- The patient is a 24-year-old male who experienced shoulder pain after falling on his left shoulder while playing football. - Physical examination revealed dropping of the left shoulder, limited range of motion, and a positive Duga's test, indicating an anterior dislocation of the left shoulder. - X-rays confirmed the diagnosis of an anterior left shoulder dislocation. The dislocation was reduced using the traction-counter traction method. - The shoulder was immobilized in a sling for 3 weeks, with passive range of motion exercises beginning after immobilization. Follow-up was scheduled for 2 weeks.

1. EXTERN CONFERENCE
By Kan Panyapinitnugoon

2. Patient profile
ชายอายุ 24 ปี อาชีพรับจ้าง ภูมิลาเนา อาเภอเมือง จังหวัดนครราชสีมา
CC : ปวดไหล่ซ้ายมา 1 ชม PTA

3. Present illness
•1hr PTA ขณะเล่นฟุตบอล ล้มไหล่ซ้ายกระแทกพื้น ปวดมาก
ขยับแขนไม่ได้ ไม่มีชา ไม่มีบาดแผล ศีรษะไม่กระแทก ไม่มีรอย
ช้า ขยับข้อมือ นิ้วมือได้ปกติ

4. Past history
•2 yr PTA ระหว่างขายของ หกล้มเอาไหล่ซ้ายลงไหล่หลุดไป
รพ. ดึงไหล่เข้า ใช้งานไหล่ได้ปกติ
•1 wk PTA ขณะอาบน้าลื่นหกล้มไหล่ซ้ายกระแทกพื้นหลุด ไป
รพ. ดึงไหล่เข้า ใช้งานได้ปกติ
•No underlying disease

5. Physical examination
• A – Can speak, no posterior cervical tenderness
• B – Equal breath sound both lung
• C – BP 144/93 mmHg, PR 118/min
• D – E4V5M6 , Pupil 3 mm RTLBE
• E – As in picture

6. Physical examination
• V/S – BP 144/93 mmHg, PR 118 /min , T 36.8 c, RR 18
/min
• GA – Alert, good conscious
• CVS – Normal S1,S2 , no murmur
• Lung – Clear both lung
• Abd – Soft not tender

9. Physical examination
• Lt shoulder
• Dropping of left shoulder
• Present of bony prominence distal to clavicle
• Limit ROM
• No loss of sensation
• Brachial pulse 2+ , Capillary refill < 2s
• Full ROM at elbow, wrist, finger
• Duga’s test Positive

10. Film
Lt. shoulder AP Lt. Shoulder transcapular view

12. Diagnosis Anterior left shoulder dislocation

13. Glenohumeral joint dislocation
• Type
• Anterior (>95%)
• Subcoracoid
• Subglenoid
• Subclavicular
• intrathoracic
• Posterior
• Inferior

14. Mechanism
Anterior type
• Posteriorly directed
force on the shoulder
when the shoulder is
abducted , extension ,
and external rotation

15. Presentation
• Shoulder pain
• Feeling instability
• Shoulder abduction and external rotation
• Prominent humeral head
• Hamilton ruler test
• Duga’s test
• Axillary nerve injury (33%) – numbness at deltoid

16. Duga’s test
Ruler test
Positive is inability to do

17. Deltoid sensation

19. Film
• AP view
• Lateral view
• Transcapular (Y-view)

20. Management
• Pain control
• Neurovascular examination
• Reduction
• Hippocrates
• Stimson
• Kocher
• Traction-counter traction
• Milch

21. Hippocrates

22. Stimson
2 kg , 5-10 mins

23. Kocher

24. Milch

25. Traction-Counter traction

26. Traction-Counter traction

27. Postreduction
• Recheck neurovascular and Film
• Immobilized with sling and swath (or
interlocking sling) for 1-3 wks
• <40 yrs : 3 wks
• >40 yrs : 1wk due to stiffness
• Begins passive, active ROM after 3 wks (ex
Pendulum exercise, overhead pulley system)
• Strengthening exercise after 3 months (rotator
cuff exercise)

28. Complication
• Recurrent dislocation
(Usually in first 2 yrs)
<20 yrs rate 90%
>40 yrs rate10-15%
• Fracture
• Hill-Sachs lesion
• Proximal humerus
• Greater tuberosity
• Coracoid
• Acromion
• Rotator cuff tear
• Neurovascular injury

29. Instability Severity Score
Variable Parameter SCORE
AGE
< 20 years 2
> 20 years 0
DEGREE OF SPORTS PARTICIPATION
Competitive 2
Recreational/none 0
TYPE OF SPORT PARTICIPATION
Contact/forced overhead 1
Other 0
SHOULDER HYPERLAXITY
Hyperlaxity (anterior/inferior) 1
Normal 0
HILL SACHS ON AP XRAY
Visible on external rotation 2
Not visible on external rotation 0
GLENOID CONTOUR LOSS ON AP
XRAY
Loss of contour 2
No lesion 0
Clinical Implications Total Possible = 10
An acceptable recurrence risk of 10% with arthroscopic stabilization. < 6 points
A score of > 6 points has an unacceptable recurrence risk of 70% and should be
advised to undergo open surgery (i.e. Laterjet procedure).
> 6 points

30. Hill Sachs lesion

31. In this patient
• Pain control by
• Morphine 4 mg IV
• Valium 10 mg IV
• Traction-Countertraction
• Immobilize by arm sling
• Follow up in 2 wks

32. Film post reduction

34. Thank you for your attention