Shoulder dislocations have been depicted in Egyptian tomb art from 3000 BC. There are different types of shoulder dislocations including anterior, posterior, and inferior. Anterior dislocations are the most common. Clinical signs include pain, inability to contour the shoulder, and an anterior bulge. Radiographs can confirm and classify the dislocation. Reduction maneuvers include traction-countertraction, Hippocrates, Kocher, and scapular manipulation methods. Post-reduction, patients are immobilized and followed up to prevent recurrent dislocations, which occur in 50-90% of young patients.

1. Shoulder Dislocation
Types and Management Methods of
Reduction
Dr. Uzair Ahmed

2. Shoulder dislocation isdocumented inEgyptian tomb
muralsas earlyas3000BC,withdepiction of a
manipulation forglenohumeral dislocationresembling
theKocher technique.
A painting inthetomb ofIpuy,
1300BC, the sculptor of Ramses II
depicts a physician reducing a
dislocated shoulder, using a similar

3. Epidemiology
• ~1.7% population
• Bimodal distribution:
• Men in 20-30 yo (M:F 9:1)
• Women 61-80 (M:F 1:3)
• Less in children as their epiphyseal plate is weaker and tends to
fracture before dislocating.
• More common in elderly as the collagen fibres have fewer cross links
weaker capsule / tendons / ligaments.

4. Anatomy:
Glenohumeral stability depends on both passive and active mechanisms, including:
Passive :
 Joint conformity
• Vacuum effect of limited joint volume.
• Adhesion and cohesion owing to the presence of synovial fluid.
 Scapular inclination : zero to thirty degrees
 Glenoid labrum
 Bony restraints
 Coracoid, Acromian and Glenoid Fossa
 Ligamentous and capsular restraints
 Joint capsule
 Superior, middle and inferior GLENOHUMERAL LIGAMENTS
 CORACOHUMERAL LIGAMENT

7. .
■ Active:
• Biceps, long-head
• Rotator cuff
• Scapular stabilizing muscles

8. Pathoanatomy of shoulder dislocations:
• Stretching/ tearing of capsule
• Avulsion of glenohumeral ligaments usually off the glenoid
• Labral injury
◦ Bankart lesion
• Impression fracture
◦ Hill-Sach lesion
• Rotator cuff tear

9. BANKARTS LESION
Seen in anterior dislocation.
Stripping of glenoid labrum along
with periosteum .
Antero inferior Surface of glenoid and
scapular neck.
Avulsion of anteroinferior Glenoid rim
causes Bony Bankart Lesion.

10. CT Reconstruction

11. HILL SACHS LESION
Depresson on humeral
head in its postero lateral
quadrant
Due to impingment by
the anterior edgeof
glenoid on the head as it
dislocates

12. Dislocation of the Shoulder
 Mostly Anterior > 95 % of dislocations
 Posterior Dislocation occurs < 5 %
 True Inferior dislocation (luxatio erecta) occurs <1%
 Habitual - Non traumatic dislocation may present as Multi
directional dislocation due to generalized ligamentous laxity and is
Painless

13. Mechanism of Injury
COMMONEST :Fall on an outstretched hand wiiththe shoulder abducted
and externally rotated.
POSTERIOR DISLOCATION:by direct blow fromthe front of the shoulder or
from epileptiform convulsions or electric Shock.

14. ANTERIOR DISLOCATION POSTERIOR DISLOCATION

15. Clinical Picture
Pain
Holds injured limb with
other hand close to
trunk
The shoulder is
abducted and the elbow
is kept flexed

16. Clinical Picture
Loss of the normal
contour of the shoulder -
appears as a step
Anterior bulge of head
of humerus may be
visible or palpable
Empty glenoid socket

17. POSTERIOR SHOULDER DISLOCATION
(adducted and internally rotated arm)
ANTERIOR DISLOCATION
(Slight abducted and internal
rotated arm)
INFERIOR DISLOCATION

18. Radiographic Evaluation
Trauma series of the affected shoulder:
• Anteroposterior (AP),
• Scapular-Y, and
• Axillary views taken in the plane of the scapula

22. VELPEAU AXILLARY VIEW
If a standard axillary cannot be obtained
because of pain, the patient may be left
in a sling and leaned obliquely backward 45
degrees over the cassette. The beam is
directed
caudally, orthogonal to the cassette,
resulting in an axillary view with
magnification.

