Abstract
Background:
A number of shoulder girdle injuries are associated with acute anterior glenohumeral dislocations. In the present study we evaluated the prevalence of neurological deficits, greater tuberosity fractures, and rotator cuff injuries in a population of unselected patients who presented with a traumatic anterior glenohumeral dislocation.
Methods:
A prospective trauma database was used to record the demographic details on 3633 consecutive patients (2250 male patients and 1383 female patients with a mean age of 47.6 years) who had sustained a traumatic anterior glenohumeral dislocation between 1995 and 2009. On the basis of these data, we assessed the prevalence of and risk factors for ultrasound-proven rotator cuff tears, tuberosity fractures, and neurological deficits occurring in association with the dislocation.
Results:
Of the 3633 patients who had a dislocation, 492 patients (13.5%) had a neurological deficit following reduction and 1215 patients (33.4%) had either a rotator cuff tear or a greater tuberosity fracture. A dislocation with a neurological deficit alone was found in 210 patients (5.8%), a dislocation with a rotator cuff tear or a greater tuberosity fracture was found in 933 patients (25.7%), and a combined injury pattern was found in 282 patients (7.8%). Female patients with an age of sixty years or older who were injured in low-energy falls were more likely to have a rotator cuff tear or a greater tuberosity fracture. The likelihood of a neurological deficit after an anterior glenohumeral dislocation was significantly increased for patients who had a rotator cuff tear or a greater tuberosity fracture (relative risk, 1.9 [95% confidence interval, 1.7 to 2.1]; p < 0.001).
Conclusions:
The prevalence of rotator cuff tear, greater tuberosity fracture, or neurological deficit following primary anterior glenohumeral dislocation is greater than previously appreciated. These associated injuries may occur alone or in combined patterns. Dislocations associated with axillary nerve palsy have similar demographic features to isolated dislocations. Injuries associated with a rotator cuff tear, greater tuberosity fracture, or complex neurological deficit are more common in patients sixty years of age or older. Careful evaluation of rotator cuff function is required for any patient with a dislocation associated with a neurological deficit, and vice versa.
Level of Evidence:
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Acute anterior glenohumeral shoulder dislocation may be complicated by neurological deficits1-6, injuries to the rotator cuff, and fractures of the greater tuberosity7-12. These lesions are clinically important in the early phase of treatment because they can compromise subsequent recovery of function, either through dysfunction of the rotator cuff or as a result of denervation of important prime movers of the shoulder girdle. Early recognition is important when counseling patients about their anticipated delayed recovery and to ensure appropriate and expeditious treatment. Other lesions associated with glenohumeral dislocation include osteochondral fracture of the posterior aspect of the humeral head (Hill-Sachs lesion), avulsion of the glenoid labrum, and fractures of the glenoid rim. All of these lesions are implicated in the development of shoulder instability, but they only occasionally influence early functional recovery.
Both tears of the rotator cuff tendons and fractures of the greater tuberosity may compromise the early recovery of rotator cuff function following glenohumeral dislocation, either through injury to the musculotendinous units of the rotator cuff itself or through detachment of their insertion on the greater tuberosity7-12. The most common neurological deficit is isolated axillary nerve palsy, although any component of the brachial plexus may be injured1-6. Dislocations therefore are best considered as a clinical spectrum that includes (1) isolated dislocations, (2) injuries producing either detachment of the rotator cuff or neurological deficit alone, and (3) combined injuries13-16. Previous studies of injuries associated with anterior glenohumeral dislocation were limited to small clinical series3,8,10,17,18 or case reports13,14,19,20. The purpose of the present study was to evaluate the prevalence of and risk factors for rotator cuff tears, tuberosity fractures, and neurological deficits associated with dislocation in a large consecutive series of patients who were managed in our unit.
Demographic Characteristics
From January 1995 to May 2009, we recorded the injury details for all patients from our local population who were over the age of thirteen years and who underwent treatment of a primary traumatic anterior shoulder dislocation. All data were anonymously stored on a trauma database. This unit provides the only acute musculoskeletal trauma service for patients over the age of thirteen years in the local population. In 2002, at the midpoint of the present study, the total population served by our institution was 778,36721.
