GLENOHUMERAL Sherly Desnita Savio

JOINT DISLOCATION 1871112004

 GLENOHUMERAL JOINT
Inherently unstable joint with huge ROM Glenohumeral joint is commonly
potential. Static and dynamic stabilizers dislocated due to

Static: glenoid, labrum, articular The shallowness of the glenoid

congruity, glenohumeral socket
ligaments & capsule, negative
intraarticular pressure
The extraordinary range of
Dynamic: rotator cuff movement
muscles/tendons, biceps tendon,
scapular stabilizers (periscapular Underlying conditions such as
muscles), proprioception ligamentous laxity or glenoid
dysplasia
GLENOHUMERAL JOINT
DISLOCATION
Most commonly dislocated joint (45% of all dislocations)

11.2 to 23.9/100,000 person/years

Male > Female

Common in young/athletic patients (recurrence >90% if <25 y.o.)

Associated w/ labral tears (<40y.o.) and rotator cuff tears (>40y.o.)

Associated fractures: tuberosity or glenoid rim (“bony Bankart”)

Posterior dislocations associated w/ seizures

EPIDEMIOLOGY
 ANTERIOR DISLOCATION
Most common type of shoulder instability
Typically the result of trauma to the arm when in the abducted and externally rotated position
PATHOANATOM

Capsulolabral
• Bankart lesion : avulsion of the anterior-inferior capsulolabral complex with extension into the scapular
periosteum and rupture of the periosteal tissue.
• Found to occur in 90% of patients with recurrent anterior shoulder instability
Osseous
• Glenoid bone loss may occur as an identifiable fragment with its attached capsulolabral structures (bony
Bankart lesion) or as a result of impaction and erosion.
• Present in 40% of first-time dislocators and 85% of recurrent dislocators
• Significant bone loss (20-25% width of the glenoid at the level of the bare spot) 6 to 8 mm of bone loss.
• Hill-Sachs lesion (40% of patients with recurrent subluxations, 90% of first-time dislocators, and almost 100%
Y

of recurrent dislocators). An “engaging” Hill-Sachs lesion is oriented in such a manner that placing the
shoulder in abduction and external rotation  humeral head losing contact with the glenoid and subsequent
subluxation or dislocation.
POSTERIOR DISLOCATION
Electric shocks and epileptic seizures
because the stronger shoulder internal
Trauma to the arm in
Typically the result of rotators (latissimus dorsi, pectoralis
flexion, adduction,
higher-energy trauma major, subscapularis and teres major)
and internal rotation
overpower the weak external rotators
(infraspinatus and teres minor).

Patients may exhibit

Weightlifters, football
positive results with Lack of external
linemen, swimmers,
load-and- shift and rotation.
and gymnasts
jerk testing.

Anteroposterior radiographs are

Patients may present with
unreliable but may demonstrate a
their arms internally rotated
“lightbulb” sign. An axillary lateral
and with observable coracoid
radiograph is critical in making the
and posterior prominence.
diagnosis.
A Kim lesion is an incomplete and
concealed avulsion of the
posteroinferior labrum.
 The jerk (posterior lesion) and Kim
(posteroinferior lesion) tests have been shown
to be highly sensitive and specific.
 MR arthrography can be helpful in
establishing the diagnosis, but findings may be
subtle or falsely negative.
MULTIDIRECTIONAL
INSTABILITY
• TUBS: Traumatic unilateral dislocations with a Bankart lesion
• Often necessitate surgery because they typically occur in young patients and have recurrence
rates of up to 90% with nonoperative management.
• Anterior instability much more common
AMBRI: Atraumatic multidirectional bilateral shoulder
dislocation/subluxation
• Often responds to rehabilitation
• Sometimes an inferior capsular shift or plication is required.
Insidious onset of pain and sensation of looseness about the
shoulder, atraumatic mostly.

