Orthopaedic

1. Faculty of Clinical Sciences
Department of Orthopedics & Trauma Medicine
Physical Traumatology I
By
JK. Mwangi
DISLOCATIONS

2. Learning Objectives
Dislocations;
1. Glenohumeral joint, Hip joint dislocation
2. Introduction & definitions
3. Etiology
4. Mechanism of injury
5. Clinical presentation
6. Imaging
7. Management
8. Reduction maneuvers
9. Complications

3. Introduction
High yield definitions;
Dislocation?
Subluxation?
Sprain?
Strain?

5. Introduction
Etiology of dislocations;
Trauma
Direct or indirect
Falls, RTI, Accidents;
Sports injuries
Joint instability due to ligament or capsular damage
Congenital conditions
Hip dysplasia

6. Introduction
Commonly affected joints
Shoulder
Commonest; REASONS?
Hip
Elbow
Knee
Patellar dislocation
Fingers
Interphalangeal joints

7. Introduction
Clinical presentation;
Severe pain
Visible deformity
Depending on joint affected & type of dislocation sustained
Swelling
Loss of ROM
Numbness or tingling distally if nerves are affected

8. Introduction
Diagnosis;
History
Clinical presentation
Physical examination
Imaging
Xray to confirm diagnosis & r/o fractures
MRI if soft tissue injury suspected

9. Introduction
Management;
Pain management / anesthesia
Reduction
Immobilization
Rehabilitation
Surgical intervention

10. Introduction
Complications;
Immediate
Early
Late
Injury to adjacent tissues, ligaments, tendons, nerves, blood
vessels, viscera
Recurrent dislocations
Post-traumatic O.A

11. Faculty of Clinical Sciences
Department of Orthopedics & Trauma Medicine
Physical Traumatology I
By
JK. Mwangi
SHOULDER
DISLOCATIONS

12. Introduction
Shoulder dislocations
The shoulder / glenohumeral joint is the most dislocated major
joint in the body. REASONS?
Dislocation usually involves displacement of the humeral head
from the glenoid cavity of the scapula

13. Anatomy of the shoulder
Joint
Ball-and-socket joint
Components
Humeral head – ball
Glenoid fossa – socket
Stabilizing structures
Dynamic stabilizers
Static stabilizers

14. Anatomy of the shoulder
Shoulder stabilizers
Statis stabilizers
Glenoid labrum
Glenohumeral ligaments
Negative intra-articular pressure
Dynamic stabilizers (muscles and tendons)
Rotator cuff muscles – SITS
Rotator interval
Long head of the biceps

16. Types of Shoulder Dislocations
Anterior dislocations (95-97%)
Posterior dislocation (2-4%)
Inferior dislocations (Luxatio Erecta) (<1%)
Multidirectional instability

17. Anterior dislocations (95-97%)
The humeral head is displaced forward in relation to the
glenoid
Mechanism of injury
Forceful abduction, external rotation and extension
 FOOSH injuries
 Forceful overhead movements – throwing sports
Associated injuries
Hill-Sachs lesion
Bankart lesion
Axillary nerve injury

18. Anterior dislocations (95-97%)
Clinical presentation
Symptoms
 Severe shoulder pain
 Inability to move the arm
 Sensation of the shoulder “popping out”
Signs
 Deformity
 Arm held in slight abduction & external rotation
 Palpable humeral head anteriorly under the coracoid process
 Limited ROM
Neurovascular assessment
 Axillary nerve – motor & sensory
 Vascular compromise

19. Anterior Shoulder Dislocation - DIAGNOSIS
Clinical examination
Position of the arm – abducted & externally rotated
Prominent acromion posteriorly & laterally – “SQUARED OFF” shoulder
Palpable humeral head anteriorly
Reduced ROM
Imaging
Xray
 AP, Axillary, Scapular Y
 Humeral head ,medial & inferior to glenoid fossa
CT/MRI
 r/o soft tissue injuries
 r/o complex injuries

23. Anterior Shoulder Dislocation – Management
Reduction
Closed reduction with IV sedation & muscle relaxation
Kocher maneuver - TEAM
Milch technique
Stimson technique
Hippocratic technique
Post-reduction pain management
Post-reduction xrays
Neurovascular assessment post-reduction
Sling x3/52 – x6/52
Then shoulder rehabilitation

27. Anterior Shoulder Dislocation – Management
Surgical management
Recurrent shoulder instability (dislocations or subluxations; in <30yrs)
Failed closed reduction
Bankart lesion
Hill-Sachs lesion
Rotator cuff tears
Bilateral instability
First-time dislocations in select cases
 Young active pts with high risk of recurrence (contact sports, <30yrs)
Fracture-dislocations
Chronic shoulder dislocation
 Prolonged instability, idiopathic shoulder pain, idiopathic reduced ROM