To be included in the present study, a patient had to reside locally and had to have sustained a radiographically confirmed acute primary traumatic anterior dislocation of the shoulder following an injury (defined as a fall, collision, seizure, or other cause of musculoskeletal trauma). Patients with posterior and luxatio erecta dislocations and patients receiving treatment of recurrent instability were excluded. Bilateral metachronous dislocations in the same patient were considered as separate injury events. Patients with Neer two-part tuberosity fractures22 associated with the anterior dislocation were included, but patients with three and four-part anterior fracture-dislocations were excluded. We also excluded 154 patients who were managed locally but were not permanent residents in our local catchment area, ninety-six patients who did not return for follow-up visits, and seven patients who presented late (more than one week) following the primary dislocation.
A total of 3633 patients (2250 male patients [61.9%] and 1383 female patients [38.1%]) with a shoulder dislocation were included in the present study. The mean age was 47.6 years (95% confidence interval [CI], 46.8 to 48.4 years; range, thirteen to 104 years). The right side was affected in 1970 patients (54.2%), and the left side was affected in 1663 patients (45.8%). The dominant arm was affected in 1923 patients (52.9%), and the nondominant arm was affected in 1710 patients (47.1%).
Initial Treatment
With the patient under conscious sedation, closed reduction of the glenohumeral dislocation was performed with use of either the Milch or the Hippocratic technique23. The attempted closed reduction failed in twenty-seven patients. Of these patients, twenty-four then had closed reduction under general anesthesia and three had open reduction. All patients were referred to trauma clinics during the week after the injury, where they were reviewed by an attending surgeon specializing in musculoskeletal trauma or a senior trainee.
Clinical Examination and Investigations
All patients had documentation of the date of injury, primary treatment, age, sex, side of injury, mechanism of injury, and history of shoulder problems when they attended the trauma clinic. The patients also underwent rotator cuff function and neurological examinations at the time of a follow-up consultation within one week after the injury. In addition, 2655 patients had another follow-up visit within the first six weeks after the injury to document the resolution of neurological or rotator cuff deficits or to clarify doubts about the integrity of the rotator cuff or neurological status.
At each consultation, specific validated clinical tests were used to assess subscapularis, supraspinatus, and infraspinatus muscle function24-26. All patients in whom a rotator cuff tear was suspected on the basis of an abnormal result on clinical testing of muscle function were investigated with an ultrasound examination that was performed or supervised by a single senior consultant radiologist on a semi-urgent basis within one week after the clinical test. Tears that were confirmed on ultrasound examination were graded according to the degree of chronicity, anatomic location (supraspinatus, infraspinatus/teres minor, and subscapsularis), and size with use of the Bateman system27. Tear chronicity was assessed on the basis of the degree of retraction, suspected atrophic change, and fatty infiltration within the muscle on ultrasound examination. Magnetic resonance imaging (MRI) was performed for 107 patients who had inconclusive findings regarding tear chronicity on ultrasound examination. Anteroposterior and modified axial radiographs were used to assess the presence of any associated fractures28. Greater tuberosity fractures were graded according to size and displacement.
Muscle motor power testing (with use of the Medical Research Committee grading system) and pain/light touch sensory testing were performed to assess the segmental nerve roots of the brachial plexus and the axillary, radial, ulnar, median, and musculocutaneous nerves. In the present study, we excluded transient palsies that had been present prior to relocation and had fully resolved after shoulder relocation by the first clinical assessment. Electrophysiological testing (electromyography, testing of somatosensory evoked potentials, and nerve conduction testing) was performed by a specialist neurophysiologist for the assessment of all patients with complex nerve injuries (defined as those involving more than a single nerve), patients in whom the extent of the injury was unclear, and patients who had had persistent lesions beyond six weeks.
Statistical Analysis
The age and sex-specific prevalence of dislocation per 100,000 person-years of exposure to risk was calculated with use of local population demographic data. The person-years-at-risk methodology, with censorship at death or at the end of the study, was used to control the confounding effect of increasing mortality rates with advancing age.
