Reposisi dislokasi bahu

1. DISLOCATION OF
SHOULDER JOINT
PROGRAM PENDIDIKAN DOKTER SPESIALIS ILMU BEDAH
FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
Oleh :
dr. Tania Nugrah Utami
Pembimbing: dr. Eko Setiawan,Sp.OT, AIFO (K)

2. Epidemiology
45% dari seluruh kasus dislokasi
96% kasus merupakan dislokasi anterior
Dislokasi posterior —> 2% hingga 4%
Dislokasi Inferior (luxatio erecta) dan
superior  jarang (0,5%)

3. ANATOMY
• Sternoclavicular
• Synovial-saddle
• Diarthrosis
• Acromioclavicular
• Synovial-plane
• Diarthrosis
• Glenohumeral joint
• Synovial-ball&socket
• Diarthrosis
• Many ligaments
• Muscle reinforcement
• Great Mobility

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5. Associated injury
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7. 7

9. Pathoanatomy of shoulder dislocations
Stretching or tearing of the capsule due to avulsion of
the glenohumeral ligaments (HAGL lesion)
Labral damage: A “Bankart” lesion refers to avulsion of
anteroinferior labrum off the glenoid rim.
Hill-Sachs lesion: A posterolateral head defect is caused
by an impression fracture on the glenoid rim

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12. SHOULDER DISLOCATION
ANTERIOR
POSTERIOR

13. ANTERIOR GLENOHUMERAL DISLOCATION
Kasus terbanyak pada usia muda
96% kasus merupakan dislokasi anterior
Tipe dislokasi anterior
Subcoracoid (paling banyak,
anterior)
Subglenoid (anteroinferior)
Subclavicular
(anterosuperior)

15. MECHANISM OF INJURY
as a result of trauma,
secondary to either direct or indirect forces.
Indirect trauma:
🡪 abduction, extension, and external rotation is the most common
mechanism.
Direct :
🡪 anteriorly directed impact to the posterior shoulder.

16. Clinical Presentation
• “Squared off”
shoulder
• Patient resists
abduction and
internal rotation
• Humeral head
palpable anteriorly
• Must test axillary
nerve function/
sensation

17. Anterior Shoulder
Dislocation

18. CLINICAL EVALUATION
the shoulder owing to a relative prominence of the acromion, a relative hollow
beneath the acromion posteriorly, and a palpable mass anteriorly.

19. TREATMENT - NONOPERATIVE
Closed reduction.
Traction–countertraction
Hippocratic technique: This is effective with only one person performing
reduction, with one foot placed across the axillary folds and onto the chest wall,
with gentle internal and external rotation with axial traction on the affected
upper extremity.
Stimson technique: After administration of analgesics and/or sedatives, the
patient is placed prone on the stretcher with the affected upper extremity
hanging free. Gentle, manual traction or 5 lb of weight is applied to the wrist,
with reduction effected over 15 to 20 minutes.

20. TREATMENT - NONOPERATIVE
Scapular manipulation technique: The patient is placed prone similar to the
Stimson technique. Once the patent is relaxed, the inferior tip of the scapula
is pushed medial and inferior while the superomedial scapula is held
stationary.
Milch technique: With the patient supine and the upper extremity abducted
and externally rotated, thumb pressure is applied by the physician to push the
humeral head into place.
Kocher maneuver: The humeral head levered on the anterior glenoid to
effect reduction; this is not recommended because of increased risk of
fracture.

22. OPERATIVE
Indications for surgery include:
✔First-time dislocation in young active men
✔Soft tissue interposition
✔Displaced greater tuberosity fracture that remains >5 mm superiorly displaced following joint
reduction
✔Glenoid rim fracture >5 mm in size
Surgery for stabilization typically involves arthroscopic ligamentous repair of the
anterior/inferior labrum (Bankart lesion).

23. POSTOPERATIVE MANAGEMENT
Includes : the use of a shoulder sling or immobilizer for (depending on the type of
surgical stabilization):
✔ up to 3 weeks in patients <30 years
✔ 2 weeks for patients 30 to 40 years
✔ 1 to 2 weeks for patients >50 years of age
Patients are allowed to remove the immobilizer two to four times per day for shoulder,
wrist, and hand range-of-motion exercises.

24. Complications
Recurrent anterior dislocation: related to ligament and capsular changes
( most common)
Most recurrences occur within the first 2 years and tend to occur in men.
Prognosis is most affected by age at the time of initial dislocation.

25. COMPLICATIONS
Osseous lesions:
Hill-Sachs lesion
Soft tissue injuries:
Rotator cuff tear (older patients)
Capsular or subscapularis tendon tears
Vascular injuries: ( elderly patients)
Nerve injuries: involve most commonly the musculocutaneous and axillary nerves, usually
in elderly individuals;

26. POSTERIOR GLENOHUMERAL DISLOCATION
Mechanism of Injury
Indirect trauma: (most common)
✔The shoulder typically is in the position of adduction, flexion, and internal
rotation.
✔Electric shock or convulsive mechanisms
 Direct trauma:
🡪 Force application to the anterior shoulder resulting in posterior translation
of the humeral head.

27. CLINICAL EVALUATION
does not present with striking deformity;
🡪 typically held in the traditional sling position of shoulder internal rotation and adduction.
 neurovascular examination to rule out axillary nerve injury
🡪
On examination: limited external rotation (often <0 degrees) and limited anterior forward
elevation (often <90 degrees) may be appreciated.

28. A palpable mass posterior to the shoulder, flattening of the anterior shoulder,
and coracoid prominence may be observed.

29. RADIOGRAPHIC EVALUATION
Trauma series of the affected shoulder: (AP views)
✔Absence of the normal elliptic overlap of the humeral head on the glenoid
✔Vacant glenoid sign: The glenoid appears partially vacant (space between anterior rim and
humeral head >6 mm).
✔Trough sign: impaction fracture of the anterior humeral head caused by the posterior rim of
glenoid (reverse Hill-Sachs lesion). This is reported to be present in 75% of cases.
✔Loss of profile of humeral neck: The humerus is in full internal rotation.
✔Void in the superior/inferior glenoid fossa, owing to inferosuperior displacement of the
dislocated humeral head.

31. POSTERIOR SHOULDER DISLOCATION
TREATMENT (NON OPERATIVE)
Closed reduction requires full muscle relaxation, sedation, and analgesia.
patient supine, traction should be applied to the adducted arm in the line of deformity with
gentle lifting of the humeral head into the glenoid fossa.
The shoulder should not be forced into external rotation because this may result in a humeral
head fracture if an impaction fracture is locked on the posterior glenoid rim.

32. TREATMENT (OPERATIVE)
Indications for surgery include:
 Major displacement of an associated lesser tuberosity fracture
A large posterior glenoid fragment
 Irreducible dislocation or an impaction fracture on the posterior glenoid preventing
reduction
Open dislocation
An anteromedial humeral impaction fracture (reverse Hill-Sachs lesion):
✔20% - 40% humeral head involvement Transfer the lesser tuberosity with attached
🡪
subscapularis into the defect (modified McLaughlin procedure).
✔> 40% humeral head involvement hemiarthroplasty with neutral version of the
🡪
prosthesis
✔Recurrent instability

33. COMPLICATION
 Fractures
 Recurrent dislocation
 Neurovascular injury
 Anterior subluxation

34. THANK YOU