Neglected shoulder dislocation management x ray views for shoulder joint reverse shoulder arthroplasty

1. PREOP PLANNING DISCUSSION
Old unreduced anterior shoulder
dislocation
Dr ARJUN K
Resident dept of orthopaedics
Unit C
LHMC

2. 60 yr old lady with right hand dominant ,house maker
by occupation resident of delhi came to Ortho opd
with c/o
pain left shoulder and decrease in left shoulder
movement X 25 DAYS

3. A/H/o fall from stairs at her residence and
sustained injury to left shoulder 25 days prior
to the presentation.
• c/o pain left shoulder + since then
• Acute onset
• Initially progressively increased in intensity
then gradually reduced but still persisting in
mild severity
• Non radiating
• Aggrevated by shoulder movements
• Relieved partially by rest and analgesics

4. • Limitation of movement of left arm and swelling in
the axilla and front of the shoulder.
• Not able to lift the weight
• Not able to lift the hand above the head level
No ho numbness / weakness in the upperlimb
No ho any breathlessness or cough
No ho LOC,vomitting, seizure , ENT bleed
No ho any other joint pain or trauma to any other
part of the body

5. Past history
• No previous episodes of shoulder dislocation
or # around the shoulder
• No ho DM ,HTN, TB, ASTMA or any chronic
drug use

6. Examination
• Gc fair
• Afebrile
• Vitals stable
• No signs of generalised ligamentous laxity
• Beighton score joint hypermobility

8. • Swelling :
bulge + anterior and lateral edge of acromion
• Tenderness
#GT (33%)
Rotator cuff tear( 40% in less than 60 yrs
80% in more than 60 yrs of age)
Prox humerus #
• Crepitus

9. • Neurovascular deficits(13- 65%)
Axillary N more then Musculocutaneous N
• Deformity
RESTRICTED
• ABD+ IR : ANTERIOR DISLOCATION
• ADD+ ER: POSTERIOR DISLOCATION
• Dugas test
• Hamilton ruler test

11. Posterior dislocation
(< 5% all shoulder dislocations)
• Comcomittant fracture/ multiple injury
• Unresponsive
• Intubated/ sedated/ alcohol
• Shock/ seizure

12. STABILITY

13. INVESTIGATIONS
• XRAY
• CT SCAN
• MRI

14. X ray views
• Ap
• True ap ,Grashey view( 35- 40 oblique to sagital)
• Valpeau axillary
• Trauma axillary
• West point view( for glenoid rim #- in prone
positon)
• Stryker notch view(for Hill sachs lesion)
• Apical oblique view

17. AXILLARY LATERAL

18. AXILLARY LATERAL

19. Valpeau axillary

20. V –Y VIEW

21. Scapular y view

22. Stryker notch view(for Hill sachs lesion)

23. Apical oblique view

24. CT SCAN ( ideal for bony lesion)
• 3D reconstruction
• Size of gelnoid # segment
• # proximal humerous
• Hill sach lesion
GLENOID BONE LOSS
GOLD STANDARD TEST CT 3D RECONSTRUCTION

25. % BONE LOSS
=
RADIUS OF BEST FIT CIRCLE - DISTANCE FROM CEMNTER TO ANTERIOR DEFECT
DIAMETER OF THE BEST FIT CIRCLE

27. MRI
• Rotator cuff tear
• Humeral avulsions of gleno humeral ligament.
• MRI ARTHROGRAM ( IOC)

28. TREATMENT OPTIONS
• NO TREATMENT
• CLOSED REDUCTION(+/- ARTHROSCOPY ASSISTED)
• ORIF
• HEMIARTHROPLASTY
• SHOULDER TOTAL ARTHROPLASTY

29. No treatment
• Dementia
• Very old age( too sick for surgery)
• Low demand
• Good shoulder function and no pain

30. CLOSED REDUCTION
ASESS
• AGE
• OSTEOPOROSIS (disuse osteopenia)
• VASCULAR STATUS ( axillary artery)
• DURATION OF TRAUMA (3- 4 weeks)
Closed reduction should be considered carefully
after 4 weeks because
• Fibrous tissue in the glenoid cavity
• Retracted rotator cuff muscle
• Soft tissue contractures

31. Not indicated in
• Impression defect involving more than 20% of
articular surface
• dislocated for more than 4 weeks
• If at all done do under GA
Chance of axillary artery repture+
• Immobilise for 3-4 weeks

32. OPEN REDUCTION
Indicated when
• More than 4 weeks old dislocation
• Failed closed reduction under GA
• Intraop instability
• Axillary nerve / arterial injury

33. OPEN REDUCTION
 Difficulty Encountered due to
• Replacing humeral head because of fibrosis
• Shortening of muscles
• Contracture
• Bowstringing of capsule across the glenoid
• Defect in humeral head
 Difficulty in maintaing the reduction because
of instability

34. • Subscapularis tenotomy
• Extensive posterior capsular release
• Excision of intra articular portion of long head of
biceps and tenodese with P . MAJOR
Bony / soft tissue recontruction procedure may be
needed for managing intra op instability
• Bankart procedure
• Latarjet procedure
• Iliac crest BG
• Allograft BG

35. How to treat the humeral head defect in
old unreduced dislocations
1 . Filling the defect using sub scapularis tendon
2. Elevation + bone grafting( cab be used in defects
upto 40%)
3. Hill sachs defect more than 45% -complete
humeral head replacement

36. SOFT TISSUE PROCEDURE
Bankart capsulo labral repair ( open/ arthroscopic)
• Open preferred in neglected cases ,when anatomy
is altered, dfoemity+,HAGL, revision surgery
BONY PROCEDURES
LATARJET PROCEDURE
Indication
• Glenoid defect more than 25%
• Hill sach more than 25% of the humeral head
coracoid osteotomy (along with conjoined tendon
and coracoacromial ligament)

37. Internal fixation
SWISS SCREW K WIRES
ACROMIAN TO HUMERAL HEAD
(WILSON AND McKEEVER)

38. Post op management after ORIF
PROTECTED ORTHOSIS X 6 WEEKS
• ROM STARTS AT 6 WEEKS
SHOULDER STRENGTHENING AT 3 MONTHS
ONWARDS

39. Hemiarthroplasty
• Less than 50 yrs with good glenoid cartilage
• If the duration is more than 6 months
• Large defect more than 45%

40. TOTAL SHOULDER ARTHROPLASTY
• Old patients with significant glenoid changes
• bone graft may be necessary if extensive
erosion of the posterior margin of the glenoid fossa
REVERSE SHOULDER ARTHROPLASTY
ELDERLY PATIENTS IF
A) rotator cuff defieciency
B) persistent instability

41. • Rouhani and Nawali
• Anterior capsular repair for chr. Ant. D/L (mean
1 yr follow up – 8 patients)
1 fair, 3 good, 4 excellent
avg Rowe & Zarin score :86

42. J Shoulder Elbow Surg 2003;12:446-50.)
No recurrent
dislocations
2 fair
5 good
3 excellent results