We examined differences in the demographic patterns of associated injury to the rotator cuff unit and neurological deficit with use of the Mann-Whitney U test for continuous data and with use of the Fisher exact test or the chi-squared test for categorical data. Factors that were significant at the p < 0.05 level were considered in a multivariate logistic regression to determine those that were independently predictive of these associated injuries with use of forward stepwise methodology.
Sources of Funding
No external funding source was used for this study.
We considered the subgroups of patients according to whether they had associated injuries and whether these injuries occurred in isolation or in combined injury patterns.
Dislocations without an Associated Injury (Group I)
Of the 3633 dislocations, 2208 (60.8%) were isolated dislocations with no associated neurological deficit, greater tuberosity fracture, or evidence of rotator cuff tear (Table I). The mean age of these patients was 39.9 years (95% CI, 39.0 to 40.8 years; range, thirteen to 104 years). These patients had a bimodal distribution (Fig. 1). The first peak was in patients between the ages of thirteen and twenty-nine years, 85.1% of whom were male and 85.0% of whom had sustained sports injuries. The second peak was in older patients (those with an age of seventy years or more), 70.5% of whom were female and 93.1% of whom had sustained the injury as the result of a low-energy fall.
Dislocations Associated with a Neurological Deficit, Greater Tuberosity Fracture, or Rotator Cuff Tear (Groups II, III, and IV)
Four hundred and ninety-two patients (13.5%) had a persistent neurological deficit, and 1215 patients (33.4%) had either a greater tuberosity fracture on radiographs or an ultrasound-confirmed rotator cuff tear, either alone or as a combined injury. Two hundred and ten patients (5.8%) had a dislocation with a neurological deficit alone (Group II), 933 patients (25.7%) had a dislocation with either a greater tuberosity fracture or rotator cuff injury (Group III), and 282 patients (7.8%) had a combined injury pattern (Group IV) (Fig. 2). These patients were further considered according to this subclassification.
Dislocation with a Neurological Deficit (Group II)
The 210 patients (5.8%) with a neurological deficit were very similar to the patients with an isolated dislocation in terms of overall distribution with regard to sex, mechanism of injury, and bimodal age distribution (Table I). Single-nerve lesions (Group IIA) were most prevalent (Table II), accounting for 190 (90.5%) of the 210 patients in this group. Solitary axillary nerve palsy was the most common single-nerve lesion, accounting for 155 (73.8%) of the 210 patients who had had a dislocation with neurological deficit and most commonly occurring in the young, predominantly male population during sports activities (Table III). Other single-nerve lesions appeared less frequently, with isolated ulnar and median nerve palsies being the next two most common lesions (Table II).
In contrast, patients with multiple-nerve lesions (Group IIB) were more likely to be sixty years of age or older at the time of the injury (relative risk, 3.3 [95% CI, 2.1 to 5.1]; p < 0.001), were more likely to be female (relative risk, 2.1 [95% CI, 1.4 to 3.3]; p = 0.001), and were more likely to have sustained the injury in a low-energy fall (relative risk, 3.0 [95% CI, 1.9 to 4.9]; p < 0.001). Electrophysiological testing in these patients typically showed widespread brachial plexus lesions that were invariably more severe than had been apparent on clinical examination.
Dislocation with a Greater Tuberosity Fracture or Rotator Cuff Tear (Group III)
A dislocation with a greater tuberosity fracture or a rotator cuff tear was seen in 933 patients (25.7%); of these, 566 patients (60.7%) had a fracture of the greater tuberosity (Group IIIA), and 367 patients (39.3%) had a rotator cuff tear (Group IIIB). Although patients in Group IIIB were significantly older than those in Group IIIA (mean age, 69.3 years compared with 60.3 years; p < 0.001), there were no significant differences between these groups in terms of sex or the mechanism of injury. In patients sixty years of age or older, the prevalence of Group-III injuries was greater than that of Group-I injuries (Fig. 1).
