Practice Easily missed?

Posterior shoulder dislocations

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h75 (Published 28 January 2015) Cite this as: BMJ 2015;350:h75
  1. Robert C Jacobs, resident in orthopaedic surgery,
  2. Nicole A Meredyth, fourth year medical student,
  3. James D Michelson, attending orthopaedic surgeon
  1. 1Department of Orthopaedics and Rehabilitation, University of Vermont School of Medicine, Burlington, VT 05401, USA
  1. Correspondence to: J D Michelson james.michelson{at}uvm.edu
  • Accepted 16 December 2014

The bottom line

  • •Consider posterior shoulder dislocation in patients with indirect trauma and the arm flexed at the shoulder in adduction and internal rotation, or those with shoulder pain after a seizure or electrocution

  • •Request radiography of the shoulder with two orthogonal views, anterioposterior and axillary views being the preferred choices; however, the Velpeau or scapular Y view may also be used with the anterioposterior view

  • •Urgent referral to an emergency department for reduction is vital to reduce morbidity

After being tackled earlier that day, a 33 year old rugby player presented to a walk in clinic with diffuse left shoulder pain, limited abduction, and arm held in slight internal rotation, with a flexed, adducted, and internally rotated position (fig 1). He was discharged and diagnosed as having a spontaneously reduced anterior shoulder dislocation after an anterioposterior view of the shoulder was read as normal (fig 2).

Fig 1 Diagram of mechanism of posterior dislocation: arm flexed and adducted, with internal rotation at the shoulder

Fig 2 Pre-reduction anterioposterior radiograph of left posterior dislocation. The humeral head (H) appears to be concentrically located about the glenoid (G) and beneath the acromion (A). Slight internal rotation is present when appreciating the greater and lesser tuberosities. No fracture is seen. C=coracoid process, CL=clavicle, S=scapula

One week later he presented to the emergency department with continued symptoms and crepitus in his shoulder with attempted movement. A posterior shoulder dislocation was diagnosed when an orthogonal view (axillary) of the shoulder was taken (fig 3). After conscious …

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