Original question.
What are the varieties of Dislocation of the Shoulder-joint, and what are the principles of treatment.
The chief historical varieties are subglenoid, subcoracoid, subclavicular and posterior shoulder dislocation; treatment restores the humeral head gently, checks the axillary nerve and circulation, and restores useful movement.
The glenohumeral joint combines a large humeral head with a shallow glenoid cavity. Its range of movement depends on the comparatively loose joint capsule; the glenoid labrum, rotator cuff and surrounding muscles provide stability. An injury can therefore lever the humeral head out of the glenoid cavity while tearing the joint capsule and sometimes the glenoid labrum or adjacent bone.
- In subglenoid shoulder dislocation, the humeral head lies below the glenoid cavity, toward the axilla. Old descriptions of displacement “downwards into the axilla” need not mean the persistently overhead arm position now called luxatio erecta.
- In subcoracoid shoulder dislocation, the humeral head lies in front of the glenoid cavity, beneath the coracoid process. This is the familiar anteroinferior pattern.
- In subclavicular shoulder dislocation, the humeral head has passed farther forwards and medially, beneath the clavicle; this is a rarer, more extensive anterior displacement.
- In posterior shoulder dislocation, historically also called subspinous displacement, the humeral head lies behind the glenoid cavity, toward the scapular spine. Modern assessment is particularly alert to this pattern after a seizure or electrical injury. True inferior shoulder dislocation, luxatio erecta, and exceptional superior displacement complete the directional classification; they should not be forced into the common anterior pattern.[ref]Shoulder Dislocations: Emergency Department by the Royal Children's Hospital Melbourne. Sections 3–4: anterior and posterior displacement and their mechanisms
An 1867 answer would stress early recognition, relaxation of the muscles, and controlled traction with suitable countertraction or gentle leverage to guide the humeral head through the torn joint capsule. Anaesthesia made relaxation practicable. These are principles, not a reason to reproduce old forceful manoeuvres or indiscriminate pulley traction: force can produce a fracture or damage the axillary artery and brachial plexus.
Current assessment establishes the direction and associated fracture, usually with radiography in appropriate views. Before and after joint reduction, record pulse, perfusion, distal movement and sensation, including sensation over the lateral deltoid muscle supplied by the axillary nerve. A nerve injury accompanying joint dislocation makes prompt restoration of alignment especially important.[ref]
Peripheral Nerve Injury by the British Orthopaedic Association. BOASt, response to identification of peripheral nerve injury, recommendation 5
Joint reduction is performed by trained clinicians with suitable analgesia and, when needed, sedation or anaesthesia. Repeated forceful attempts are inappropriate; irreducibility or associated complex fracture requires specialist management.[ref]After joint reduction, reassess the axillary nerve and circulation and confirm alignment and relevant fractures with radiography. A temporary sling relieves pain, followed by progressive physiotherapy to restore movement and rotator cuff function. The balance is between recurrent instability and stiffness: prolonged immobilisation is not a universal solution. Recurrent instability, significant structural injury and persistent weakness require further assessment.[ref]
Shoulder Dislocations: Emergency Department by the Royal Children's Hospital Melbourne. Sections 7–10: gentle reduction, repeat neurological examination, imaging and follow-up; this source specifically addresses children and adolescents
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