Shoulder dislocations are the most common joint dislocations, particularly in adults, with anterior dislocations being more frequent than posterior. Diagnosis involves examining the shoulder for typical symptoms and may require imaging, while treatment often includes reduction and immobilization, along with potential surgical interventions for recurrent dislocations. Common complications include nerve injury and a high rate of recurrence, often mitigated through appropriate early management and surgical options.

1. DISLOCATIONS OF THE
SHOULDER
Dr. Saumya Kine
MPT, COMT

2. DISLOCATION OF THE SHOULDER
• This is the commonest joint in the human body to
dislocate. It occurs more commonly in adults and is
rare in children.
• Anterior dislocation is much more common than
posterior dislocation.
• Shoulder instability is a broad term used for
shoulder problems, where head of the humerus is
not stable in the glenoid. It has a wide spectrum -
from minor instability or a loose shoulder to a frank
dislocation.
• In instability, the patient may present with just pain
in the shoulder, more on using the shoulder. Pain
occurs due to stretching of the capsule, as the head
'moves out‘ in some direction without actually
dislocating.

3. • A patient with frank instability may present with an abnormal movement of the head of the
humerus. This could be subluxation (partial movement) which gets spontaneously reduced to
a dislocation.
• Subluxation: articular surfaces only partly displaced but retain some contact b/w them.
Dislocation: articular surfaces completely displaced such that all contact is lost
• The instability may be unidirectional or bidirectional or may be in multiple directions –
anterior, inferior, posterior, where it is called multi-directional instability (MDI).

4. MECHANISM
• A fall on an out-stretched hand with the shoulder
abducted and externally rotated, is the common
mechanism of injury.
• Occasionally, it results from a direct force pushing
the humerus head out of the glenoid cavity.
• A posterior dislocation may result from a direct
blow on the front of the shoulder, driving the head
backwards.
• More often, posterior dislocation is the
consequence of an electric shock or an epileptic
form convulsion.

5. PATHOANATOMY
Classification: They are following types:
a) Anterior dislocation: In this injury, the head of humerus comes
out of the glenoid cavity and lies anteriorly. It may be further
classified into three subtypes depending on the position of the
dislocated head.
• Preglenoid: The head lies in front of the glenoid.
• Subcoracoid: The head lies below the coracoid process. Most
common type of dislocation.
• Subclavicular/Infraclavicular: The head lies below the clavicle.

6. Classification:
b) Posterior dislocation: In this injury, the head of
the humerus comes to lie posteriorly behind the
glenoid.
c) Luxatio erecta (inferior dislocation): This is a
rare type, where the head comes to lie in the
subglenoid position.
PATHOANATOMY

7. • Pathological changes: The following pathological changes occur in the commoner, anterior
dislocation:
a) Bankart's lesion: Dislocation causes stripping of the glenoidal labrum along with the periosteum
from the antero-inferior surface of the glenoid and scapular neck. In severe injuries, it may be
avulsion of a piece of bone from antero-inferior glenoid rim, called bony Bankart lesion.
b) Hill-Sachs lesion: This is a depression on the humeral head in its postero-lateral quadrant, caused by
impingement by the anterior edge of the glenoid on the head as it dislocates.
c) Rounding off of the anterior glenoid rim occurs in chronic cases as the
head dislocates repeatedly over it.
There may be associated injuries: like fracture of greater tuberosity,
rotator-cuff tear, chondral damage etc.

8. DIAGNOSIS
• Presenting complaints: The patient will have his shoulder abducted and the elbow supported
with opposite hand.
• There is a history of a fall on an out-stretched hand followed by pain and inability to move the
shoulder. There may be a history of similar episodes in the past.
• On examination: The patient keeps his arm abducted. The normal round contour of the
shoulder joint is lost, and it becomes flattened. On careful inspection, one may notice fullness
below the clavicle due to the displaced head. This can be felt by rotating the arm.

9. On examination:
The following are some of the signs, associated with anterior
dislocation:
• Dugas' test: Inability to touch the opposite shoulder.
• Hamilton ruler test: Because of the flattening of the shoulder, it is
possible to place a ruler on the lateral side of the arm. This touches
the acromion and lateral condyle of the humerus simultaneously.
The diagnosis is easily confirmed on an antero-posterior X-ray of the
shoulder. An axillary view is sometimes required.

