The document discusses anatomy, mechanism of injury, classification, diagnosis, and management of anterior shoulder dislocations. Key points include: - Anterior shoulder dislocations are caused by an anteriorly directed force on the arm when abducted and externally rotated, which can tear the anterior labrum and ligaments. - Associated injuries may include bone fractures like bony Bankart lesions or Hill-Sachs defects. Labral injuries include Bankart lesions in 80-90% of cases. - Treatment depends on any associated injuries and classification. Most cases are treated non-operatively with sling immobilization followed by physical therapy. Surgery is required for repair of labral tears or bone defects.

1. Fracture and dislocation of the
shoulder girdle

2. clavicle

3. Anatomy :-
The clavicle is an irregular S-shape that holds the scapula and shoulder joint in a
functional position away from the chest wall.
Middle 1/3 is narrowest (most common location of fracture).
Subcutanous bone.
First bone to ossify and last to fuse.
It articulates with the manubrium of the sternum medially through SC joint, and to
the acromion of the scapula laterally through AC joint.
It is also stabilizied by the coracoclavicular CC ligaments (conoid and trapezoid)

5. Mechanism of injury
Fall onto the shoulder
(87%)
direct blow to lateral aspect
of shoulder 6%
fall on an outstretched arm
or direct trauma

6. Classification:-
Allman with Neer’s modification

7. Group I (Middle third) 80%
Non-Displaced :- Less than 100%
displacement
Non-operative
displaced :-Greater than 100%
displacement
Nonunion rate of 4.5%
operative

8. Group II - Neer Classification of Lateral third
(10-15%)

9. Group II - Neer
Classification of Lateral
third (10-15%)
 Type 1 minimal
displacement
(interligamentus)
 Stable because conoid and
trapezoid ligaments remain
intact
 Nonoperative

10. Group II - Neer
Classification of Lateral
third (10-15%)
Type II displaced 2ndry to a fracture line
medial to the CC ligament
Type II A :-
conoid and trapezoid attached (fracture
medial to CC ligaments)
Medial clavicle unstable
Up to 56% nonunion rate with nonoperative
management
Operative

11. Group II - Neer
Classification of Lateral
third (10-15%)
Type II B :-
conoid torn, trapezoid attached (fracture
between the CC ligaments)
Medial clavicle unstable
Up to 30-45% nonunion rate with
nonoperative management
Operative

12. Group II - Neer
Classification of Lateral
third (10-15%)
Type III
fracture of the articular surface
Conoid and trapezoid intact therefore stable
injury
Non-operative

13. Group II - Neer
Classification of Lateral
third (10-15%)
Type IV
periosteal sleeve fracture (children)
Conoid and trapezoid ligaments remain
attached to periosteum and overall the
fracture pattern is stable
Non-operative

14. Group II - Neer
Classification of Lateral
third (10-15%)
Type V
Comminuted fracture
Conoid and trapezoid ligaments remain
attached to comminuted fragment
Medial clavicle unstable
Operative

15. Group III - Medial
third (5-8%)
Anterior displacement :-
Most often non-operative
Rarely symptomatic
Posterior displacement :-
Rare injury (2-3%)
Often physeal fracture-dislocation (age <
25)
Stability dependent on costoclavicular
ligaments
Must assess airway and great vessel
compromise
Serendipity radiographs and CT scan to
evaluate
Surgical management with thoracic
surgeon on standby

16. Presentation:-
Symptoms
• shoulder pain.
Physical exam
• Deformity.
• perform careful neurovascular exam.
• tenting of skin (impending open fracture).

18. Skin tenting

19. Imaging
Plain x-ray
• standard AP view of bilateral shoulders to measure clavicular
shortening
• 45° cephalic tilt determine superior/inferior displacement
• 45° caudal tilt determines AP displacement
CT scan
• may help evaluate displacement, shortening, comminution, articular
extension, and nonunion
• useful for medial physeal fractures and sternoclavicular injuries

20. 45-degree cephalic tilt

21. 45° caudal tilt (apical oblique view)

22. Management
Non-operative :-
• no attempt at reduction should be made.
• sling immobilization with gentle ROM exercises at 2-4 weeks and
strengthening at 6-10 weeks.
Indication :-
1) nondisplaced Group I (middle third).
2) stable Group II fractures (Type I, III, IV).
3) nondisplaced Group III (medial third).
4) pediatric distal clavicle fractures (skeletally immature).

