Shoulder dislocation

1. Shoulder
Dislocation
THURSDAY 20TH NOVEMBER 2014

2. History:
 Shoulder dislocation is documented in Egyptian tomb murals as
early as 3000 BC, with depiction of a manipulation for glenohumeral
dislocation resembling the Kocher technique.
A painting in the tomb of Ipuy, 1300BC,
the sculptor of Ramses II depicts a
physician reducing a dislocated
shoulder, using a similar technique
Kocher described in 1870.
 Hippocrates detailed the oldest known reduction method still in use
today. Hippocrates described 13 different techniques, generally
traction / counter traction.

3. Epidemiology:
 ~1.7% population
 Bimodal distribution:
 Men in 20-30 yo (M:F 9:1)
 Women 61-80 (M:F 1:3)
 Less in children as their epiphyseal plate is weaker and tends to
fracture before dislocating.
 More common in elderly as the collagen fibres have fewer cross links
 weaker capsule / tendons / ligaments.

4. Anatomy:
 Involves:
 Bones:
 Scapula, Humerus, Clavicle.
 Rotator Cuff Muscles:
 subscapularis, supraspinatus, infraspinatus, teres minor.
 Assoc. muscles: deltoid, biceps, pectoralis.
 Capsules
 Ligaments:
 Stability of the glenohumeral joint is dependent on four factors:
 The suction cup effect of the glenoid labrum around the
humeral head
 Negative gleno-humeral intra-articular pressure and limited
joint volume
 Static stabilisers, including labrum, ligaments and joint capsule
 Dynamic stabilizers especially rotator cuff and biceps muscle

5. Other associated injuries:
 Fractures:
 In ~30% cases, most commonly:
 Hill-Sach’s lesion (Hatchet deformity): ~2/3. Compression fracture that results
in a groove to the postero-lateral humeral head.
 Bankart’s Lesion: Specifically refers to disruption of capsule &/or labrum from
anterro-inferior glenoid rim, commonly refers to any bony glenoid disruption.
From the impaction of humeral head to anterior inferior glenoid.
 Assoc. capsular damage & anterior inferior ligament damage
 High assoc. (85%) with recurrent dislocations.
 Glenohumeral damage ~55% cases, esp in younger patients.
 Rotator cuff injury – more common in the elderly.
 Nerve injury: brachial pl. is possible but axillary nerve most
commonly damaged ~20-50%.
 Vascular: axillary artery, rare, but dangerous (H’toma, cool limb,
absent pulses)

6. Types

7. Anterior:
 Subcoracoid (anterior):
 Humeral head sits anterior and medial to the
glenoid, just inferior to the coracoid.
 ~ 60% of cases.
 Subglenoid (anteroinferior):
 humeral head sits inferior and slightly anterior
to the glenoid, that the humeral head has
also travelled medially.
 ~ 30% of cases.

8. Other
 POSTERIOR:
 Different mechanisms: seizure, electrocution.
 Present with flattened anterior shoulder and prominent coracoid.
 Can easily go unrecognised.
 INFERIOR: ‘luxation erecta’
 Hyperabduction injury.
 High rate of vascular, nervous, ligament, tendon injuries.

9. Xrays:
 When to do it? Which views.
 http://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_
trauma_upper_limb/glenohumeral_joint_x-ray.
html#top_second_img

10. Techniques:

12. POST REDUCTION:
 Ortho f/u in ~1/52.
 COMPLICATIONS:
 Recurrent dislocation:
 approx 50 – 90% patients under 20
 Approx 5 to 10% of patients over age 40
 ? Ways to prevent redislocation: position of immobilization, increasing
the duration of immobilization, physical therapy, and operative repair.
 Mobilisation:
 <30 – immobilise 3 weeks.
 >30 – begin mobilisation after one week.
 Position: internal rotation and adduction vs. 10 degrees external rotation
(anatomically sound but evidence not support benefit).

13. External rotation
 With the patient's arm adducted and the
elbow flexed, the forearm is slowly and gently
externally rotated. If pain or spasm is felt, the
physician stops and allows the patient to relax.
No longitudinal traction is necessary. In most
cases, by the time the shoulder is fully
externally rotated, the shoulder will have been
reduced.

14. Scapular manipulation
 The patient sits upright and leans the unaffected
shoulder against the stretcher. The physician stands
behind the patient and palpates the tip of the
scapula with his thumbs and directs a force
medially. The assistant stands in front of the patient
and provides gentle downward traction on the
humerus as shown. The patient is encouraged to
relax the shoulder as much as possible.

15. Milch technique
 The arm is abducted and the
physician's thumb is used to push the
humeral head into its proper position.
Gentle traction in line with the humerus
is provided with the physician's opposite
hand.

16. Stimson technique
 The patient is placed prone on the
stretcher with the affected shoulder
hanging off the edge. Weights (10-15
lbs) are fastened to the wrist to
provide gentle, constant traction.

17. Traction-countertraction
 Note how the clinician on the left has the sheet
wrapped around him, allowing him to use his
body weight to create traction. Some clinicians
employ gentle external rotation to the affected
arm while providing traction.

18. Spaso technique
 The arm is flexed forward and
gentle traction and external
rotation forces are applied.

19. Posterior shoulder dislocation
reduction
 The underlying approach to the traction-countertraction
technique demonstrated in
this photograph is similar to that employed in
the reduction of anterior dislocations. The
notable difference is positioning. Note that the
patient is upright and the clinician providing
traction is standing in front of the patient.