Shoulder_Dislocation.ppt

Shoulder dislocation
1. DISLOCATION- COMPLETE LOSS OF
GLENOHUMERAL ARTICULATION . CAUSE- ACUTE
TRAUMA
 2. SUBLUXATION - PARTIAL LOSS OF
ARTICULATION WITH SYMPTOM’S. CAUSE-
REPITITIVE TRAUMA.
 3. LAXITY - PARTIAL LOSS OF GLENOHUMERAL
ARTICULATION BUT PAITENT IS ASYMPTOMATIC.
SHOULDER INSTABLITY

 Shoulder is the most commonly dislocated joint[45%]
1] shallowness of glenoid socket
2]Extraordinary ROM
3] ligamentus laxity
 Humeral head 3x larger than glenoid fossa
 glenohumeral articulation is minimally constrained by
bony anatomy alone
 stability is conferred by a series of dynamic and static soft
tissue restraints

Type of dislocation
 Traumatic Dislocations
 Atraumatic dislocation
 Acquird dislocation

Traumatic dislocation
 Single force applies excessive overload to the
soft tissues of the joint and often damages the
Glenoid Labrum (Bankart Lesion) and the joint
capsule
 Anterior [85%]
 Posterior[10]
 Inferior [5]

Atraumatic dislocation
 Athelete who has joint hyperlaxity and had
multiple episode of joint subluxation
 Minor injury can results into dislocation
[Congenital hypermobility or muscle weakness.]

Acquired dislocation
 Sports such as
swimming, gymnastics
and baseball where
repetitive micro-
trauma, poor
stretching and motion
lead to capsular
stretching. Eventual
feeling of instability

Traumatic anterior dislocation
Mech. of injury
Arm in abduction and external rotation. Force is
taken on the hand or arm which increases the
external rotation of the arm causing the head of
the humerus to dislocate

 Clinical symptom:
 Pain [severe]
 Hold limb with normal limb by side of body.
 Abduction and external rotation.
 Pt can’t touch apposite shoulder [dugos test]

Clinical Evaluation
 PE:
 Prominent acromion, sulcus
sign, palpable humeral head
anteriorly
 Neuro integrity of axillary
and musculcutaneous nerves
 Apprehension Test:
reproduces sense of
instability and pain in
shoulder reduced prior to
exam

Radiographic Evaluation
 AP [fracture dislo]
 Axillary
 Special Views:
 West Point axillary: for
visualization of glenoid rim
 Hill-Sach view: internal
rotation view
 Stryker Notch: view 90% of
posterolateral humeral head

Management
 Pre-Medication
 Reduction Maneuvers
 Post-Reduction
Immobilization

Pre-Medication
 Methods of Premedication
prior to Reduction
 None
 Intraarticular Lidocaine
 IV Sedation
 Supraclavicular Block
 Suprascapular Block

IV Sedation vs Intraarticular
Lidocaine Injection
Intra-articular Lidocaine
Injection is Preferred over
IV Sedation

Reduction Maneuvers
 Is there an Ideal Method for Reduction?
 Over 24 Techniques Described
 Most Common Techniques
 Kocher (71-100%)
 External Rotation (78-90%)
 Milch (70-89%)
 Stimson (91-96%)
 Traction/Countertraction
 Scapular Manipulation (79-96%)

Kocher Maneuver
TEA I
 Traction
 ER
 Adduction
 arm is internally
rotated
 Modified [no traction]

Traction/Countertraction
 Arm in some abduction
 Traction applied to arm
 Assistant applies firm
counter-traction with
sheet across the body

Hippocratic method
 Surgeon use foot applies on
axilla for countertraction

Post-Reduction Immobilization
 Is immobilization
necessary?
 What Method
is Best?

