This document summarizes an orthopedic case of a 42-year-old Thai male who presented to the emergency room with left shoulder pain after hearing a popping sound while lifting roof tiles. On examination, he was found to have deformity and tenderness of the left shoulder with the humeral head palpable in the anterior shoulder, indicating an anterior shoulder dislocation. X-rays confirmed an anterior shoulder dislocation with an associated greater tuberosity fracture. The patient was taken to the operating room for closed reduction of the dislocation and rehabilitation.

1. Orthopedic
case teleconference
Ext. Patchara Pornsopanakorn Maharat Nakhonratchasima Hospital

2. @ER
ผู้ป่วยชายไทยอายุ 42 ปี อาชีพรับจ้าง ภูมิลาเนา จ.นครราชสีมา
Chief complaint : เจ็บไหล่ซ้าย 1 ชั่วโมง PTA

3. @ER
ผู้ป่วยชายไทยอายุ 42 ปี อาชีพรับจ้าง ภูมิลาเนา จ.นครราชสีมา
Chief complaint : เจ็บไหล่ซ้าย 1 ชั่วโมง PTA
Present illness : 1 hr. PTA
ขณะยกกระเบื้องส่งให้เพื่อนขึ้นกระบะ ได้ยินเสียงกึกบริเวณไหล่ หลังจาก
นั้นรู้สึกเจ็บไหล่ซ้าย ยกขึ้นไม่ไหว ไม่มีปวดบริเวณอื่นๆ ไม่มีล้มหัวกระแทก ไม่เคย
มีประวัติไหล่หลุดมาก่อน ปฏิเสธประวัติดื่มสุรา

4. PRIMARY SURVEY
 A : can speak, C-spine not tender
 B : equal breat sound, CCT negative
 C : BP 118/59 mmHg, PR 72 /min
 D : E4V5M6, pupil 2 mm RTLBE
 E : deformity at Lt. shoulder, tender,
mild swelling, no external wound

5. SECONDARY SURVEY
• Allergy : no food/drug allergy
• Medication : none
• Past history : no U/D
• Last meal : 4 hrPTA
• Event : as in present illness

6. Physical examination
Ref : http://www.rhpphysiotherapy.com.au/blog/1343/

7. Physical examination
• GA : A Thai male, fully alert, well co-operative
• V/S : BT 37.1 C, BP 118/59 mmHg, PR 72 /min, RR 18
/min
• HEENT : no pale conjunctivae, anicteric sclerae
• Skin : no external wound seen
• Heart : normal S1 S2, no murmur
• Lung : clear, equal breath sound both lungs
• Abdomen : soft, not tender, normoactive bowel sound

8. Physical examination
• Extremities : deformity and tenderness at left
shoulder, arm in abduction and external rotation
while resting, humeral head can palpate at
anterior of shoulder, limit ROM due to pain, ruler
sign +, duga sign -, cap. Refill 2s
• Neuro : motor power gr. V all extremities,
sensory intact, reflex 2+ all

9. Film

10. Diagnosis
Anterior shoulder dislocation
with greater tuberosity fracture

11. Shoulder Dislocations
• Definition : head of humerus loses its articulation with
the glenoid cavity of the scapula
• Classification
 Anterior dislocation (98 percents)
 Posterior dislocation (2 percents)
 Inferior dislocation (very rare)

12. Anterior shoulder dislocation
• Mechanism : anteriorly directed force on the arm
when the shoulder is abducted , extension and
externally rotated

13. Risk factors
• Young age
• Male sex
• Competitive level of sports
• Contact sports
• Excessive caosular laxity
• Large gleno-humeral bone defects

14. dwyane wade 25 yr.

15. Anatomy

16. Anatomy

19. Anterior shoulder dislocation
• Associated injuries
 labral & cartilage injuries
Ex. Bankart lesion – associated with a high recurrence rate of dislocation
 fractures & bone defects
Ex. Hill Sachs defect (a divot or flattening of humeral head)
Greater/lessor tuberosity fracture
 nerve injuries : Axillary nerve injury (transient neurapraxia)
 rotator cuff tears : depend on ages

20. Sign and symptoms
• Pain
• Resting position : slightly abduction and external rotation
• May be palpate head of humerus at deltopectoral groove
• Hamilton ruler sign
• Duga’s sign
• Axillary nerve injuries
• Deltoid weakness

21. Sign and symptoms
Hamilton ruler sign
• Flatted acromion process to lateral
epicondyle
Duga’s sign

22. Film
• AP
• Transcapular Y view

23. Management
• Early reduction (control pain / under GA)
• Interlocking sling
• Film after reduction
• Rehabilitation

24. Reduction
• Hippocrates
• Stimson
• Milch

25. Reduction
• Zero position
 Abduction 165 degree, forward flexion 45 degree, medial epicondyle on anterior
 Traction on humeral shaft axis
 Abduction with flexion

26. Reduction
• Traction and counter traction

27. Film after reduction

28. Operative
• Failed closed reduction
• Soft tissue interposition
• Greater tuberosity fracture displaces > 1 cm.

29. Interlocking sling
• Age <45 : On interlocking sling 1-3 weeks
• Age >45 : until pain relieve, early ROM exercise

30. Rehabilitation
• Phase 1 (0-7 Days)
 Interlocking sling
 Isometric exercise, wrist and hand exercises
 Avoid positions that could cause re-dislocation 6 weeks
• Phase 2 (1-3 weeks)
 ROM movement, mobility exercise
• Phase 3 (3-6 weeks)
 isometric or static strengthening exercises

31. Greater tuberosity fracture
• Fracture proximal humerus
• Neer classification
• Displaced fracture
 Displaces > 1 cm
 Angulation > 45 degrees
• Tx
 Non-displaced : arm sling
 Displaced : ORIF with P&S

32. THANK YOU