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Overview of Shoulder Dislocation

Shoulder dislocation more accurately termed a glenohumeral joint dislocation involves separation of the humerus from the glenoid of the scapula at the glenohumeral joint. Shoulder dislocation almost exclusively occurs following trauma. Shoulder dislocations are one of the most common musculoskeletal injuries and they account for more than 50% of major joint dislocations. If your shoulder is sprained upward or backward, you may displace it out of its socket.  This condition is extremely painful and it incapacitates your shoulder motion.  Ironically, what we consider seemingly simple can dislocate our shoulder, for e.g., a fall, collision with another person (especially in contact sports). The only treatment option for a dislocated shoulder is a prompt reduction. Shoulder reduction is the process of returning the shoulder to its normal position following a shoulder dislocation. Normally, closed reduction, in which the relationship of bone and joint is manipulated externally without surgical intervention, is used. A variety of techniques exist, but some are preferred due to fewer complications or easier execution. Reduction techniques can vary in terms of required force, time, equipment, and staff. In order to achieve a safe and satisfactory result many techniques are devised by the modern medical science.  One such technique is called Boss-Holzach Matter. It is a safe and effective way of placing your shoulder back in its place.

Signs and Symptoms of Shoulder Dislocation

The following are the general symptoms of shoulder dislocation:

• Severe pain in the shoulder joint is the predominant symptom of shoulder dislocation
• Moving the arm becomes extremely difficult
• Shoulder feels mushy on touching as though there is no underlying bone
• Patient may feel the shoulder is slack
• Patient may hear clicks and pops
• The affected arm may feel weak and numb
• If it is a chronic injury there may be swelling around the shoulder joint

Anterior dislocation when the top of the humerus is displaced forward, toward the front of the body is the most common type of shoulder dislocation, accounting for more than 95% of cases. In young people, the cause is typically sports-related. In older people, it usually is caused by a fall on an outstretched arm. The other type of shoulder dislocations include Posterior (backward) dislocation occurs when the humeral head moves toward the back of the body and Inferior (downward) dislocation that  results in a downward movement of the humeral head. Multidirectional dislocation is traumatic in nature and occur in patients who have inborn laxity in their joints.

If you suspect you have a shoulder dislocation, seek emergency medical treatment.  Delaying treatment will aggravate the condition resulting in unnecessary suffering and further impairment to nerves, blood vessels, muscles and tendons.

Self Reduction of Shoulder Dislocation

In the beginning, with doctor’s assistance, this technique lets the patient put the displaced shoulder back in its socket.  Later the patient can do it on his/her own.  Self-assisted reduction of shoulder has been described as the most preferred first-line choice of treatment in number of medical studies. Reduction techniques for anterior dislocations generally use axial traction and/or external rotation.  If a patient has recurrent shoulder dislocations, self-reduction is indeed a boon.  There is no trauma involved in this technique and it is quite simple. The highlight of this procedure is it can be performed by both medical and non-medical personnel. The advantage of this procedure does not end there. There is no need of analgesics or general analgesia to do this procedure. Moreover, it can be done in any setting, including a clinic. It can be done outside or in a remote countryside where accessing a medical facility can be challenging and time consuming. Reduction attempts, particularly those done without sedation, are more likely to succeed if the patient is relaxed and cooperating.  To avoid increasing muscle spasms, all reductions are done gently and gradually, and reduction methods that use less force are often tried before those that use greater force. The risks of the reduction procedure itself are minimal and include the rare incidence of fractures of the humerus, glenoid, or coracoid process. Rotator cuff injuries may also occur, but are usually present prior to reduction. Axillary artery or nerve injury may occur during reduction, especially with techniques that require a significant amount of traction, but such complications are rare.

What is Boss_Holzah Matter Technique?

Boss-Holzach Matter technique also known as the Davos reduction maneuver has been studied thoroughly by medical professionals and found to have a positive outcome in majority of cases. This technique originally described in 1993 was studied retrospectively in 100 patients with a high success rate.The Boss-Holzach-Matter technique was less painful than the physician-driven Spaso technique. What is even more exciting about this procedure is this has been reported successful and safe even if there is a fracture of the greater tuberosity or depression fracture of the humeral head. This technique can be employed once dislocation of the shoulder is confirmed. With the help of a physical examination it can be made sure if a person has shoulder displacement or not. A bulge anteriorly of the humeral head can be seen in case of a shoulder displacement and it can be palpated as well.  The deltoid muscle can be observed and it is likely to be flattened. The patient is likely to hold the displaced shoulder slightly abducted and externally rotated. Pain can be experienced in all planes in range of motion testing. The patient with anterior dislocation could not place the hand of the affected side on the opposite shoulder.

Though neurovascular injury is not generally seen in shoulder dislocation, examination of vascular status, sensory and motor is of utmost importance. While all nerves of the brachial plexus are at risk of injury during glenohumeral dislocation, the most commonly injured is the axillary nerve.The axillary nerve innervates deltoid and teres minor and provides sensation to lateral shoulder. Axillary nerve compromise presents in over 40% of dislocations,The primary symptom of this type of damage is numbness on the outside of the upper arm.If there is suspicion of a vascular rupture, it is a medical emergency.  As with any medical treatment, reduction is highly effective if done soon after the injury.  Delay in reduction of shoulder dislocation can lead to unsuccessful reduction or failure to reduce.  Hence prompt reduction is very important. Prompt reduction also reduces the amount of stretch and compression of neurovascular structures. It will restrict muscle spasm. Muscle relaxation is of prime importance for the success of the shoulder reduction. Assisting the patient to relax the muscles of the shoulder would help reduction.

Shoulder dislocation has a high overall recurrence rate.  Please see the below exhibit.

The risk factors for recurrent shoulder dislocation are young age, participation in high demand contact sports activities, presence of Hill-Sachs or osseous Bankart lesion, previous history of ipsilateral traumatic dislocation, ipsilateral rotator cuff or deltoid muscle insufficiency, and underlying ligamentous laxity.

A shoulder reduction can be of two types. One by the medical personnel and other by the patient himself. The latter gives the patient a better control of the reduction and a better control over the pain.

How is Boss-Holzach Matter Technique done?

The patient is seated on the examination table or another hard surface. The patient has to flex the ipsilateral knee bent at 90° and has to place the foot flat on the table or other surface. With the fingers interlocked about the knee, the patient gently leans backward with the neck hyperextended until the arms are fully extended, producing axial traction. Simultaneously, the patient shrugs the shoulders anteriorly, generating anteversion of the scapula on the axis of traction to facilitate reduction. This technique has a success rate of 60%. This is most effective in reducing a dislocation called sub coracoid anterior dislocation. This could be very effective in patients who have a history of repeated dislocations, who are alone and immediate medical assistance is not possible.

It has been amply proven that Boss-Holzach-Matter technique is less painful compared to conservative physician-driven techniques. 

After your shoulder splint or sling is removed, you’ll begin a gradual rehabilitation program designed to restore range of motion, strength and stability to your shoulder joint.Therapy following shoulder reduction may include exercises to strengthen the muscles that surround the shoulder and to maintain range of motion of the shoulder joint. The total rehabilitation and recovery time from a shoulder dislocation is about 12-16 weeks.

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