Does immobilization
reduce recurrence?
 usually fracture associated with dislocation are
reduced with reduction of dislocation.
 Immobilization for 3-4 weeks after shoulder
dislocation does NOT change the prognosis
compared with immediate mobilization

Internal vs External Rotation
 Level II RCT: Itoi JBJS 2007
 ER for 3 weeks
 Recurrence rate: 32%
 IR for 3 weeks
 Recurrence rate: 60%
 P = 0.007

Complication of ant.shoulder
dislocation
Early
 Rotator cuff tear
 Nerve injury
 Vascular injury
 Fracture dislocation

Late complication
 Stiffness
 Unreduced disloction [undiagnos in unconcious
and old pts. ]
closed reduction done upto 6 wks and open
reduction done after 6wks in young pts. Willful
neglect in old pts
 Recurrent dislocation

Post. Shoulder dislocation
 The arm is in flexion and adduction. Force is
taken on the hand, causing the head of the
humerus to be push out the glenoid posteriorly.
 h/o convulsion or electric shock

Clinical sign and symptom
 Diag is often missed
 Internal rotation
 Flat front of shoulder
 Prominent corocoid
 Frominent post aspect of shoulder

Radiology
 AP- electric bulb apperence
and empty glenoid sign.
 Lat – post displacement

 Treatmet
 Under GA reduction by pulling arm in
adduction to dis engage head then lateraly rotate
while pushing head anteriorly.
 Immobilization in ext rotation and abduction for
3 wks.

Inferior shoulder
dislocation[luxatio erecta]
Arm is in excessive abduction and a force is taken
on the hand pushing the head of the humerus
inferiorly out of the glenoid.
Clinical features
limb in abduction

Inferior shoulder
 Xrays –AP
 LAT

Inferior shoulder
Treatment
Traction and counter traction.
Immobilised for 3 wks

Recurrent shoulder dislocation
 Anterior dislocations account for ~95% of shoulder
dislocations
 Typically occurs in athletes who are < 25 years old
 Males are much more commonly affected than are females (85-
90%)

 Pathology most commonly found in shoulders
following a dislocation is a Bankart lesion
 Disruption of the labrum and the contiguous
anterior band of the inferior glenohumeral
ligamentous complex (IGHLC)
 Bankhart lesion occurs > 85% of the time

 Hillsach lesion –
posteriolateral
indentation of humeral
head.
 Enganging lesion is
indication of surgery

 Classification
 Instability can be classified by:
 direction of instability (anterior, posterior,
multidirectional)
 degree of instability (subluxation, dislocation)
 etiology (traumatic, atraumatic, overuse)
 timing (acute, recurrent, fixed)

TUBS or “Torn Loose”
 T raumatic aetiology, U nidirectional instability, B
ankart lesion is the pathology, S urgery is required
 AMBRI or “Born Loose”
 A traumatic: minor trauma, M ultidirectional instability
may be present, B ilateral: asymptomatic shoulder is also
loose, R ehabilitation is the treatment of choice, I
nferior capsular shift: surgery required if conservative
measures fail

 Shoulder Stabilisers – Static
 Intracapsular pressure
 Labrum: increases depth of the glenoid by 50%
 Ligaments – main static restraints
 capsule

Shoulder Stabilisers
Dynamic Rotator cuff and biceps

 How many number of dislocation is
indication of surgery.
 Frist dislocation in young pateint specially
sports person.
 Two time dislocation is definit indication of
surgery.

 Open surgery done for old and multiple
recurrent dislocation due plastic deformation of
tissue or larg bony defects.
 Arthroscopic surgery is done fresh case of
recurrent dislocation.
 Advantage

 Anatomic Repairs
 Restoring normal anatomy is guiding principle in surgery to
correct anterior shoulder instability
 If the labrum has been detached, it is reattached to the
anterior glenoid rim
 If the capsule has been stripped off the glenoid neck, the
capsule is reattached to the bony glenoid rim
 If greater than one-third of the glenoid fossa is involved, a
bone block procedure such as a Bristow or iliac crest bone
graft may be considered

 Nonanatomic Repairs [open]
 Bristow and latarjet
 Transfer coracoid process to anteroinferior glenoid
 Sling effect and bone block
 Putti-Platt -Subscapularis is cut and shortaned
Magnusen-Stack
 subscapularis tendon is detached from its insertion on the
lesser tuberosity, transferred laterally to the greater tuberosity

Putti-plat operation:
 Putti-plat operation:
 limited ER

Shoulder_Dislocation.ppt

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