Shoulder Dislocation
s
Shoulder dislocation
1. DISLOCATION- COMPLETE LOSS OF GLENOHUMERAL
ARTICULATION . CAUSE- ACUTE TRAUMA
• 2. SUBLUXATION - PARTIAL LOSS OF ARTICULATION WITH
SYMPTOM’S. CAUSE- REPITITIVE TRAUMA.
• 3. LAXITY - PARTIAL LOSS OF GLENOHUMERAL
ARTICULATION BUT PAITENT IS ASYMPTOMATIC. SHOULDER
INSTABLITY
Shoulder dislocation
• Shoulder is the most commonly dislocated joint[45%]
1] shallowness of glenoid socket
2]Extraordinary ROM
3] ligamentus laxity
• Humeral head 3x larger than glenoid fossa
• glenohumeral articulation is minimally constrained by
bony anatomy alone
• stability is conferred by a series of dynamic and static
soft tissue restraints
Shoulder dislocation
Type of dislocation
• Traumatic Dislocations
• Atraumatic dislocation
• Acquird dislocation
Traumatic dislocation
• Single force applies excessive overload to the
soft tissues of the joint and often damages the
Glenoid Labrum (Bankart Lesion) and the joint
capsule
• Anterior [85%]
• Posterior[10]
• Inferior [5]
Atraumatic dislocation
• Athelete who has joint hyperlaxity and had
multiple episode of joint subluxation
• Minor injury can results into dislocation
[Congenital hypermobility or muscle weakness.]
Acquired dislocation
• Sports such as swimming,
gymnastics and baseball
where repetitive
micro-trauma, poor
stretching and motion
lead to capsular
stretching. Eventual
feeling of instability
Traumatic anterior dislocation
• Mech. of injury
Arm in abduction and external rotation. Force
is taken on the hand or arm which increases
the external rotation of the arm causing the
head of the humerus to dislocate
• Clinical symptom:
• Pain [severe]
• Hold limb with normal limb by side of body.
• Abduction and external rotation.
• Pt can’t touch apposite shoulder [dugos test]
Clinical Evaluation
• PE:
– Prominent acromion, sulcus
sign, palpable humeral head
anteriorly
– Neuro integrity of axillary
and musculcutaneous nerves
– Apprehension Test:
reproduces sense of
instability and pain in
shoulder reduced prior to
exam
Radiographic Evaluation
• AP [fracture dislo]
• Axillary
• Special Views:
– West Point axillary: for
visualization of glenoid rim
– Hill-Sach view: internal
rotation view
– Stryker Notch: view 90% of
posterolateral humeral
head
Management
• Pre-Medication
• Reduction Maneuvers
• Post-Reduction
Immobilization
Pre-Medication
• Methods of Premedication
prior to Reduction
– None
– Intraarticular Lidocaine
– IV Sedation
– Supraclavicular Block
– Suprascapular Block
IV Sedation vs Intraarticular Lidocaine
Injection
Intra-articular Lidocaine
Injection is Preferred over
IV Sedation
Reduction Maneuvers
• Is there an Ideal Method for Reduction?
– Over 24 Techniques Described
• Most Common Techniques
– Kocher (71-100%)
– External Rotation (78-90%)
– Milch (70-89%)
– Stimson (91-96%)
– Traction/Countertraction
– Scapular Manipulation (79-96%)
Kocher Maneuver
TEA I
• Traction
• ER
• Adduction
• arm is internally
rotated
• Modified [no traction]
Stimson method
Traction/Countertraction
• Arm in some abduction
• Traction applied to arm
• Assistant applies firm
counter-traction with
sheet across the body
Hippocratic method
• Surgeon use foot applies on
axilla for countertraction
After reduction
Does immobilization
reduce recurrence?
• usually fracture associated with dislocation are
reduced with reduction of dislocation.
• Immobilization for 3-4 weeks after shoulder
dislocation does NOT change the prognosis
compared with immediate mobilization
Internal vs External Rotation
• Level II RCT: Itoi JBJS 2007
– ER for 3 weeks
• Recurrence rate: 32%
– IR for 3 weeks
• Recurrence rate: 60%
– P = 0.007
Complication of ant.shoulder dislocation
Early
• Rotator cuff tear
• Nerve injury
• Vascular injury
• Fracture dislocation
Late complication
• Stiffness
• Unreduced disloction [undiagnos in
unconcious and old pts. ]
closed reduction done upto 6 wks and open
reduction done after 6wks in young pts. Willful
neglect in old pts
• Recurrent dislocation
Post. Shoulder dislocation
• The arm is in flexion and adduction. Force is
taken on the hand, causing the head of the
humerus to be push out the glenoid
posteriorly.
• h/o convulsion or electric shock
Clinical sign and symptom
• Diag is often missed
• Internal rotation
• Flat front of shoulder
• Prominent corocoid
• Frominent post aspect of shoulder
Radiology
• AP- electric bulb apperence
and empty glenoid sign.
• Lat – post displacement
• Treatmet
• Under GA reduction by pulling arm in
adduction to dis engage head then lateraly
rotate while pushing head anteriorly.
• Immobilization in ext rotation and abduction
for 3 wks.
Inferior shoulder dislocation[luxatio erecta]
Arm is in excessive abduction and a force is
taken on the hand pushing the head of the
humerus inferiorly out of the glenoid.
Clinical features
limb in abduction
Inferior shoulder dislocation[luxatio erecta]
• Xrays –AP
• LAT
Inferior shoulder dislocation[luxatio erecta]
• Treatment
Traction and counter traction.
Immobilised for 3 wks
Recurrent shoulder dislocation
Anterior dislocations account for ~95% of shoulder
dislocations
• Typically occurs in athletes who are < 25 years old
• Males are much more commonly affected than are females
(85-90%)
Recurrent shoulder dislocation
• Pathology most commonly found in shoulders
following a dislocation is a Bankart lesion
– Disruption of the labrum and the contiguous
anterior band of the inferior glenohumeral
ligamentous complex (IGHLC)
• Bankhart lesion occurs > 85% of the time
Recurrent shoulder dislocation
Bony bankart
• Hillsach lesion –
posteriolateral
indentation of humeral
head.
• Enganging lesion is
indication of surgery
Recurrent shoulder dislocation
Recurrent shoulder dislocation
• Classification
• Instability can be classified by:
– direction of instability (anterior, posterior,
multidirectional)
– degree of instability (subluxation, dislocation)
– etiology (traumatic, atraumatic, overuse)
– timing (acute, recurrent, fixed)
Recurrent shoulder dislocation
Recurrent shoulder dislocation
• Shoulder Stabilisers – Static
• Intracapsular pressure
• Labrum: increases depth of the glenoid by 50%
• Ligaments – main static restraints
• capsule
Recurrent shoulder dislocation
Shoulder Stabilisers
Rotator cuff and biceps
Dynamic
Recurrent shoulder dislocation
Recurrent shoulder dislocation
Recurrent shoulder dislocation
Recurrent shoulder dislocation
Recurrent shoulder dislocation
• How many number of dislocation is
indication of surgery.
• Frist dislocation in young pateint specially
sports person.
• Two time dislocation is definit indication of
surgery.
Recurrent shoulder dislocation
• Open surgery done for old and multiple
recurrent dislocation due plastic deformation
of tissue or larg bony defects.
• Arthroscopic surgery is done fresh case
of recurrent dislocation.
• Advantage
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