23. Operative :-
• ORIF
• CC ligaments repair vs reconstruction indicated in type IIb fracture.
Indication :-
Absolute :-
1) unstable Group II fractures (Type IIA, Type IIB, Type V).
2) open fxs.
3) displaced fracture with skin tenting.
4) subclavian artery or vein injury.
5) floating shoulder (clavicle and scapula neck fx).
6) symptomatic nonunion.
7) posteriorly displaced Group III fxs.
8) displaced Group I (middle third) with >2cm shortening.

24. relative and controversial indications :-
1) brachial plexus injury (questionable b/c 66% have spontaneous
return).
2) closed head injury.
3) seizure disorder.
4) polytrauma patient.

25. complications
Non-operative complications :-
Non-union
Risk :- comminution.
Female.
elderly.
Smoker.
distal clavicle higher risk than middle third.
Absence of cortical contact between the fracture ends.
Malunion

26. Operative complications :-
1) hardware prominence :- 30% of pt. request to remove plate,
superior plate associated with increase irritation
2) neurovascular injury (3%) :- superior plate associated with increase
risk of subclavian artery or vein pentration.
3) nonunion (1-5%)
4) infection (~4.8%)
5) mechanical failure (~1.4%)
6) pneumothorax
7) adhesive capsulitis (4% in surgical group develop adhesive capsulitis
requiring surgical intervention)

27. Acromioclavicular joint
injuries

28. Anatomy :-
• AC joint is a synovial joint with a fibrocartilaginous disk.
• It has thin capsule that is stabilized by sup. Inf. Ant. and post.
Ligaments.
• The most robust ligaments is superior AC ligament which is
responsible for horizontal AC joint stability.
• Vertical stability is provided by the CC ligaments.
• Normal AC joint are ,5 to ,6 mm in width.
• Normal CC distance is 1,1 cm to 1,3 cm.

30. Mechanism of injury
• Fall on shoulder or
direct blow to the
acromion with arm
adducted. (most
common)
• Fall on outstretched
arm transmitted to AC
joint.
• Rugby and hockey
players frequently
sustained this injury.

31. The Rockwood classification

33. Diagnosis:-
pain and soft tissue swelling
prominence of the distal calvicle

34. Imaging
• AP view
• 15 cephalic tilt (zanca view) to evaluate joint displacement and intra-
articular fracture
• Axillary view is mandatory to determine AP displacement

35. Zanca view

37. Management
Based on type :-
 Type 1 and 2 :- non-operative (sling, analgesia and early range of
motion). Return to sports when pain free
 Type 3 :- controversy.
 Type 4, 5, 6 :- surgical repair with reconstruction of the CC ligaments.

38. Anterior shoulder
dislocation

39. Anatomy :-
• Shoulder girdle consist of clavicle, scapula, and proximal humerus,
and their associated ligaments and muscles
• Scapula has consisting of :-
1. Body: triangular, flattened region that articulate with the thorax.
The anterior surface is covered by the subscapularis muscle (one of
the rotator cuff muscle)
2. Spine: a projection that runs horizontally from across the posterior
aspect of the body, forming 2 fossae, which are the origins of the
supra and infra-spinatus and teres minor muscles. It terminates in
the acromion
3. Acromion: lateral end of spine that extend to the heighest and most
lateral point of shoulder.

40. 4. Coracoid: an anterior protrusion that is the origin of the short head
of biceps and brachialis muscles, and the insertion of the CC ligaments.
5. Glenoid: a shallow, saucer-shaped projection from the lateral aspect
of the scapula, deepened by a fibrocartilaginous labrum, which
articulates with the humeral head
• The glenoid is oriented anteriorly by around 30 degree.