In Group IIIA, the greater tuberosity fragments were small (maximum dimension, ≤2.5 cm) in 343 patients (60.6%) and large (>2.5 cm) in 223 patients (39.4%). With the numbers available, there were no significant differences in injury between the groups of patients with small and large fragments in terms of age, sex, or mechanism of injury. All fractures were initially displaced prior to shoulder relocation. Following shoulder relocation, the fracture was displaced by <1 cm and angulated <45° in 327 patients (57.8%) but remained displaced by ≥1 cm or angulated by ≥45° in 239 patients (42.2%).
In Group IIIB, fifty-two patients (14.2%) had a Grade-1 rotator cuff tear (<1 cm) on ultrasound examination, 177 patients (48.2%) had a Grade-2 tear (1 to 3 cm), ninety-one patients (24.7%) had a Grade-3 tear (>3 to <5 cm), and forty-five patients (12.3%) had a Grade-4 tear (a global tear with little or no cuff left) according to the Bateman classification system27. The remaining two patients (one eighteen-year-old man and one twenty-three-year-old man) had a panhumeral cuff avulsion with detachment of all soft tissues associated with capsule button-holing and an irreducible dislocation. One hundred and sixty-three patients (44.4%) had a single supraspinatus tendon tear, and 204 patients (55.6%) had additional tears involving the infraspinatus and teres minor tendons. Fifty-six patients (15.3%) had ultrasound evidence of a subscapularis tear from the lesser tuberosity. Patients with Grade-3 and 4 tears were significantly older than patients with Grade-1 and 2 tears (p = 0.04), although there were no differences between the groups in terms of sex or the mechanism of injury, with the numbers available. On ultrasound or MRI examination, fifty-six patients (15.3%) had a retracted tear with extensive fatty infiltration or atrophic change. These tears were all thought to be chronic or acute-on-chronic, and twenty-eight of these patients had had a history of pain or restricted shoulder function prior to the injury.
Combined Injury Patterns (Group IV)
A combination of neurological deficit and either greater tuberosity fracture or rotator cuff tear was seen in 282 patients (7.8%) (Table I). The demographic profile of patients with Group-IV injuries was similar to that of patients with Group-III injuries (Fig. 1 and Table I). As was the case in Group III, patients with a greater tuberosity fracture (Group IVA) formed the largest subgroup (206 patients; 73.1%) whereas those with a rotator cuff tear (Group IVB) represented the minority (seventy-six patients; 26.9%). Patients with Group-IVB injuries were significantly older than those with Group-IVA injuries (mean age, 63.0 compared with 56.3 years; p = 0.002), but there were no significant differences between Groups IVA and IVB in terms of sex or the mechanism of injury. As in Group III, most greater tuberosity fractures in Group IVA involved smaller fragments (59.7%; 123 of 206) and remained displaced following shoulder relocation (68.4%; 141 of 206). Group IVB was also similar to Group IIIB in terms of the size and anatomic location of the rotator cuff tears. Twelve patients (15.8%) had a Grade-1 tear, thirty-four (44.8%) had a Grade-2 tear, twenty-one (27.6%) had a Grade-3 tear, and nine (11.8%) had a Grade-4 tear. Thirty-one patients (40.8%) had a single supraspinatus tendon tear, and forty-five patients (59.2%) had additional involvement of the infraspinatus and teres minor tendons. Ten patients (13.2%) had ultrasound evidence of a subscapularis tear from the lesser tuberosity. Patients with Grade-3 and 4 tears were significantly older than patients with Grade-1 and 2 tears (p = 0.04), although there were no differences between the groups in terms of sex or the mechanism of injury, with the numbers available. On ultrasound or MRI examination, nine patients (11.8%) had a retracted tear with extensive fatty infiltration or atrophic change. These tears were thought to be chronic or acute-on-chronic, and six (7.9%) of these patients had had a history of pain or restricted shoulder function prior to their injury.
