2. Shoulder dislocation
Definition
Shoulder joint anatomy
Hx, Classification and clinical
evaluation
Diagnosis and management(reduction
techniques)
complications
DEFINITION: shoulder dislocation is
when the head of the humerus
separates from the scapula at the
glenohumeral joint.
3. Glenohumeral joint is a multiaxial ball and socket joint in which the head
of the humerus articulates with the glenoid cavity of the scapula.
GH joint is enclosed by a joint capsule that encapsulates the structures of
the joint in a fibrous sheath. Synovial membrane forms the lining of the
inner surface of the joint capsule & produces synovial fluid to reduce
friction between the articular surfaces.
Shoulder (glenohumeral) joint
anatomy
5. STABILITY OF JOINT
DYNAMIC STABILIZERS
Contractile tissue of the shoulder complex
(tendons, muscles and tendon-muscular
junctions) predominantly the rotator cuff
muscles, supras.S, infra.S., subscapularis and
teres minor, maintain centralization of the
humeral head during static postures and
dynamic movements), proprioceptive and
neuromuscular control
STATIC STABILIZERS
Non contractile tissue of the GH joint,
important in end range-ROM(point where
active mobility ends)
Glenoid labrum and glenohumeral ligaments,
joint capsule.
MOVEMENTS OF THE JOINTS: flexion,
extension, abduction, adduction, external
rotation, internal rotation and circumduction
6.
7. ANATOMY CONT…
MAJOR BLOOD VESSEL: axillary
artery with its branches: superior
thoracic artery, thoracoacromial
artery, lateral thoracic artery,
subscapular artery, a. humeral
circumflex artery, p. humeral
circumflex artery.
NERVE SUPPLY: Suprascapular,
axillary, lateral pectoral nerves
(branches of C5-C6 of brachial plexus)
8. HISTORY, CLASSIFICATIONS AND CLINICAL
EVALUATION
HX: patients may report popping sensation, sudden onset of pain with decreased range of
motion or a sensation of joint rolling out of the socket post trauma.
ANTERIOR DISLOCATION: acc for 96% of cases. Subcoracoid, subglenoid,luxatio erecta,
subclavicular, supraglenoid, intrathoracic, fx-dislocation.
Mechanism of injury is usually a blow to an abducted, externally rotated and extended extremity.
It may also occur with posterior humerus force.
On exam, the arm is usually abducted and externally rotated, and the acromion appears
prominent, a relative hollow beneath the acromion posteriorly and a palpable mass anteriorly.
There are associated injuries in up 40% of anterior dislocations including nerve damage, or tears
and fractures associated with the labrum, glenoid fossa, and/or humeral head.
POSTERIOR DISLOCATION: acc for 2-4% of cases. subacromial, subglenoid, supspinous. It may
also be a result of violent muscle contractions (seizures, electricution).the shoulder is typically in
a position of adduction, flexion and internal rotation.
9.
10.
11. CLASSIFICATIONS AND CLINICAL EVALUATION
CONT…
On exam, the arm is usually held in adduction, and internal rotation and
patient is unable to rotate externally. A palpable mass posterior to the
shoulder, flattening of anterior shoulder and prominent coracoid may be
observed
Higher risk of associated injuries such as fractures of surgical neck or
tuberosity, reverse Hill-Sachs lesions (also called a McLaughlin lesion which is
an impaction fracture of anteromedial aspect of humeral head), and injuries of
the labrum or rotator cuff.
INFERIOR DISLOCATION: 0.5-1%. infraglenoid( luxatio erecta) more common
in elderly.
Usually caused by hyperabduction or with axial loading on the abducted arm.
On exam, patient presents with characteristic “salute” the arm is held above
and behind the head and patient is unable to adduct arm. The humeral head is
palpable on the lateral chest wall and axilla
Often associated with nerve injury, rotator cuff injury, tears in the internal
capsule, and the highest incidence of axillary nerve and artery injury of all
shoulder injuries.
12.
13. DIAGNOSIS AND MANAGEMENT
Clinical diagnosis.