23. West Point axillary:
This is taken with patient prone
with the beam directed cephalad
to the
axilla 25 degrees from the
horizontal and 25 degrees
medial. It provides a tangential
view of the
anteroinferior glenoid rim.

24. Stryker notch view:
The patient is supine with the
ipsilateral palm on the crown of
the head
and the elbow pointing straight
upward. The x-ray beam is
directed 10 degrees cephalad,
aimed
at the coracoid. This view can
visualize 90% of posterolateral
humeral head defects.

25.  Computed tomography may be useful in defining humeral head
or glenoid impression fractures,loose bodies, and anterior labral
bony injuries (bony BANKARTS LESION )
 Single- or double-contrast arthrography may be utilized to
evaluate rotator cuff pathologic processes.
 Magnetic resonance imaging may be used to identify rotator cuff,
capsular, and glenoid labral (Bankart lesion) pathologic processes.

26. Anterior:
Subcoracoid (anterior):
Humeral head sits anterior and medial tothe
glenoid, just inferior to thecoracoid.
~60%of cases.
Subglenoid (anteroinferior):
humeral head sits inferior and slightlyanterior
to the glenoid, that the humeral head has
also travelled medially.
~30%of cases.

27. Other
POSTERIOR:
Different mechanisms: seizure, electrocution.
Present with flattened anterior shoulder and prominentcoracoid.
Can easily go unrecognised.
INFERIOR:‘luxationerecta’
Hyperabductioninjury.
High rate of vascular, nervous,ligament, tendon injuries.

28. Anterior Dislocation of Shoulder

29. Inferior Dislocation

30. Posterior Dislocation

31. Management
• Emergency
• Should be reduced in < 24 hours or else AVN of head of
humerus
• Immobilised strapped to the trunk for 3-4 weeks and rested in a
collar and cuff

32. Reduction Maneuver's
1. Traction-countertraction method
2. Hippocrates method
3. Stimpson’s technique
4. Kocher’s technique
5. Milch Technique
6. Scapular Manipulation

33. 1. Traction-countertraction
Note how the clinician on the
left has the sheet wrapped
around him, allowing him to
use his body weight to create
traction. Some clinicians
employ gentle external rotation
to the affected arm while
providing traction.

34. Traction-countertraction

35. Traction-countertraction

36. 2. Hippocrates Method

37. Hippocrates Method

38. Hippocrates Method

39. 3. Stimpson’s technique
The patient isplaced
prone on the
stretcher with the
affected shoulder
hanging off the edge.
Weights (10-15 lbs)are
fastened to the wrist
to provide gentle,
constanttraction.

40. 4. KOCHERS MANOUEVRE
I)Traction –with the elbow flexed at right angle
,steady traction applied along long axis of
humerus
II)External Rotation
III)Adduction
IV)Internal Rotation

41. 5. Milchtechnique
The arm isabducted and the
physician's thumb isused to
push the humeral head into its
proper position. Gentle traction
in line with the humerus is
provided with the physician's
opposite hand.

42. Scapularmanipulation
The patient sitsupright and leans the
unaffected shoulderagainst the
stretcher.The physicianstands behind
the patient and palpates the tip of the
scapula with histhumbs and directs a
force medially. The assistant stands in
front of the patient and provides gentle
downward traction on the humerus as
shown. The patient isencouraged to
relaxthe shoulderas much as possible.

43. POSTREDUCTION:
Ortho f/u in~1/52.
COMPLICATIONS:
Recurrentdislocation:
approx 50 –90%patients under 20
Approx 5 to 10%of patients over age 40
? Ways to prevent redislocation: position of immobilization, increasing
the duration of immobilization, physical therapy, and operative repair.
Mobilisation:
<30–immobilise 3 weeks.
>30–begin mobilisation after one week.
Position: internal rotation and adduction vs. 10 degrees externalrotation
(anatomically sound but evidence not support benefit).