Conference Ext.พีรพนธ์ 23 มีค.61

1. Orthopedic Conference
Peerapon S.
6th Year Medical Cadet
Phramongkutklao College of Medicine

2. Case
 ผู้ป่ วยหญิงไทย อายุ 67 ปี
 อาชีพ แม่บ้าน
 ภูมิลาเนา นครราชสีมา

3. Chief complaint
ปวดไหล่ซ้าย 2 ชั่วโมง

4. Present illness
2 hrs. PTA ผู้ป่ วยขี่ MC เฉี่ยวกับ MC
เสียหลัก ล้ม ไหล่และแขนซ้ายกระแทก
พื้น ปวดไหล่ซ้ายและต้นแขน ซ้าย
ขยับไหล่ซ้ายไม่ได้ ไม่มีศีรษะกระแทก
พื้น ไม่ สลบ จาเหตุการณ์ได้

5. Primary Survey at MNRH

6. A : Can speak, Can flex neck, patent airway
,not tender at
posterior midline of neck
B : Trachea in midline, equal breath sound,
no subcutaneous emphysema
C : BP 163/78 mmHg, PR 80/min, no wound
, no bleeding
D : E4M5V6, pupil 3 mm RTLBE
E : tender at Lt. shoulder , limit ROM at Lt.
shoulder ,
no wound

7. Secondary Survey

8. A : No history of food and drug
allergy
M : No current medication
P : Underlying : DM , HT , No
history of surgery
L : Last meal 14.00
E : As present illness
Secondary Survey

9. Head to Toe Examination

10. General appearance :
Good consciousness, well
cooperated
HEENT :
Not pale conjunctivae, anicteric
sclerae, no external wound at face and
neck, no abnormal mass, no
lympadenopathy
Heart :
Normal S1S2, no murmur

11. Lung
Clear ,equal breath sound
Abdomen
Soft , not tender , no guarding ,
no rebound
Neuro
E4V5M6 , pupil 3 mm RTLBE

12. Extremities
tender, limit ROM shoulder,
Ruler and Dugar sign
positive , can palpate head
of humerus , Pinprick
sensory intact
Can flex/extend
elbow and finger ,
pinprick sensory
intact

14. Investigation

15. Film X-Ray

16. Left anterior shoulder
dislocation with Greater
tuberosity fracture
Film X-Ray

17. Anatomy of abdomen
• Valium 10 mg IV stat
• Morphine 4 mg IV stat
• Closed reduction
• On Lt. arm sling
Management

19. Shoulder Dislocation

20. Anatomy of shoulder

21. Anatomy of shoulder

22. Anatomy of shoulder

23. • Anterior shoulder dislocation
• Posterior shoulder dislocation
• Superior shoulder dislocation
• Inferior shoulder dislocation
Shoulder Dislocation

24. Radiological evaluation

25. Radiological evaluation

26. Radiological evaluation
Anterior shoulder
dislocation

27. Radiological evaluation
Posterior shoulder
dislocation

28. • Most common shoulder injuries
• Mechanism : anteriorly directed force on
the arm when the shoulder is abducted
and externally rotated
• Associated injury
–Axillary nerve
–Hill Sachs defect
–Bony Bankart lesion
–Greater tuberosity fracture
Anterior shoulder dislocation

29. Anterior shoulder dislocation

30. Anterior shoulder dislocation

31. Anterior shoulder dislocation

32. Anterior shoulder dislocation

33. Clinical presentation & Physical
examination
• Pain [severe]
• Hold limb with normal limb by side
of body.
• Abduction and external rotation.
• Pt can’t touch apposite shoulder
[Dugar test]

34. Clinical presentation

35. Physical examination
• Load and shift test
– Grade I - increased translation, no subluxation
– Grade II - subluxation of humeral head to, but
over, glenoid rim
– Grade III - dislocation of humeral head over
glenoid rim
• Apprehension sign
• Relocation sign

36. • Reduction
• simple traction-countertraction is
most commonly used.
• relaxation of patient with sedation
and analgesics.
• Immobilization for 3-4 weeks after
shoulder dislocation does NOT change
the prognosis compared with
immediate mobilization
Management

37. Reduction Maneuvers
• Most Common Techniques
–Kocher (71-100%)
–External Rotation (78-90%)
–Milch (70-89%)
–Stimson (91-96%)
–Traction/Countertraction
–Scapular Manipulation (79-96%)

38. Reduction Maneuvers

39. Reduction Maneuvers

40. • More missed diagnosis .
• Mechanism : flexed, adducted, and
internally rotated arm is a high-risk
position.
Posterior shoulder dislocation

41. Clinical presentation
• Internal rotation
• Flat front of shoulder
• Prominent coracoid
• Prominent post aspect of shoulder

42. Management
• Under GA reduction by pulling arm in
adduction to disengage head then
lateraly rotate while pushing head
anteriorly.
• Immobilization in external rotation and
abduction for 3 wks.

43. Thank you