Of the PT Persuasion: Shoulder Dislocations
Have you ever wished for a resource that helped writers cut back on hours and hours of researching how to accurately portray injuries and medical conditions? Look no further. In this blog series, I’ll be discussing just that. What makes me qualified to do so? Well, I’m a Physical Therapist! Or, rather, I’m a writer…Of the PT Persuasion.
When we first met and subsequently (inevitably) fell in love with James Alexander Malcolm MacKenzie Fraser, he was a smelly rebel with one working arm. Jamie, as we now fondly know him, explains in the book Outlander by Diana Gabaldon, that he fell off his horse, landing on his outstretched hand. The fall resulted in a shoulder dislocation and a shining moment of nursing heroism for our lovely leading lady, Claire.
So, let’s break this down, starting with the relevant anatomy of the shoulder. For simplicity’s sake, we’ll say the shoulder is a joint comprised of the humeral head (the upper arm bone) and the glenoid fossa of the scapula (the shoulder blade); we won’t be including the clavicle (the collar bone) in this discussion. Considering golf originated in Scotland, let’s look at it this way: the humeral head is round and fits into the shallow cup of the glenoid fossa like a golf ball sitting on a tee.
The shoulder is the most mobile joint in the body. It allows you to bring your arm up, down, to the side, twist, and go all around, just like Jamie would need to do in a harrowing duel. That’s because it’s a ball-and-socket joint, and if you think of our golf ball sitting on its tee, you can imagine how much mobility that allows, but in the world of anatomy, mobility comes at the risk of stability. This trade-off makes the shoulder joint the most susceptible to dislocation.
And so the shoulder needs to make up for bony instability with soft tissue stability. Between the ball and tee is a cushion called a labrum, which you’ve probably heard in reference to the hip, the other major ball-and-socket joint in the body. The labrum, attached to the glenoid fossa, provides a bit of extra surface area on the tee to cup the ball and improve stability. There are also numerous ligaments holding the shoulder joint into place. And, if you’re a strapping highlander, the surrounding musculature provides some support, as well.
Okay, we now know the shoulder is flimsy. But what does ‘dislocation’ really mean? Dislocation is a form of instability, which ranges from hypermobility to subluxation to dislocation.
Hypermobility: greater than typical mobility or ‘give’ to a joint that can be pathologic (i.e. problematic) or normal
Subluxation: when the two bones forming the joint slip out of normal alignment but are still touching. They are very painful and usually self-correcting
Dislocation: when the two bones forming the joint are completely misaligned such that the surfaces that normally touch one another are no longer touching
For the shoulder, this means that the humeral head has displaced from the glenoid fossa and the labrum, usually tearing through strong, thick ligaments in order to do so.
How does this even happen?
Shoulder dislocations usually occur in the anterior direction, meaning the humeral head pops forward of the glenoid. (It can also dislocate posteriorly or inferiorly, but we’ll be sticking with the most common, by far.) The joint is most susceptible when the shoulder is abducted and externally rotated—that’s like the position for giving someone a high-five or how you throw a ball. You can probably feel the tightness and pressure in the front if you put your arm in that same position! When excessive force drives the arm further into that range, like the bodyweight of a Scottish rebel falling off a horse, the humeral head dislocates anteriorly.
And that, my friends, is extremely painful. I’ve never experienced it for myself (*throws salt over shoulder* *burns sage* *turns in a circle three times while sipping holy water*), but I have treated several patients who report that this injury truly isn’t a good time. In other words, your character won’t just be popping that sucker back in and jumping into a fistfight.
Now, let’s talk about your writing. You can depict the injury happening through a fall, especially when the arm is outstretched and overhead (think swan dive-ish); the arm being lifted, twisted, and pushed backward with a good deal of force; or a blow to the arm—and not the shoulder—that forces the arm backward. The injury is accompanied by intense pain, followed by muscle guarding, swelling, bruising, and inability to move the arm. In addition to torn ligaments, one might see torn rotator cuff muscles, a torn labrum, bone fracture, damage to the axillary artery, or damage to the brachial plexus or axillary nerves. With nerve damage, it’s possible to see sensory changes down the arm. Furthermore, due to the collateral effects, a dislocated shoulder is more prone to subsequent dislocations.
Then let’s talk about treatment options.
First: relocation. Your characters would have to determine the position of the humeral head in relation to the glenoid fossa in order to know exactly where it has to be repositioned to. There are several relocation techniques, but our heroine Claire uses Kocher’s Method. The involved arm is held at the elbow and the wrist, and it’s then externally rotated (the arm rotates away from the body) while keeping the elbow at the side. Maintaining that rotation, the arm is lifted forward until resistance is met, then internally rotated (bringing the hand onto the stomach) to relocate the humeral head.
The patient would feel an immediate reduction in pain, though a dull, throbbing, or achy pain would remain. Now, remember all the ligaments and potential muscle, bone, nerve, and blood vessels affected? It’s very important, at this time, to let those heal. Immobilization is key, and the arm should be placed in a sling for at least a few days, depending on the severity of the injury.
Now, what does the PT say about rehabilitation? After the tissues have healed over the course of immobilization, the shoulder should be gently moved through its pain-free range. Strength can and should be maintained in the unaffected tissues, especially the peri-scapular musculature that supports the shoulder. Once the shoulder joint is fully healed, strengthening the shoulder/rotator cuff muscles will help support the weakened joint. All in all, it takes about 3 months for full healing, though the arm can be used for most daily activities, like grooming the horses at Castle Leoch’s stable, within a few weeks.
And there you have it! The full life cycle of an anterior shoulder dislocation, seen throughout literature and film but correctly portrayed and treated in Outlander.
Thank you for reading! I hope you enjoyed this installment to Of the PT Persuasion.
Disclaimer:
If you’re seeking medical advice for yourself or someone you know, you should speak to a medical professional. This blog is not intended for diagnosing or treating real-life medical conditions, only fictional ones.
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