42. Shoulder stability
Static stability
1. Bone shape: the glenoid
provides a shallow concave
surface to the humeral head.
2. Labrum: this fibrocartilaginous
rim markedly increases the
glenoid depth.
3. Capsular ligaments: consist of
superior, middle, inferior (ant.
&post. Band) glenohumeral
ligaments
4. Joint capsule.
Dynamic stability
1. Rotator cuff muscles: form a
cuff of muscle that encloses
the glenohumeral joint.
Contraction of these m. result
in concavity compression
which maintains shoulder
congruence and stability
during movement.
2. Long head of biceps: its
position above and anterior to
the humeral head acts to resist
anterior dislocation.

45. GLENO-HUMERAL LIGAMNEBTS
Anterior band of IGHL (main restraint)
•provides static restraint with arm in 90° of abduction and external rotation
MGHL
•provides static restraint with arm in 45° of abduction and external rotation
SGHL
provides static restraint with arm at the side

46. Mechanism of injury
anteriorly directed
force on the arm
when the shoulder is
abducted and
externally rotated

47. Associated injury
1. Labral and cartilage injury (bankart lesion, humeral avulsion of the
GHL, glenoid labral articular defect, anterior labral periosteal sleeve
avulsion).
2. Fracture and bone defect (bony bankart lesion, Hill sachs defect,
G.T. fracture, L.T. fracture).
3. Nerve injury (axillary nerve).
4. Rotator cuff tear.

48. Labral and cartilage injury:

49. Bankart lesion:
is an avulsion of the
anterior labrum and
anterior band of the IGHL
from the anterior inferior
glenoid.
is present in 80-90% of
patients with TUBS.

50. Humeral avulsion of
the glenohumeral
ligament (HAGL):
occurs in patients slightly
older than those with
Bankart lesions
associated with a higher
recurrence rate if not
recognized and repaired
an indication for possible
open surgical repair.

51. Glenoid labral articular
defect (GLAD)
is a sheared off portion of
articular cartilage along
with the labrum
This lesion results from
impaction of humeral
head against the glenoid

52. Anterior labral periosteal sleeve avulsion (ALPSA)
the labrum is displaced by the IGH ligament with intact anterior capsular
periosteum

53. fractures & bone defects

54. Bony Bankart lesion
•is a fracture of the anterior
inferior glenoid
•present in up to 49% of
patients with recurrent
dislocations
•higher risk of failure of
arthroscopic treatment if
not addressed

56. Hill Sachs defect
is a chondral impaction injury
in the postero-superior
humeral head secondary to
contact with the glenoid rim.
is present in 80% of traumatic
dislocations and 25% of
traumatic subluxations
is not clinically significant
unless it engages the glenoid

59. Symptoms and signs
• Shoulder pain
• Feeling instability
• The shoulder has a typical squared off appearance, with prominence
of the acromion without the usual contour of humeral head
• Careful neurovascular assessment. Axillary nerve palsy results in
numbness in the regimental badge area

61. Imaging
Radiographs
• true AP
• scapular Y
• axillary
other helpful views
• West Point view :- shows glenoid bone loss
• Stryker view :- shows Hill-Sachs lesion
• CT scan
• helpful for evaluation of bony injuries
• MRI
• best for visualization of labral tear
• addition of intraarticular contrast
• increases sensitivity and specificity

62. True AP

63. Scapular Y view

64. Axillary view

65. West point view

66. Stryker view

67. Close reduction
Close reduction doesn’t require the application of huge force.
Excessive force can lead to fracture of the humerus or brachial plexus injury.
Indication :-
• Close reduction in ER is indicated with no humeral neck fracture, with or
without an isolated tuberosity fracture.
Methods :-
1. Kocher’s technique.
2. Hippocratic method
3. Milch’s technique.
4. Stimpson’s technique.
5. simple traction-countertraction.
None of the above methods has shown convincing superiorly over anthor.

