plexus at risk during
anterior shoulder dislocation. Brachial plexus injuries resulting from anterior shoulder
dislocation are typically infraclavicular lesions and mainly affect the axillary nerve and the
posterior cord. The primary mechanism of injury is stretching of the brachial plexus, which
can occur during anterior dislocation, causing neurapraxia that typically resolves completely
in 4 to 6 months in 80% of cases. If no sign of nerve recovery is documented on
electromyography at 3 to 4 months, exploration of the plexus is recommended.

Terrible Triad of the Shoulder

The concurrent incidence of anterior shoulder dislocation, rotator cuff tear, and
brachial plexus injury has been coined the terrible triad of the shoulder. The first documented
case reports noted the difficulty of diagnosing rotator cuff tear in the presence of brachial
plexus palsy. This has important functional consequences because the results of early rotator
cuff repair are better than those of delayed repair. In a study of six patients with a mean age
of 57 years and with terrible triad injury, approximately 74° of forward flexion and 9 lb of
forward flexion strength was gained by a mean of 5.6 years after rotator cuff repair. Five
patients recovered from their nerve injury.

Vascular Injury
Vascular injury to the axillary artery is an uncommon but well-described sequela to
anterior shoulder dislocation in the elderly. More than 90% of axillary artery injuries
resulting from shoulder dislocations occur in patients aged >50 years. The proposed
mechanism is aging-related sclerotic changes in arteries and loss of elasticity, causing tearing
rather than stretching of the arteries. A mechanism has been described in which the
hyperabducted humeral head exposes the axillary artery and pushes it against the pectoralis
major muscle, which acts as a fulcrum and contributes to arterial injury. The third part of the
axillary artery, defined as the segment below the lower edge of the pectoralis minor muscle,
is the location of injury in up to 86% of patients. Most axillary artery injuries occur when
chronically dislocated shoulders in older patients are reduced closed. In chronic unreduced
shoulders, the axillary artery is scarred down and tethered by the pectoralis minor muscle.
The excessive force required to reduce a chronically dislocated shoulder is enough to cause
injury to the axillary artery.
Signs and symptoms of damage to the axillary artery include pallor, paresthesia,
decreased temperature, diminished or absent radial pulse, and an expanding axillary
hematoma. Prompt diagnosis and management are crucial to prevent irreparable harm to the
extremity. Exploration is obligatory in any patient with hematoma, ischemia, and absence of
a radial pulse. In patients with diminished distal pulses, angiography should be obtained
because collateral flow could be responsible for the presence of a radial pulse. Vascular
surgery consultation is warranted in these patients.
In the presence of subclavian or axillary artery injury, the treating surgeon should also
have a high index of suspicion for associated brachial plexus injury. If there is concern for
brachial plexus injury, brachial plexus exploration should be performed at the time of arterial
exploration rather than waiting 2 to 3 months, as is classically taught.

Recurrent Instability
 The recurrence rate after initial shoulder dislocation is much lower in older patients
than in younger ones, possibly because older patients tend to sustain rotator cuff ruptures
whereas younger patients tear the anterior stabilizing structures and glenohumeral ligaments.
In one study of patients aged ≥40 years, only 4% experienced recurrent shoulder dislocations.
Another study found the average age of patients with recurrent dislocations to be 55 years,
with an incidence of 11%.
In the patient with a combined displaced anteroinferior labral tear (ie, Bankart tear)
and acute rotator cuff injury, the surgeon should consider performing a combined repair to
promote shoulder stability. Our algorithm is to repair the labrum with minimal capsular shift
and address the rotator cuff tear. Postoperative stiffness is a concern with such a combined
repair; thus, the appropriate therapy should be promoted to begin early motion within a
protected range.