Increased generalized laxity (Beighton criteria) and a positive

sulcus sign. The sulcus sign should reproduce the patient’s
symptoms.
HISTORY AND PHYSICAL
EXAMINATION
The apprehension-relocation test (Fowler test)
• The most sensitive.
• The arm is placed into abduction and external rotation.
• As the arm is brought into this position, the patient experiences a sense of
instability.
• The examiner then places a posterior force on the arm and the sense of instability is
Therelieved.
load-and-shift test
• Can be used to “classify” degrees of instability based on distance of humeral head
translation
An evaluation of generalized laxity
The Drawer Test
While stabilizing the scapula with one hand, the other
hand grasps the humeral head. A gentle pressure is then
applied toward the center of the glenoid. At the same
time, the humeral head is manually translated in the
anterior and in the posterior direction.
The sulcus test for inferior instability of the shoulder.
With the patient in the sitting position, a downward traction is placed on the adducted arm (A). With
a positive test (B), excessive inferior translation produces a dimple (arrow) on the lateral aspect of
the acromion. By performing this test with the arm in external rotation, the maneuver can also be
used to test the integrity of the rotator interval structures.
The apprehension and the fulcrum tests for anterior instability.
In the apprehension test, the shoulder is abducted and externally rotated such that it
is in a position vulnerable to dislocation with the patient in supine position (A).
Symptomatic patients will report the sensation of apprehension or “getting ready to
dislocate.” In the fulcrum test, this sensation of instability is accentuated by placing
an anteriorly directed force on the posterior humeral head (B).
The relocation test for anterior instability.
With the patient supine, the shoulder is abducted and
externally rotated such that it is in a position vulnerable
to dislocation. With a positive relocation test, the
apprehension is reduced with a posteriorly directed
force on the shoulder.

The crank test for anterior instability.

The shoulder is abducted and externally rotated such that it
is in a position vulnerable to anterior dislocation with the
patient in sitting position. With an anteriorly directed force
on the posterior humeral head, the instability is
accentuated to cause the sensation of apprehension or
“getting ready to dislocate.”
The jerk test for posterior instability.
With the patient in either sitting or supine position,
the arm is abducted and internally rotated. An axial
load is then placed on the humerus while the arm is
moved horizontally across the body. With a
positive test, a sudden jerk occurs when the
humeral head slides off of the back of the glenoid
and when it is reduced back onto the glenoid.
IMAGING
 Standard radiographs, including an axillary view, are obtained to
ensure the shoulder is located.
 Specialized views are helpful for detecting glenoid and humeral
head bone loss
 CT scan  accurate identification of glenoid bone loss.
 MRI  increase sensitivity.
Posterior Dislocation
Techniques for obtaining axillary lateral
 TREATMENT- ANTERIOR
DISLOCATION • Reasonable for most patients with an initial uncomplicated anterior shoulder
dislocation.
Nonsurgical • A brief period of immobilization is followed by range-of-motion (ROM) exercises
treatment and rotator cuff and periscapular strengthening.
• A brace or harness to limit external rotation may help in-season athletes return to
activity.

• The goals of surgery are to repair the Bankart lesion and retension the anterior
capsulolabral complex
• Equivalent results with open and arthroscopic techniques.
• Open Bankart procedure with capsulorrhaphy is an extremely reliable procedure
Surgical with very high patient satisfaction indices and recurrence rates of approximately 5%
to 10%.
Treatment • Bony deficiencies involving more than 20% of the anteroinferior glenoid require
procedures such as open reduction and internal fixation of acute fractures, structural
bone grafting, and coracoid transfer procedures (e.g. Bristow-Latarjet)
• Surgical options for engaging Hill-Sachs lesions include remplissage, allograft
reconstruction to restore the humeral surface, and arthroplasty.
TREATMENT- POSTERIOR
DISLOCATION
• Nonsurgical treatment should always be attempted first.
• Following a single traumatic injury, the arm should be immobilized in
Nonsurgica
neutral rotation with the elbow at the side. A short period of
l treatment immobilization is followed by rotator cuff strengthening and
periscapular stabilization.

• Soft-tissue procedures include open or arthroscopic labral repair and

capsular shift. Some authors recommend plication of the rotator interval
Surgical as part of an arthroscopic procedure (controversial).
Treatment • Procedures for engaging reverse Hill-Sachs lesions include structural
bone graft to the humeral head and the McLaughlin procedure (open or
arthroscopic transfer of the lesser tuberosity into the defect).
TREATMENT- NEGLECTED
DISLOCATION
• “Skillful neglect” (nonsurgical management) is reserved for the elderly,
Nonsurgical debilitated patient who has limited functional deficits or a potentially high
treatment risk of surgical morbidity or mortality.