28. Anterior Shoulder Dislocation – Complications
Recurrent dislocations
Common in younger pts <30yrs & athletes
Chronic instability
May -> subluxations or recurrent dislocations
Arthritis
Post-traumatic OA due to recurrent dislocations or damage

29. Posterior Shoulder Dislocation
Summary
Less common than anterior dislocations; but are more commonly
missed
Acute dislocation Diagnosis is made via radiographs
Chronic dislocations can be diagnosed with presence of +ve
posterior instability provocative tests & confirmed with MRI
(posterior labral pathology)
Rx – non-op or operative depending on;
Chronicity of symptoms
Recurrent dislocations
Severity of labrum &/or glenoid defects

30. Posterior Shoulder Dislocation
Introduction
2%-5% of all unstable shoulders
Risk factors
Bony abnormality
Ligamentous laxity

31. Posterior Shoulder Dislocation
Mechanism of injury;
Traumatic
Microtrauma
Seizures & electric shock

32. Posterior Shoulder Dislocation
Mechanism of injury;
Traumatic
50% of cases
Direct trauma to the anterior shoulder,
FOOSH with the arm in abduction
Microtrauma
Seizures & electric shock

33. Posterior Shoulder Dislocation
Mechanism of injury;
Traumatic
Microtrauma
Repetitive microtrauma
Repeated posterior stresses on the joint – overhead movements in
sports, -> chronic posterior instability or dislocation
Seizures & electric shock

34. Posterior Shoulder Dislocation
Mechanism of injury;
Traumatic
Microtrauma
Seizures & electric shock
Violent muscle contractions during an attack – tonic-clonic seizures, &
Severe electrical shock
These 2 can cause sudden internal rotation and adduction of the
shoulder

35. Posterior Shoulder Dislocation
Associated conditions
Avulsion of posterior band of IGHL
Posterior bankart lesions
Reverse Hill-Sachs lesions
Posterior labral cyst
Posterior glenoid rim fracture

36. Clinical presentation
History
Symptoms
Signs

37. Clinical presentation
History
Pt reports of a fall, trauma, or seizure, with an inability to move the
shoulder normally
There may be a delay in diagnosis, especially if initial radiographs miss
the dislocation
Symptoms
Signs

38. Clinical presentation
History
Pt reports of a fall, trauma, or seizure, with an inability to move the
shoulder normally
There may be a delay in diagnosis, especially if initial radiographs miss
the dislocation
Symptoms
Pain in the shoulder, especially with attempts at movement
A feeling of instability or locking
Signs

39. Clinical presentation
History
Pt reports of a fall, trauma, or seizure, with an inability to move the
shoulder normally
Symptoms
Pain in the shoulder, ; A feeling of instability or locking
Signs
Flattening of the anterior shoulder contour
Prominent coracoid process
Posterior bulge due to displaced humeral head
Limited external rotation & abduction
The arm is held in INTERNAL ROTATION & ADDUCTION

40. Posterior Shoulder Dislocation
Diagnosis
Diagnosis is often delayed to subtle findings on physical exam
and imaging
Xrays
Gold standard for making a diagnosis
Ct scan
Useful in confirmation of the diagnosis & assessing associated injuries
like fractures
MRI
Helps evaluate associated soft tissue injuries, such as rotator cuff
tears or labral damage

41. Posterior Shoulder Dislocation
Diagnosis
Diagnosis is often delayed to subtle findings on physical exam
and imaging
Xrays
Gold standard for making a diagnosis
True AP view – may appear normal or show overlap of humeral head with
the glenoid
 Shows a “LIGHT BULB” sign (humeral head appears rounded due to internal
rotation)
 “RIM SIGN” (widening of the joint space)
Axillary view
 Best to demonstrate a dislocation

45. Posterior Shoulder Dislocation
Management
Acute Posterior Dislocation
Closed reduction
 Under sedation / GA
 Traction-counter traction method
• Apply gentle traction with external rotation & abduction
 Stimson method
Post-Reduction Care
 Immobilization of the shoulder in a sling for a shirt period (1-2wks)
 Gradual rehabilitation focusing on restoring ROM & strengthening

46. Posterior Shoulder Dislocation
Management
Chronic Posterior Dislocation
Surgical intervention
 Required if the dislocation is missed or reduction is unsuccessful
 ORIF – If associated with a fracture
 Bone grafting or glenoid reconstruction for severe posterior defect
 Reverse shoulder arthroplasty in older pts with severe damage
Rehabilitation
 Focuses on restoring external rotation & strength in the rotator cuff and
periscapular muscles

47. Posterior Shoulder Dislocation
Complications
Immediate
Early
late
Recurrent instability
Joint stiffness
O.A
Neurovascular injury

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