Chronic Unreduced Dislocations

Chronic shoulder dislocation is uncommon. These injuries are typically found in older
patients, and trauma is the most common etiology. Shoulder dislocation is considered chronic
when the glenohumeral joint is dislocated for several days. The primary complaint of patients
with chronic shoulder dislocations is loss of motion with pain. On physical examination, old
anterior dislocations present with restriction of abduction and internal rotation and old
posterior dislocations demonstrate restriction of abduction and external rotation. The most
common neurologic deficit involves the axillary nerve and presents as deltoid weakness.
Disuse atrophy can be apparent depending on the length of time the shoulder has been
dislocated.
Suspected chronic shoulder dislocation should be confirmed radiographically. Further
imaging with standard and three-dimensional CT is useful to evaluate the associated bony
injuries.
Not all patients with chronically dislocated shoulders require treatment. Patients with
a functional upper extremity despite slight discomfort and limited motion may opt to leave
the shoulder dislocated. Nonsurgical treatment should be considered for patients who are
poor surgical risks. Pain relief is the primary indication for reduction of a chronically
dislocated glenohumeral joint. Restoration of motion is secondary.
The first treatment option to consider is closed reduction. Patient age, duration of
dislocation, vascular status, and degree of humeral osteoporosis must be considered before
performing this maneuver. Closed reduction should not be attempted on a shoulder with a
≥20% impression defect of the humeral head or on a shoulder that has been dislocated longer
than 4 weeks. Closed reduction should be done under general anesthesia with total muscle
relaxation and minimal traction without leverage to avoid fracture of the proximal humerus or
rupture of the axillary artery.
If closed reduction is not possible, open reduction should be considered. This surgery
is difficult for many reasons. First, there is potential difficulty in reducing the humeral head
into the glenoid fossa because of fibrosis and capsular bowstringing across the glenoid.
Second, contraction of rotator cuff muscles and the usual humeral head defect make
maintenance of the reduction difficult. Neviaser recommends a stripping operation wherein
the capsule, rotator cuff, and fibrous adhesions are stripped before reduction is attempted.
Large humeral head defects (>45% of the humeral head) are best managed with
hemiarthroplasty. With this procedure, retroversion of the humeral component can be
decreased to reduce the tendency of the head to subluxate posteriorly in posterior dislocation.
In a study of 11 patients (12 arthroplasties) treated with hemiarthroplasty for chronic shoulder
dislocation, significant improvement in flexion (P = 0.021), abduction (P = 0.007), and
external rotation (P = 0.003) range of motion was noted at an average 37-month follow-up.
Reverse shoulder arthroplasty should be considered for patients aged ≥70 years who present
with chronic, symptomatic shoulder dislocations with humeral head bone loss and rotator cuff
deficiency.

Management
Management of shoulder dislocation in the older patient begins in the emergency
department with prompt closed reduction of the dislocation. Most acute dislocations are
readily reducible under sedation in the emergency department. Chronic dislocations (ie,
treated 3 to 4 weeks postinjury) may require closed reduction in the operating room under
complete muscular paralysis. In one study, 88% of patients had uneventful closed
reduction in the emergency department, 5% needed general anesthesia, and only 3% required
open reduction.
Thorough neurovascular examination should be performed, and vascular surgery
consultation should be obtained if warranted. The patient is discharged in a sling for comfort.
Early range-of-motion exercises and physical therapy are started within the first week to
prevent posttraumatic shoulder stiffness. Patients begin with passive pendulum and Codman
exercises and add progressive passive and active range of motion under the supervision of a
therapist for 3 to 4 weeks. Patients who fail physical therapy in 3 to 4 weeks and have
persistent cuff weakness should be evaluated with MRI to screen for underlying pathology.
However, if on initial presentation significant cuff weakness exists, earlier imaging may be
indicated. Surgeons must maintain a very high index of suspicion, especially in older and
elderly patients who acutely lose function after shoulder dislocation. The most common
injury is a traumatic rotator cuff tear in the setting of attritional, degenerative tissue. Failure
to identify this injury could result in chronic, painful dysfunction.

Outcomes of Rotator Cuff Repair

The main difference between primary shoulder dislocation in older patients versus
young patients is that older patients with known traumatic rotator cuff injury are more likely
to be treated surgically. In older patients with shoulder dislocation, early diagnosis and
repair of the traumatic rotator cuff tear yields optimal outcomes. Other authors have also
shown better outcomes with surgical management than non-surgical management of rotator
cuff tear.
Patients aged ≥40 years who are treated surgically for shoulder dislocations have
shown equivalent redislocation rates compared with patients aged <40 years who have
undergone surgical treatment (P>0.05). An increase in Constant scores has been reported in
patients aged 40 to 60 years who were treated arthroscopically for rotator cuff tears.

Summary
The pathology of shoulder dislocation in older patients is significantly different from
that in younger patients. Whereas dislocation leads to capsulolabral tears in the young, it
typically results in rotator cuff tears or fractures in the elderly. Older patients are more likely
than younger patients to sustain injuries to the axillary nerve or brachial plexus. This is
because of lesser compliance in the older shoulder. However, neural injury should not be
assumed in all cases. Patients should be assessed for rotator cuff tear. Treatment should be
focused on early closed reduction and physical therapy with the goal of restoring motion and
strength. For older patients who fail nonsurgical treatment, early diagnosis and treatment of
the associated rotator cuff tear can lead to satisfactory outcomes.
REFERENCE:
Murthi, AM, dan Ramirez, MA. 2012. Shoulder Dislocation in the Older Patient. J Am Acad
Orthop Surg 2012;20:615-622.