Most neurological deficits in Group IV were single-nerve palsies (78%; 220 of 282) (Tables II and III). Axillary nerve lesions accounted for 174 (61.7%) of the nerve injuries. However, a significantly greater proportion of the neurological deficits in Group IV were multiple-nerve lesions (22%; sixty-two of 282) in comparison with Group II (relative risk, 2.0 [95% CI, 1.3 to 3.2]; p = 0.003). As was the case in Group II, patients with multiple-nerve lesions were more likely to be sixty years of age or older (relative risk, 1.6 [95% CI, 1.2 to 2.2]; p < 0.004), to be female (relative risk, 1.6 [95% CI, 1.2 to 2.2]; p = 0.006), and to have sustained the injury as the result of a low-energy fall (relative risk, 1.8 [95% CI, 1.2 to 2.6]; p = 0.004). Patients with multiple-nerve lesions also were more likely to have a residually displaced tuberosity fracture after relocation or a Bateman Grade-3 or 4 rotator cuff tear (p = 0.04).
Risk Factors for Associated Injuries
On univariate analysis, the likelihood of neurological deficit with dislocation increased with female sex and low-energy injury (p < 0.1). On multivariate analysis, only low-energy injury was independently predictive of nerve palsy (p = 0.015). When isolated nerve palsies (Group-IIA injuries) were excluded, univariate analysis revealed an increased risk of multiple-nerve deficits (Group-IIB injuries) in patients who were sixty years of age or older at the time of the injury, in female patients, and in patients who had sustained a low-energy injury (p < 0.1). When these factors were considered together on multivariate analysis, only female sex and low-energy injury were predictive of nerve palsy (p = 0.009 and 0.001, respectively).
On univariate analysis, the likelihood of a rotator cuff or greater tuberosity injury with dislocation increased with the factors of an age of sixty years or more at the time of the injury, female sex, and low-energy injury (p < 0.1). When these factors were considered together on multivariate analysis, only the factors of an age of sixty years or more and low-energy injury were independently predictive (p < 0.001 for both). Of the 1213 patients with an age of sixty years or more who had sustained the injury after a low-energy fall, 733 (60.4%) had evidence of injury to either the rotator cuff or the greater tuberosity.
On univariate analysis, the risk of a Group-IV combined injury was associated with an age of sixty years or more at the time of the injury, female sex, and low-energy injury. When considered together on multivariate analysis, an age of sixty years or more (p = 0.006), female sex (p = 0.019), and low-energy injury (p < 0.001) remained independently predictive. Of the 808 female patients with an age of sixty years or more who sustained the injury as the result of a low-energy fall, seventy-nine (9.8%) had a Group-IV injury. The likelihood of a neurological deficit after an anterior glenohumeral dislocation was significantly increased for patients who had a rotator cuff tear or a greater tuberosity fracture (relative risk, 1.9 [95% CI, 1.7 to 2.1]; p < 0.001).
The present study demonstrated the high prevalence of greater tuberosity fractures, rotator cuff tears, and neurological deficits associated with acute anterior dislocation of the glenohumeral joint. Of the 3633 patients with dislocations, approximately one-third (33.4%) had either a greater tuberosity fracture or a rotator cuff tear, and 13.5% had evidence of a neurological deficit. These lesions occurred either in isolation or in combination, and, of the 3633 patients with a dislocation, 210 (5.8%) had a neurological deficit (Group II), 933 (25.7%) had either a greater tuberosity fracture or a rotator cuff tear (Group III), and 282 (7.8%) had a combined injury (Group IV).
The majority of isolated neurological deficits (Group II) occurring with dislocation were isolated lesions of the axillary nerve. Other solitary nerve lesions and multiple nerve lesions were relatively uncommon. The demographic features of patients with isolated neurological deficits were indistinguishable from those of the larger group of patients with isolated dislocations in that the injuries occurred in a relatively young, predominantly male population and were commonly sustained during sports activities. In contrast, rotator cuff tears, greater tuberosity fractures, and these injuries combined with neurological lesions (Groups III and IV) showed a progressive increase in prevalence with advancing age, with all of these injuries being more common than isolated dislocations in patients who were sixty years of age or older. In addition, Group-III and IV injuries were relatively more common in women and were more likely to be sustained as a result of low-energy falls.