Pre-reduction imaging(AP,Scapular,axillary) for associated Fx can be useful and should
be done when trauma is known.
REDUCTION OF DISLOCATED SHOULDER.
-CONTRAINDICATIONS TO REDUCTION
Anterior Dislocation
Fractures of humeral neck can lead to avascular necrosis
Subclavicular and/or intrathoracic dislocations include a subacute dislocation in an
elderly patient and an associated surgical neck fracture
Avoid multiple attempts in injuries that include neurovascular compromise (including
brachial plexus involvement, axillary nerve, a musculocutaneous nerve, etc.). If prompt
reduction cannot occur without further injury, may need surgical help.
The suspected arterial injury may need urgent angiography first.
14. Posterior Dislocation
Delayed presentation to the emergency department (more than 6 weeks)
Multipart or displaced fracture/dislocations
Inferior Dislocation
Humeral neck or shaft fractures should be done in a surgical setting
Any potential of vascular injury
15. Reduction techniques for anterior
shoulder dislocation
Scapular Manipulation (80% to 100%
successful)
Upright or prone
Stand behind patient and use one
thumb over tip of scapula and push
medially while pushing acromion
inferiorly with the other thumb
Assistant simultaneously provides
traction by grabbing patient’s wrist
with one hand and flexed elbow with
other hand and pushing down on
elbow
16. External Rotation Technique (hennepin).
Easy and can do alone
With patient supine, elbow flexed to 90
degrees, elbow held with one hand, and
wrist is held with another hand
Slowly allow the arm of the patient to
fall to the side, externally rotating the
forearm, as the arm externally rotates,
reduction occurs.
Reduction usually occurs with arm
externally rotated between 70 to 110
degrees.
17. Milch Technique (add Milch
technique if external rotation
unsuccessful)
Patient is supine, fingers over the
shoulder with thumb in axilla to
stabilize
Arm is externally rotated and then
abducted over patient’s head while
maintaining external rotation with
simultaneously placing direct pressure
over the humeral head
18. Cunningham Technique
Patient is seated with examiner seated
in front of patient, and the patient
places ipsilateral hand on top of
examiner’s shoulder
The clinician rests one arm in patient’s
elbow crease and uses the other hand
to massage the patient’s biceps,
deltoid, and trapezius muscles
Have patient relax and instruct to pull
their shoulder blades together and
straighten their back
19. REDUCTION TECHNIQUES
Stimson Technique
No assistant needed and no need for conscious sedation
Patient is prone with affected arm hanging off the side of bed with 5 lb (2.3
kg) to 15 lb (6.8 kg) of weight
Reduction is usually achieved within 30 minutes
Traction Countertraction
A sheet is wrapped under the axilla, and one assistant provides continuous
traction at the wrist or elbow while the other provides countertraction with
the sheet from the opposite side
21. Reduction techniques
Spaso Technique
Patient is supine while examiner grasps wrist
or distal forearm and lifts vertically with gentle
vertical traction and external rotation
Fares Technique
Patient is supine with upper extremity at their
side
The examiner holds patient’s wrist and gently
pulls the arm to provide traction
The arm is abducted while continuously
moving arm in anteriorly and posteriorly in
small oscillating movements (about 10 cm)
If shoulder has not reduced by 90 degrees of
abduction, add external reduction
22.
23. Reduction techniques
Fulcrum Technique
Patient is supine or sitting, and a rolled towel or
sheet is placed in axilla
The distal humerus is adducted with
simultaneous posterolateral force on the
humeral h
Requires increased force, may have increased
complications
Kocher’s: the elbow is bent to 90° and held close
to the body; no traction should be applied. The
arm is slowly rotated 75 degrees laterally, then
the point of the elbow is lifted forwards, and
finally the arm is rotated medially. This technique
car- ries the risk of nerve, vessel and bone injury
and is not recommended.
Hippocratic Technique: place heel into patients
axilla and apply traction to the arm, foot acts as a
lever to push the humeral head laterally.