68. Kocher’s technique
Relocation can occur during
any point of described
manoeuver.

69. Stimpson’s technique

70. Hippocratic method
Patient on supine position
Foot is placed in the patient’s
axilla, resting between the
chest and the humeral head.
The wrist is grasped in both
hands with gentle traction
and external rotation applied
to the arm
Traction is maintained for
several minutes to allow
muscle relaxation

71. Simple traction counter-traction

72. Milch technique
Patient on supine position.
The surgeon places his hand over
dislocated humeral head at the
axilla.
The patient’s wrist is grasped firmly
with the other hand or by an
assistant and the arm slowly and
gradually abducted fully
Once it is above the patient’s head,
gentle external rotation and
traction are applied to the wrist,
whilst lateral pressure is
simultaneously applied to the head
of the humerus.

73. Operative
Indication
1. Irreducible dislocation or fracture dislocation
2. Displaced G.T. Fracture: most fractures of the GT will reduce when
humeral head is relocated, if the fracture remains displaced the
supraspinatus will remain de-functioning and ORIF should be
considered
3. Acute rotator cuff tear: An acute rotator cuff tear in young pt. is an
indication for acute repair.
4. Prophylactic stabilization: high chance of re-dislocation, athletic
patient, recurrent dislocation.
5. Late presentation: after around 3 weeks close reduction may prove
impossible and open reduction with stabilization are indicated.

74. Complications
1. Recurrence
2. Shoulder pain
3. Nerve injury :- musculocutaneous N. axillary N.
4. Stiffness :- especially in external rotation

75. Posterior shoulder
dislocation

76. • Posterior shoulder dislocations are less common than anterior
dislocations, but more commonly missed.
• 50% of traumatic posterior dislocations seen in the emergency
department are undiagnosed.
• Common cause :- seizures and electrical shock (tetanic muscle
contraction pulls the humeral head out)
• mechanism :-
flexed, adducted, and internally rotated arm is a high-risk position.

78. Presentation
History
trauma with the arm in a flexed, adducted, and internally rotated position.
Symptoms
pain with flexion, adduction, and internal rotation of the arm.
Physical exam
• Inspection:-
prominent posterior shoulder and coracoid.
• Motion:-
limited external rotation.
shoulder locked in an internally rotated position common in undiagnosed
posterior dislocations.
pain on flexion, adduction and internal rotation for posterior instability.

79. Imaging
Radiography
• AP :- unreliable and cannot be exclude posterior dislocation.
may show lightbulb sign.
• Axillary lateral :- best view to demonstrate a dislocation.
• Velpeau view :- if patient is unable to abduct arm for axillary view.
CT
analyze the extent and location of bone loss in a chronic dislocation.
MRI
• evaluate for suspected associated rotator cuff tear.

80. AP view

81. Axillary view

82. Velpeau view

83. Close reduction
• Indication for all acute posterior shoulder dislocation.
• Most dislocations reduced spontaneously.
• Technique :-
1. the Patient is supine with the arm held by the side
2. Traction is applied to the arm with some internal rotation
3. The shoulder is flexed and adducted while further internal rotation
is add
4. Direct pressure to the humeral head from behind can facilitate
reduction
5. Once it is unlocked the humerus is externally rotated gently, don’t
attempt a forceful external rotation if the shoulder remains locked.

84. Inferior shoulder dislocation
(luxation erecta)

85. Incidence :- very rare, only 0.5% of all shoulder dislocations.
mechanism of injury :-
typically a high-energy injury.
hyperabduction force applied to arm, levering the proximal humerus
onto the acromion, injuring inferior capsule/labrum, which subsequently
allows for disengagement of HH inferiorly from glenoid.
commonly involves variable sized tearing of static glenohumeral
ligaments.
Associated conditions
neurovascular injury :- has greatest incidence of neurovascular injury of
all types of shoulder dislocations.
proximal humerus fractures :- especially greater tuberosity.
rotator cuff tears.

87. Symptoms and signs
Symptoms :-
1. shoulder pain
2. inability to move shoulder
3. neurovascular injury :-
• neurologic injury up to 60%
• vascular injury up to 39%
Physical exam :-
• patient presents with the arm in a fixed, abducted position

90. Close reduction
traction-countertraction
• similar technique as for anterior shoulder dislocations

91. Complication :-
1. Axillary nerve palsy (usually resolves with reduction of shoulder).
2. Axillary artery thrombosis (may occur late).
3. Rotator cuff tear (especially in older patients).