10. • Posterior dislocation usually occurs following a
convulsion. There are few symptoms and signs. This injury
is often missed even on X-ray.
• A clinical examination eliciting loss of external rotation,
and a careful look at the X-ray may help diagnose these
cases. CT scan may be diagnostic.
TREATMENT
• Treatment of acute dislocation is reduction under sedation
or general anaesthesia, followed by immobilization of
the shoulder in a chest-arm bandage for three weeks.
After the bandage is removed, shoulder exercises are begun.

11. TECHNIQUES OF REDUCTION OF SHOULDER DISLOCATION
KOCHER’S manoeuvre: Most commonly used method. Steps (TEAM) are as follows:
1) Traction: with the elbow flexed to a right angle steady traction is applied along the long axis of the
humerus
2) External rotation: the arm is rotated externally
3) Adduction: the externally rotated arm is adducted by carrying the elbow across the body towards the
midline; and
4) Internal rotation: the arm is rotated internally so that the hand falls across to the opposite shoulder.
After Treatment: After the reduction, the arm should be fastened to the chest with a body bandage for a
minimum period of three weeks. Failure to do this leads to the development of recurrent dislocation of the
shoulder due to the faulty healing of the capsular rent.

12. • HIPPOCRATES manoeuvre: In this method, a firm and
steady pull on the semi-abducted arm is applied by keeping
foot in the axilla against the chest wall. The head of the
humerus is levered back into position using the foot as a
fulcrum.
• Stimson’s gravity method / with weights

13. Early complications:
• Injury to the axillary nerve may occur resulting in paralysis of the deltoid muscle, with a small
area of anaesthesia over the lateral aspect of the shoulder.
The diagnosis is confirmed by asking the patient to try to abduct the shoulder. Though shoulder
abduction may not be possible because of pain, one can feel the absence of contraction of the
deltoid.
Treatment is conservative, and the prognosis is good.
Late complications:
• The shoulder is the commonest joint to undergo recurrent dislocation. This results from the
following causes:
(i)anatomically unstable joint
(ii)inadequate healing after the first dislocation
(iii)an epileptic patient.

14. RECURRENT DISLOCATION OF
SHOULDER (RDS)
This is a very common complication of anterior dislocation of shoulder and accounts
for greater than 80% of dislocations of the upper extremity. (One in every three
anterior dislocation of shoulder becomes recurrent dislocation of shoulder)
Causes
• Failure to immobilize the shoulder for 3 to 4 weeks after initial dislocation.
• Size and nature of damage at the time of initial dislocation.
• Greater the trauma, lower the incidence.
• Younger the patient, less is the recurrence.

15. CLINICAL FEATURES
• Usually, the patient gives history of a previous episode of traumatic
dislocation. After that, there could be one or two instances of repeated
dislocations during abduction.
• The clinical features and the presentation will be like in anterior
dislocation of shoulder but the far less severity. There could be wasting
of deltoid, supraspinatus and infraspinatus muscles.
• Clinical Tests: 3 tests help to identify instability of the shoulder prone to
develop RDS:
• The sulcus test with the arm hanging at the side stabilize the scapula
from behind and pull the humerus down. A large gap appears beneath
the acromion. This suggests inferior laxity and is a test for superior
glenohumeral and coracohumeral ligaments.
• The apprehension test: This is a provocative test where if the arm is
placed in abduction, extension and external rotation and if a force is
applied, the patient becomes apprehensive and resists the provocation.
• Relocation test: The joint can be dislocated and relocated back into its
position by manual pressure.

16. TREATMENT
• Putti-Platt operation: Double-breasting of the subscapularis tendon is performed in order to
prevent external rotation and abduction, thereby preventing recurrences. (Subscapularis tendon and
capsule is overlapped and tightened)
• Bankart's operation: The glenoid labrum and capsule are re- attached to the front of the glenoid
rim. This procedure has become simpler with the use of special fixation devices called anchors.
(Detached anterior structures are attached to the rim of the glenoid cavity with suture)

17. • Bristow's operation: In this operation, the coracoid process, along with its attached muscles,
is osteotomized at its base and fixed to lower-half of the anterior margin of the glenoid. The
muscles attached to the coracoid provide a dynamic anterior support to the head of the
humerus. (Transplantation of coracoid’s process with its attachments to the anterior rim of
glenoid)
• Arthroscopic Bankart repair: With the development of arthroscopic techniques, it has become
possible to stabilise a recurrently unstable shoulder arthroscopically. Initially it was considered
suitable for cases where number of dislocations has been less than 5. But, with present day
arthroscopic techniques, it is possible to stabilise most unstable shoulders arthroscopically. Apart
from being a more cosmetic option, the rehabilitation after arthroscopic repair is faster and better.
It is a technically demanding operation, and the anchor sutures used for repair are expensive.