shoulder dislocation

Shoulder Dislocation

By: Hashem Bukhary

ANATOMY The most commonly dislocated joint in the body,

Why ? Stability is sacrificed for High Motion Small (ball & Socket Joint)

Muscle That contribute to shoulder joint.

• Glenoid Tubricle is “Log.H Biceps Attachment”

The Labrum is a lignment [ bumper + deep 50% ]

Types:

•Anterior ( 90-95 % )

•Posterior ( 2-5 % )

•Inferior (<1%)

Shared Complication

•Recurrence “ Most Common “ (Esp: <30)

•Nerve Injury (Esp: Axillary)

• Rotator cuff or capsular tear ( Esp : Old )

Recurrence

Recurrence rate depends on age of 1st dislocation:

<20 yrs = 65-95%;

20-40 yrs = 60-70%;

>40 yrs = 4-20%

Nerve Injury

Axillary N. “Post. Crod” = Teris Minor and deltoid Mus. + skin over Shoulder

Numbness & Weakness “ Transient Nuropraxia”“ 5%”

Musculocutaneous nerve (sensory patch on lateral forearm)

The "regimental badge" area Examine pin-prick sensation to this area to assess axillary nerve sensory function.

Anterior Dislocation


•Subcoracoid (90%), Subglenoid (7%), Subclavicular(<3%)

Anterior Dislocation 1/ Hx and Mechanism :

Traumatic VS Atraumatic

Posterior direct force OR Blow to Posterior shoulder :

with position [ Abduction + Extension + Ext. Rot ]

VS

Loose joint with more stretching

[ Chronic pain or feeling of instability ]

Anterior Dislocation 1/ Hx, Ex and Mechanism :

•Sever Pain.

•Lat. outline shoulder flattened.

•Possible bulge under acromion.

•Possible Nerve / Vessel injury.

Anterior Dislocation 1/ Hx. Ex and Mechanism :

Ass. With:

•(Anterio-Inferior) Labral tear [+/- Bony] = Bankart Lesion

•# Greater Tuberosity ( esp: > 50 yrs )

•# ( Back indentation ) to Humeral “Post-Superior” Head = Hill-Sachs lesion.


Labral tear only vs With Bony Lesion


Post-Superior Hum. Head


2/ Special Ex:

•Apprehension Test ( In Supine/ abduct 90” & Ext. Rot)


2/ Special Ex:


•Relocate test ( apply Post-Pushing Force )


2/ Ex:


2/ Special Ex:


•Relocate test ( apply Post-Pushing Force )

•Load & Shift test.( Humeral Head draft force )

•Role OUT dislocation if pt. can Touch the opposite shoulder.


3/ Radiology Finding:

•X ray Views = AP, Trans-scapular ” Y ”, Axillary.

• MRI = to evaluate Labral Tear

•CT = for small bony #


Lateral Scapular View


Lateral “Y”


Axillary


Bankart

BONYLesion


MRI w/ Intra Articular Contrast: Anterior Labral injury


Hill-Sach injury


Management:

Non Operative VS Operative


Management : Non Operative (Conservative)

1/ Closed reduction with:“ IV sedation and muscle relaxation

Or

Local Anasthesia [ 20cc + 1% Lidocan] just below to acromion process .

2/ Imoblization 1-3 wks: Avoid abduction (still Controversial for duration & position).

3/ PT for restoring Painless ROM.

Anterior Dislocation Methods :

I: Traction-countertraction:

In Adduction – Seen in Hippocrates & Strap Methods.

In F.F. – Seen in Stimson and Spaso

In lateral elevation – Seen in the Eskimos

Anterior Dislocation Hippocratic method:

• Place heel into patient's axilla and apply traction to arm foot acts as a a lever to

PUSH the humeral head laterally.

• 30-40° abduction

for 1 mint.


•Better to flex the Elbow 90° to relax the biceps muscle.

•Most effective for Subglenoid dis.

•Brach. Plex and vessel injuries are common No longer use nowadays.


Strap Method:

•With elbow 90°

•Assistant stabilizes body with a folded sheet wrapped across the chest while the surgeon applies gentle steady traction along the axis of the arm in 30-40° abduction.