When we considered all patients in the present study, the likelihood of neurological deficit with dislocation increased with female sex and low-energy injury. However, only low-energy injury was independently predictive of neurological injury, which is counterintuitive and may reflect low-energy injury as a surrogate for frailty, predisposing the patient to a more severe injury pattern in relation to the injury mechanism. There was no association between female sex and low-energy injury in patients sixty years of age and older because the great majority of glenohumeral dislocations occurring in older patients resulted from low-energy trauma, irrespective of sex.
In the past, the combined Group-IV injury pattern was regarded as relatively uncommon, and most previous accounts were case reports (see Appendix)1,7,13-20,29-34. The present study suggested that this pattern of injury was more common than previously recognized, with 7.8% of the cohort having this injury pattern. The demographic features of Group-III and Group-IV injuries were similar. As was the case with Group-II injuries, the neurological deficit associated with Group-IV injuries was most commonly an isolated axillary nerve lesion. However, the prevalence of the more severe multiple nerve lesions was more than two times greater in Group IV than in Group II. In the absence of a greater tuberosity fracture on postreduction radiographs, it is advisable to image the rotator cuff in patients with more complex neurological deficits as the likelihood of concomitant rotator cuff injury is high. These complex dislocations are the most devastating form of glenohumeral dislocation as the recovery of function may be compromised by both an injury to the rotator cuff and the severe neurological deficit. Although the majority of older patients who sustain these injuries will be managed nonoperatively for the nerve injury, it is important that rotator cuff injuries are detected and treated expediently to reduce later functional incapacity should the neurological deficit resolve7.
Previous longitudinal studies have shown a high prevalence of both isolated nerve palsies and rotator cuff injuries after acute glenohumeral dislocation (see Appendix)1-3,5,7-12,17,35-37. Those studies also demonstrated that routine use of advanced diagnostic studies, such as electromyographic investigation and imaging of the rotator cuff, revealed a greater prevalence of these injuries than was apparent on clinical evaluation alone (see Appendix). The prevalence of associated lesions varied widely in the reported series and depended on the population studied. Some studies evaluated the prevalence of complications in selected series or solely in the elderly population (see Appendix). To our knowledge, the present study represents the largest unselected population sample examining this group of injuries.
Although the patient cohort in the present study was large, we did not have a routine protocol for imaging the rotator cuff or for specialist evaluation of nerve injuries for all patients. However, the purpose of the present study was not to evaluate the prevalence of all rotator cuff tears but to assess the prevalence of those that were detectable on the basis of the findings of rotator cuff muscle weakness on clinical examination and subsequent confirmation on ultrasound examination within the first week after the injury. Routine imaging of the rotator cuff also would have identified a number of preexisting asymptomatic cuff tears that are known to be more prevalent in the elderly38-40. Although it was possible that we underestimated the overall prevalence of rotator cuff tears in the present study cohort, we believe that the study provided an accurate estimation of the prevalence of clinically important tears that are likely to require treatment. It also was possible that we overestimated the prevalence of rotator cuff tears by including some tears that may have existed before the dislocation. An assessment of the interobserver reliability of a senior orthopaedic trainee, compared with an attending surgeon, would benefit future studies.
Our findings support the use of routine advanced imaging (ultrasound or MRI) on patients sixty years of age or older who have clinical signs of rotator cuff weakness without evidence of a greater tuberosity humeral fracture. Similarly, a high index of suspicion is required when assessing the subgroup of younger patients forty years of age or older with anterior glenohumeral dislocations. Although these patients had a much lower prevalence of rotator cuff tears, clinicians should have a low threshold for performing an ultrasound or MRI examination if a rotator cuff tear is suspected, given the devastating consequences of missing this type of injury in younger, more active patients.
In summary, the prevalence of rotator cuff tears, greater tuberosity fractures, and neurological injuries associated with traumatic anterior glenohumeral dislocation increases with advancing age, female sex, and low-energy injury.
Tables showing the published case reports and case series of patients with Group-IV injuries (dislocation in association with rotator cuff tear or greater tuberosity fracture and neurological injury) and the published studies of the prevalence of brachial plexus palsies, tuberosity fractures, and/or rotator cuff tears in patients with acute primary anterior shoulder dislocations are available with the online version of this article as a data supplement at jbjs.org.
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