Transcript 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.
Muscle
Origin on scapula
Attachment on humerus
Function
Innervation
Supraspinatus
muscle
supraspinous fossa
superior and middle facet of
the greater tuberosity
abducts the arm
Suprascapular nerve
Infraspinatus
muscle
infraspinous fossa
posterior facet of the greater
tuberosity
externally rotates the
Suprascapular nerve
arm
Middle half
Teres minor muscle of lateral border
Scapula
inferior facet of the greater
tuberosity
externally rotates the
Axillary nerve
arm
Subscapularis
muscle
lesser tuberosity (60%)
or humeral neck (40%)
internally
Upper and Lower
rotates the humerus subscapular nerve
Subscapular fossa
• 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
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.
Anterior Dislocation
Anterior Dislocation
Labral tear only
vs
With Bony Lesion
Anterior Dislocation
Post-Superior Hum. Head
Anterior Dislocation
2/ Special Ex:
•Apprehension Test ( In Supine/ abduct 90” & Ext. Rot)
Anterior Dislocation
Anterior Dislocation
2/ Special Ex:
•Apprehension Test ( In Supine/ abduct 90” & Ext. Rot)
•Relocate test ( apply Post-Pushing Force )
Anterior Dislocation
2/ Ex:
Anterior Dislocation
2/ Special Ex:
•Apprehension Test ( In Supine/ abduct 90” & Ext. Rot)
•Relocate test ( apply Post-Pushing Force )
•Load & Shift test.( Humeral Head draft force )
•Role OUT dislocation if pt. can Touch the opposite shoulder.
Anterior Dislocation
3/ Radiology Finding:
•X ray Views = AP, Trans-scapular ” Y ”, Axillary.
• MRI = to evaluate Labral Tear
•CT = for small bony #
Anterior Dislocation
Anterior Dislocation
Lateral Scapular View
Anterior Dislocation
Lateral Scapular View
Anterior Dislocation
Lateral “Y”
Anterior Dislocation
Axillary
Anterior Dislocation
Anterior Dislocation
Bankart
BONY
Lesion
Anterior Dislocation
Anterior Dislocation
MRI w/ Intra Articular Contrast: Anterior Labral injury
Anterior Dislocation
Hill-Sach injury
Anterior Dislocation
Management:
Non Operative VS Operative
Anterior Dislocation
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.
Anterior Dislocation
•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.
Anterior
Dislocation
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.
Anterior Dislocation
Management:
 Stimson (Hanging Arm) :
• 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.
Anterior Dislocation
Management:
 Stimson (Hanging Arm) :
* 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% ; SubCoracoid
Less 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.
Anterior Dislocation
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
Anterior Dislocation
Management:
III. Scapular manipulation & direct pressure or pulsion
Anterior Dislocation
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 510 minutes.
Anterior Dislocation
Scapular manipulation
methods:
• +ve / simple, easy, fast,
effective, safe, atraumatic,
need No Sedation.
• -ve / Hard to countere prone
position, difficult in obese
patients.
Anterior Dislocation
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.
Anterior Dislocation
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.
Anterior Dislocation
Anterior Dislocation
Management:
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.
Anterior Dislocation
Management:
Hill-Sachs bony reconstruction
• Indication
Engaging Hill-Sachs lesions
• By :
Arthroplasty or Allograft reconstruction
Anterior Dislocation
Management:
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'’
Posterior Dislocation
The humeral head is Much SYMETRICAL + and the Joint space WIDER
Posterior Dislocation
Posterior Dislocation
Missed Post. Dislocation
Posterior 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.
2.
3.
4.
5.
Anterior.
Posterior.
Inferior.
Superior.
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
Inferior Dislocation
Sulcus Test Grading Scheme
Grade 1  not over glen. Rim = Acro.humeral interval <1cm
Grade 2  over but spo.reduc = Acro.humeral interval 1-2cm
Grade 3  locked over gle.rim = Acro.humeral interval >2cm
Inferior Dislocation
• 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
Inferior Dislocation
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
Inferior Dislocation
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