Anterior Dislocation Strap Method:

•Simple, safe, effective, quick, and may be less painful. •However, they require adequate space and at least two persons. •Towels or sheets can cause friction injury to the fragile skin of the elderly.

Anterior Dislocation Management:

Stimson (Hanging Arm) :

• Pt. lies prone with arm hanging over table edge.

• Hang about 5-7 kg weight on wrist for 20-30 min .

Never let pt. Grap the wit due to engagement Long. Head of Biceps.



• If Still not occur spontaneously

Gentle longitudinal traction (with elbow at 90°) and internal or external rotation are applied to the arm or direct pressure applied on the humeral head.



* Best for elderly or obese pt.

*BUT : Slow, time consuming, fatiguing, unsuitable for tall patients, Painful Position.

Anterior Dislocation Spaso’s Method: “Reverse Stimson”

•Pt. supine position: grasp the affected arm at the wrist or forearm and lift gently vertically

Traction, externally rotate .

•If still palpate and gently push the

humeral head posteriorly with the opposite hand.

Anterior Dislocation Spaso’s Method “Reverse Stimson”

Simple, effective, atraumatic.Safe reduction technique.

Requiring minimal force and a single operator only.

Anterior Dislocation Chair Method:

•Pt. sit upright on a chair with a well-padded backrest.

•Using the backrest as fulcrum in the axilla gentle downward traction with external rotation is applied to the wrist.

Anterior Dislocation Self-reduction method:

With 90° flexed ipsilateral knee pt. leans backward with neck in hyperextension, extending the elbows and hip. So Shoulder rotating the scapula around a vertical axis.Success = 60% ; SubCoracoidLess successful >60 years of age, subclavicular and especially subglenoid dislocations.

Anterior Dislocation Eskimo (Hanging Pt.)

• Grasp the dislocated arm, pulled upwards and lifted the shoulder a couple of centimeters off the ground.

•Still not work Press the humeral head towards its socket.

•Simple, No facilities needed.

•Can be by nonmedical personnel.


Management:

II. Leverage “Force” :

exemplified by Kocher and Milch

Anterior Dislocation Milch Methods:

With Arm ( F.F & abduction & Pt. Supine or 30°):

I.Put hand over dislocat. shoulder (to support the top) & Thumb is under the dislocated humeral head to hold it in place. II. The elbow of the affected arm may be put into 90° flexion left hand gently abducts the arm into the overhead position ( abducted & ext. rotated)

Direct pressure with thumb to humeral head over the glenoid rim with Axial traction may be applied.

Anterior Dislocation Milch Methods:

•Relatively painless, safe, and free from complications & requires little sedation. However, the manoeuvres are complex.

•It has been claimed to have a very high success rate.

Anterior Dislocation Kocher’s Methods:

•With longitudinal traction to humerus, and arm slightly away from pt.

1/ Elbow flexed to 90° with pressed (adducted) against the body & to full external rotation until resistance.

2/ Elbow is lifted & adducted arm across the chest wall to midline.

3/ The affected hand is then placed on the opposite shoulder (internally rotated).

Anterior Dislocation Kocher’s Methods:

•Not for: Obese , Old

•Increased risk of:

( Recurrent dislocation, Spiral fractures of the humerus and axillary nerve injuries when compared to other techniques)

Not Common


III. Scapular manipulation & direct pressure or pulsion


Scapular manipulation methods:• Manipulates the scapula so that the glenoid rotates down to meet the humeral head. •In prone pt. = shoulder in 90° of F.F. and ext. rotation. •Suspended maintained hanging 5-7 Kg weight to the wrist / manual traction for 5-10 minutes.


Scapular manipulation methods:•+ve / simple, easy, fast, effective, safe, atraumatic, need No Sedation.

•-ve / Hard to countere prone position, difficult in obese patients.


Shoulder reduction in the elderly (Direct Pressure or pulsation )

•Stand behind the seated patient Put flexed forearm into the axilla of the affected shoulder.Gentle traction on the flexed forearm Pt. + pulls in lateral direction and upward the head of the humerus into the socket.

It is simple, atraumatic, direct and effective.


Conclusion

Acute anterior shoulder dislocation is a common presentation to emergency departments. Most dislocations can be reduced in the emergency department using simple methods. The success rates and complication rates of the various techniques are summarised in Table.

