Recurrent Shoulder Dislocation in the Elderly – what are the Potential Complications?
Chua Si Yong Ivan1, Fatimah Lateef*2
1Residen, Department of Emergency Medicine, Singapore General Hospital, Singapore
2Associate Professor, Department of Emergency Medicine, Singapore General Hospital, Singapore
Figure 1. (left) is an AP right shoulder X-ray taken 3 years ago in 2009.
Figure 2. (middle) was taken during the current admission prior to M&R. Fig. 3 (right) shows a new surgical neck of humerus fracture after M&R.
The X-rays above correspond to the lateral views of Figure 1-3
There is a bimodal age distribution for anterior shoulder dislocation – the first group being young adult men with high-energy injuries to the shoulder and the second group comprising of older patients with lower impact injuries4. 20- 44% [4-6] of shoulder dislocations occurs in patients aged more than 60 years of age. However, whereas most young and middle-aged patients with shoulder dislocations are male, most of the elderly patients are female, likely a result of longer life expectancy. In addition, many of these injuries are not isolated injuries and there are significant problems that arise more frequently in the older population, including rotator cuff injury, brachial plexus injury and axillary artery injury .
The prevalence of recurrent shoulder dislocation is around 50-75% for adolescents and young adults (up to 25 years of age)  whereas various studies on patients over 60 years old have quoted prevalence up to 22% in elderly patients . Nevertheless, the recurrence in older patients may reflect a more significant injury with potential need for imaging and reconstructive surgery. Kinnett et al identified 3 risk factors for recurrence of dislocations in the elderly – increased ligamentous laxity, increased activity level and high-energy dislocation .
Up to 83%  of elderly patients with a shoulder dislocation have a tear of the rotator cuff, and it is important to evaluate symptomatic elderly patients with imaging 2-4 weeks after reduction as earlier rotator cuff repairs may yield better results .
The prevalence of nerve injury after anterior shoulder dislocation increases with age. In a study by Gumina et al, 9.3% of elderly patients had an injury of the axillary nerve compared to 4.6% in patients less than 60 years of age . Thankfully, most of the nerve damage was mainly neurapraxia which resolved spontaneously within a few months.
Extreme care is also necessary when dealing with chronically dislocated shoulders in the elderly (defined as more than 3 weeks) due to risk of axillary artery rupture . Closed reduction should be attempted under general anaesthesia in the operating theatre with a view to proceed with open reduction if gentle, closed reduction techniques have failed.
Various techniques have been described in the literature for manipulation and reduction of anterior shoulder dislocation and their efficacy is similar between 70-90% reduction on first attempt. Hippocratics’ and Kocher’s methods have been criticized for their significant association with complications such as neurovascular injury in the former and spiral fractures of the humerus in the latter. In addition, the risk of fracture in attempting another reduction is much higher .
Conflict of Interest
Cite this article: Lateef F. Recurrent Shoulder Dislocation in the Elderly – what are the Potential Complications?. J J Emergen Med. 2016, 3(1): 024.