• Closed procedure—A closed reduction may be attempted up to 3 weeks

after initial injury, although this time frame is arbitrary.
• Open procedures
• Procedures for a chronic anterior dislocation include transfer of the
greater tuberosity into the defect, allograft, resurfacing arthroplasty,
Surgical hemiarthroplasty, and total shoulder arthroplasty.
Treatment • Procedures for a large (>30%) defect of the glenoid involve
augmentation of the glenoid with a bone graft or bone transfer.
• Procedures for a chronic posterior shoulder dislocation include the
McLaughlin procedure (transfer of the lesser tuberosity into the defect)
and hemiarthroplasty, resurfacing arthroplasty, or total shoulder
arthroplasty.
 TREATMENT
• Several techniques
• No difference between
intraarticular injection of
Reduction lidocaine and intravenous
sedation with regard to the
success rate of reduction, pain
during reduction, or
postprocedural pain

Sling • Duration of immobilization has

immobilizatio not been found to influence rates
n of redislocation.
TREATMENT
Posterior dislocations respond well to acute reduction and immobilization.

Rehabilitation focuses on rotator cuff and deltoid strengthening.

Surgical intervention is typically performed only after rehabilitation has failed

Multidirectional instability
• The focus of treatment is prolonged rehabilitation.
• This should focus on rotator cuff and deltoid strengthening, as well as correction of
scapulothoracic mechanics.
 SURGICAL STABILIZATION
Latarjet procedure
• Should be considered when glenoid deficiency is greater than 20% to 25% of the glenoid width
• Also useful in a revision setting.
• Mechanism of stabilization:
• Sling effect from subscapularis and conjoint tendon
• Bone block effect from the transferred coracoid
• Capsular
Chronic dislocations withofhumeral
repair effect suturing articular deficiency
coracoacromial greater
ligament to thethan 40% should be treated with
capsule.
allograft in younger patients and hemiarthroplasty in older patients.

Rotator interval closure results in decreased external rotation in shoulder adduction and
posteroinferior translation.

Remplissage
• Tenodesis of the posterior capsule and infraspinatus into a Hill-Sachs lesion
• Indicated in medium to large or engaging Hill-Sachs lesions.
REDUCTION
 Proximal humeral fracture dislocations (A1.3, B3,
and C3) require prompt reduction of the
glenohumeral joint dislocation.
 Since the reduction of the dislocation may be
difficult, regional or general anesthesia, including
muscle relaxation, is recommended.
 Axial traction on the arm is almost always helpful.
Even with a fracture of the proximal humerus
there is usually sufficient intact soft tissue so that
the traction is transmitted to the humeral head.
Direct manipulation of the dislocated head
segment can assist the reduction. Pressure should
be applied over the prominent humeral head, and
directed to push it back into the glenoid. Beware
pressure on neurovascular structures.
IMMOBILIZATION

Sling and swath (A), shoulder

immobilizer (B), Gilchrist bandage (C)
VARIOUS SURGICAL
PROCEDURES
 LATARJET PROCEDURE
 Should be considered when glenoid deficiency is greater than 20% to 25% of the glenoid width, also useful
in a revision setting.
 The mechanism of stabilization of the Latarjet:
 Sling effect from subscapularis and conjoint tendon
 Bone block effect from the transferred coracoid
 Capsular repair effect of suturing coracoacromial ligament to the capsule.
 Coracoid tip undergoes osteotomy with its muscular attachments to the short head of the biceps and
coracobrachialis intact.

BRISTO This bone block is then brought through a subscapularis split and fixed to the glenoid base with a screw
and its long axis perpendicular to the glenoid.

W-
LATARJE Latarjet modified this technique to use a longer segment of bone and fix its axis parallel to the glenoid

T 2 primary effects:
• The bone block acts as to increase the anterior diameter of the glenoid

PROCED • Conjoined tendon creates a dynamic sling to reinforce the anteroinferior capsule by lowering the
inferior subscapularis when the arm is abducted and externally rotated. The conjoined tendon also
may provide blood supply to the bone block.

URE Many surgeons also perform a capsulolabral reconstruction by suturing the coracoacromial ligament to the
anteroinferior joint capsule.

Any labral repair is performed posterior to the coracoid transfer, which generally remains extracapsular.
LATARJET PROCEDURE
OPEN ANTERIOR CAPSULOLABRAL
(BANKART) REPAIR

Labral repair is then performed with suture anchors,

or bone tunnels. Three or four suture anchors are
typically needed to span the 3 o’clock-to-6 o’clock
(or 9 to 6 on a left shoulder) position along the
anteroinferior glenoid
 SAHA PROCEDURE
The insertion zone was An osteotomy with an
Y shaped (Cyber-cut)
identified for the oscillating saw was
Patient in lateral skin incision was given,
trapezius at the made at the base of the
position. centered over the
acromion and the distal acromion and through
acromion.
aspect of the clavicle. the clavicle.