Because No single shoulder reduction technique is infallible, the So physician should be proficient in several methods in case of failed first attempts.


Arthroscopic VS open

Bankart repair +/- capsular shift

Arthroscopic

1st time traumatic shold. Dislo with Bankart lesion confirmed MRI ( athlete younger than 25 yrs ) Equally efficacious as open But less pain & more Motion preservation.


Hill-Sachs bony reconstruction

• Indication

Engaging Hill-Sachs lesions

• By :

Arthroplasty or Allograft reconstruction


ALLWAYS:

•obtain post-reduction x-rays

•check post-reduction NVS

•Shoulder rehabilitation (dynamic stabilizer strengthening)

Posterior Dislocation

Posterior Dislocation •1/ Hx and Mechanism :

•Up to 60-80% are missed on initial presentation due :

Poor physical exam and radiographs.

FOOSH OR Blow to Anterior shoulder: with position

[ Adduction + Flexed Arm+ Int. Rot ]

Posterior Dislocation Ass. With:

•3 E's ( Epileptic seizure, EtOH, Electrocution)

•Reverse bony Bankart lesion: avulsion of the posterior glenoid labrum from the bony glenoid rim.

•# Lesser Tuberosity

•Reverse Hill-Sachs lesion (75% of cases).

Posterior Dislocation 2/ Ex:

•Jerk Test

( Add + FF )

•Load-and-shift Test

•Most Reliable Sign : Shoulder being Locked in Internal. Rot.

Posterior Dislocation •3/ Radiology Finding:

Dislocation:

AP view: partial vacancy of glenoid fossa (vacant glenoid sign) humeral head may resemble a lightbulb due to internal rotation (lightbulb sign).

axillary view: humeral head is posterior.

trans-scapular view: humeral head is posterior to centre of "Mercedes-Benz sign'’


The humeral head is Much SYMETRICAL + and the Joint space WIDER


Missed Post. Dislocation

Posterior Dislocation •4/ Management:

Non-operative Management:

•Reduction (under anaesthesia)

•Immobilisation : in 20 ° of external rotation (up to 6/52)

•Activity restriction

•Exercise rehabilitation & P.T.

• A 35-year-old male injured his right shoulder while playing basketball. Came to ER with significant pain and his shoulder abducted at 140 degree. He is unable to lower his arm. Radiographs will most likely show that his glenohumeral joint has dislocated in what direction?

1. Anterior.2. Posterior. 3. Inferior.4. Superior.5. Lateral.

Inferior Dislocation“Luxatio Erecta”

Inferior Dislocation 1/ Hx and Mechanism :

•Forceful hyperabduction of the shoulder.

•Happens when the humerus anchor-on/“pushed over” with the Acromion and the Humeral Head delivered out the glenoid Cavity.

•The Greatest type w/ Axillary Nr injured But it will usually spontaneously recovers.

Inferior Dislocation 1/ Hx and Mechanism :

•Pt presnt : "locked" in abduction of varying degrees.

“hyperabducted Arm , with the elbow flexed and forearm resting on top of or behind the head”

Inferior Dislocation

Sulcus Sign ( Inf. Force w/ arm @ side) inc. Acr-Hum interval


Sulcus Test Grading SchemeGrade 1 not over glen. Rim = Acro.humeral interval <1cmGrade 2 over but spo.reduc = Acro.humeral interval 1-2cmGrade 3 locked over gle.rim = Acro.humeral interval >2cm


•So all view needed : AP, Lat Y, Axillary.

•Axillary X-ray: usually looks Normal .

•MRI Obtained after shoulder is relocated to assess shoulder

injuries Capsulolabral pathology & rotator cuff tears (common)

• Inferior glenohumeral dislocation with arm fully abducted


Non-OP. Rx:

Closed reduction and immobilization:

• Pt. w/ good response to non-operative treatment

• inactive elderly patients

• initial reduction and immobilization

• followed by ROM exercises

• physical therapy focusing on rotator cuff strengthening


Operative . Rx:

reconstruction with arthroscopic or open repair

For• capsulolabral damage/ or rotator cuff tear

• Especially active younger patients

By: repair vs reconstruction of shoulder pathology

Thank You

shoulder dislocation

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