SIDELINE MANAGEMENT OF ACUTE DISLOCATION OF THE GLENOHUMERAL JOINT‐ A UNIQUE APPROACH TO ATHLETE SELF‐REDUCTION

Abstract

The acute anterior dislocation of the glenohumeral joint (GHJ) poses a challenge to sports medicine providers at all levels and in all settings. This macrotraumatic injury occurs in athletes who participate in a wide variety of sports, most typically as a result of contact or collision mechanisms. Quick and effective relocation of the GHJ is an important skill for on the sideline or on the field management of this type of dislocation when appropriate and allowable by facility protocol. This clinical suggestion describes one possible technique for athlete self‐reduction that may be appropriate in some circumstances. This is in contrast to forcible reduction by the health professional, which is outside of the scope of this clinical commentary.

Level of Evidence:

5

INTRODUCTION

The acute anterior dislocation of the glenohumeral joint (GHJ) poses a challenge to sports medicine providers at all levels and in all settings. This macrotraumatic injury occurs in athletes who participate in a wide variety of sports, most typically as a result of contact or collision mechanisms. The athlete who experiences an acute anterior GHJ dislocation will experience a moderate to severe amount of debilitating pain. Quick and effective relocation of the GHJ is an important skill for on the sideline or on the field management of this type of dislocation when appropriate and allowable by facility protocol. This clinical suggestiong describes one possible technique for athlete self‐ reduction that may be appropriate in some circumstances. This is in contrast to forcible reduction by the health professional, which is outside of the scope of this clinical commentary. This self‐reduction technique is not a part of the standard American Red Cross Emergency Medical Response course and should only be utilized when the medical professional in charge has been trained to assist during its performance.

EPIDEMIOLOGY

The GHJ is inherently unstable due to the bony anatomy that, by design, allows for the wide range of motion employed in daily and sporting activities. This wide range of motion is possible due to the incongruency of the bony articulation between the glenoid fossa and the humeral head as well as the adaptable soft tissue support structures that are present. This relative “instability” has been described by some as similar to a golf ball resting on a golf tee. The GHJ is the most commonly dislocated joint in sports.^1,2 Dislocations can occur in inferior, posterior, and anterior directions with the anterior direction being the most common (up to 96%).¹ The most common fracture associated with a shoulder dislocation is the fracture of the greater tuberosity which occurs in 12‐15% of the cases.³

MECHANISM OF INJURY

The most common mechanism of injury associated with the acute anterior GHJ dislocation in sports occurs with the upper extremity in a position of glenohumeral hyperabduction with external rotation and the elbow extended.⁴ This position of the upper extremity allows the head of the humerus to be positioned in contact with the anterior rim of the glenoid. As additional force is applied to the upper extremity to further force the extremity into abduction and external rotation the head of the humerus slides anteriorly over the anterior rim of the glenoid, often in a slightly inferior direction, and the athlete sustains a dislocation.

SIGNS AND SYMPTOMS

On the field, the athlete will likely be lying in a supine position with the upper extremity held in an abducted and externally rotated position.^2,4 The athlete will complain of pain in the affected shoulder region. Caution must be taken by the therapist/physician/trainer to quickly evaluate pulse and sensation distal to the shoulder injury. Should pulse or sensation be altered or absent, the player should be immobilized in the position in which they were found and promptly transported to the nearest emergency facility for further evaluation. Should the pulse and sensation be intact, the attending professional should palpate the shoulder complex to determine the position of the humeral head and rule out a humeral fracture. In the case of an anterior dislocation it will be located on the anterior‐lateral aspect of the upper chest; anterior and likely inferior to the normal location of the humerus in the glenohumeral joint. (Figure 1) Further palpation should be carried out along the length of the clavicle. (Figure 2) The attending professional should palpate for deformity, crepitus, or an open wound, indicating the presence or absence of a fracture of the clavicle. Should a fracture be suspected, the extremity should be splinted as found and the athlete transported to the nearest emergency facility. This evaluation of the shoulder complex should be performed on the field in a very short period of time in order to determine if the athlete is a candidate for self‐reduction. Should the athlete be capable of removing him/herself or being assisted from the field of play, the evaluation can take place on the sidelines, but should be performed in a minimal amount of time or approximately 2‐3 minutes.

Figure 1.

Palpation of the anterior aspect of the shoulder joint for abnormalities as part of assessment prior to attempting this procedure. Note: This procedure should only be attempted with an anterior glenohumeral joint dislocation; it is imperative that other diagnoses are ruled out prior to proceeding.

Figure 2.

Palpation of the clavicle to check for deformity, crepitus, and open wounds prior to attempting this procedure. Note: This procedure should only be attempted with an anterior glenohumeral dislocation.

SHOULDER SELF‐REDUCTION TECHNIQUE

Many options exist for GHJ reduction following dislocation.³ Physicians perform most reductions in settings where post‐reduction radiographs can be taken or pain medications can be administered. However, in some cases, sideline self‐reduction by the injured athlete may be attempted. Following the initial evaluation of the athlete and the injured extremity, the athlete should be assisted to a long sitting position with the injured extremity being stabilized by the attending professional. (Figure 3) The athlete is then asked to flex the hip and knee on the affected side of the body. The injured extremity is then placed with the grasping the area of the patellar tendon and supported by the athletes opposite hand. (Figure 4) The attending professional then assists the athlete into the more upright sitting position by placing one hand around the posterior aspect of both the athlete's shoulders in order to support the trunk. The opposite hand of the professional is placed over the hands of the athlete to provide support and stabilization of the distal aspect of the injured extremity over the knee. These are safety measures provided by the attending professional in case of loss of consciousness or slippage of the hand of the athlete off the knee. The athlete is then asked to relax and lean backward into the supporting arm of the professional, while maintaining the grasp of the flexed knee. (Figure 5) Should the athlete be able to relax sufficiently, the affected shoulder will reduce spontaneously. This timely approach to self‐reduction by the athlete is due to the athlete's ability to overcome the posterior pull on the head of the humerus by the subscapularis by employing a self‐traction maneuver. Should the athlete be able to apply this gentle form of self‐traction in the anterior direction, the head of the humerus is allowed to gently slip posteriorly over the anterior rim of the glenoid, thus reducing the dislocation.

Figure 3.

Step 1: The sports physical therapist assists the athlete to a seated position while supporting the injured extremity.

Figure 4.

Step 2: The hand of the athletes injured extremity is placed over the same side flexed knee, and joined by the hand of the non-injured extremity.

Figure 5.

Step 3: The sports physical therapist supports and stabilizes of the hand of the injured extremity over the knee, to prevent slippage, and the athlete is instructed to slowly lean posteriorly, while maintaining the hands on the knee. The sports physical therapist supports the trunk of the athlete as they lean in the posterior direction to self-relocate the glenohumeral joint.

The key to this self‐reduction by the athlete is the quick evaluation of the injured extremity with special attention being paid to contraindications to this procedure, such as a possible fracture or compromise of neurovascular structures, and the willingness of the athlete to participate in the procedure. By performing this procedure as described, the athlete will have successfully reduced his or her own shoulder without physical intervention by the attending professional.

POST REDUCTION CARE

A physician with knowledge of sports related injuries should evaluate any athlete who has experienced an acute anterior GHJ dislocation and subsequent reduction, regardless of type of reduction. ³ Sideline management following successful self‐reduction includes placing the injured extremity in a sling in order to immobilize the extremity, and the application of ice. The athlete should not be allowed to return to competition until a physician performs a thorough and complete evaluation, which typically includes a post‐reduction radiograph series. Return to play authorization by the athlete's physician is also required.