In 90" of abduction
and 20" external
rotation, the acromion
Postoperatively, the was fixed to the
shoulder was proximal humerus with
The inferior part of the The deltoid was
immobilized with an two 4.5 mm malleolar
acromion and the lateral longitudinally sectioned
abduction brace screws but before
part of the proximal to expose the proximal
preformed before deltoid transfer. Two
humerus were buried. humerus.
operation at 90" during muscles from the
6 weeks. steering group were
restored. The deltoid
was sutured over the
transferred trapezius.
COMPLICATIONS

Dependent on the Recurrent instability: Infection and axillary

procedure 10% of patients nerve injury

Latarjet complications
include injury to the
Dislocation arthropathy musculocutaneous nerve,
is a common late- fibrous union or
occurring condition. nonunion of the
coracoid, and screw
breakage.
PROGNOSIS
Age at first dislocation is the most important factor in
predicting recurrence. Rate of redislocation:
 Almost 100% in persons with open growth plates
 70% to 95% of persons younger than 20 years
 60% to 80% in persons aged 20 to 30 years
 15% to 20% in persons older than 40 years
 REHABILITATION
2-3 weeks posttrauma
Maximal support - a sling and swath equivalent worn
continuously. If the patient is uncomfortable, a sitting
position may be preferred for sleeping.
A patient who is very comfortable, at the beginning of
treatment or after some recovery, may need less
immobilization, and even begin gentle use of the injured
arm.
As soon as pain permits, pendulum exercises should begin.
Active hand and forearm use should also be encouraged.
Isometric exercises can begin as soon as tolerated for the
shoulder girdle including scapular stabilizers, and the upper
extremity.
Active assisted exercises: 3-6 weeks post- operative
To relieve tension on the supraspinatus tendon and
greater tuberosity, one may support the arm in
abduction. This can be done with a so-called airplane
splint or a shoulder abduction cushion as shown.

Shoulder therapy set: 3-6 weeks postoperative

An exercise bar, which lets the patient use the
uninjured left shoulder to passively move the
affected right side.
A rope and pulley assembly. With the pulley placed
above the patient, the unaffected left arm can be used
to provide full passive forward flexion of the injured
right shoulder.
Strengthening: from week 6 on
As passive motion improves, and the fracture
becomes fully consolidated, active motion against
gravity and resistance exercises are added to build
strength and endurance.
Many surgeons advise forward flexion before
abduction against gravity, which puts significant
strain on the supraspinatus.
Elastic devices can be used to provide varying
degree of resistance, and ultimately the athletic
patient can progress to resistance machines and free
weights. Physical therapy instruction and
supervision may be helpful for optimal
rehabilitation or if the patient is not progressing
satisfactorily.
Remember to monitor rotator cuff strength.
Significant weakness may indicate an unidentified
rotator tendon cuff rupture in need of surgical repair.
CASE EXAMPLE
Male, 51 yo
Unable to flex his right elbow since 2 month prior to
admission, patient fell down while walking with his
right hand hitting the ground.
After the incident the right shoulder was completely
immovable. Brought to traditional massage 5 times
but it didn't improve
Patient is right handed
Right Shoulder Region:
L: Deformity (+) Shoulder Abduction External Rotati on, Square Shoulder (+) Swelling (-),
Bruise (-)
F: Tenderness (+) Around Shoulder, radial artery palpable, CRT<2", normal sensati on
M: Acti ve ROM Shoulder Limited Due To Pain
Acti ve ROM Elbow 0/130
 SHOULDER X-RAY AP VIEW
SANGLAH HOSPITAL (22/10/2020)
SHOULDER X-RAY AXILLARY VIEW
SANGLAH HOSPITAL (22/10/2020)
SHOULDER X-RAY SCAPULAR Y VIEW
SANGLAH HOSPITAL (22/10/2020)
Diagnosis:
Neglected Fracture Dislocation Right Anterior Glenohumeral Joint

Treatment:
Closed reduction if needed Open Reduction Latarjet Procedure
ORIF screwing
THANK YOU