Shoulder Dislocation
s
Shoulder dislocation
1. DISLOCATION- COMPLETE LOSS OF
GLENOHUMERAL ARTICULATION . CAUSE- ACUTE
TRAUMA


2. SUBLUXATION - PARTIAL LOSS OF
ARTICULATION WITH SYMPTOM’S. CAUSEREPITITIVE TRAUMA.
3. LAXITY - PARTIAL LOSS OF GLENOHUMERAL
ARTICULATION BUT PAITENT IS ASYMPTOMATIC.
SHOULDER INSTABLITY
Shoulder dislocation




Shoulder is the most commonly dislocated joint[45%]
1] shallowness of glenoid socket
2]Extraordinary ROM
3] ligamentus laxity
Humeral head 3x larger than glenoid fossa
glenohumeral articulation is minimally constrained by
bony anatomy alone
stability is conferred by a series of dynamic and static soft
tissue restraints
Shoulder dislocation
Type of dislocation



Traumatic Dislocations
Atraumatic dislocation
Acquird dislocation
Traumatic dislocation




Single force applies excessive overload to the
soft tissues of the joint and often damages the
Glenoid Labrum (Bankart Lesion) and the joint
capsule
Anterior [85%]
Posterior[10]
Inferior [5]
Atraumatic dislocation
Athelete who has joint hyperlaxity and had
multiple episode of joint subluxation
 Minor injury can results into dislocation
[Congenital hypermobility or muscle weakness.]

Acquired dislocation

Sports such as
swimming, gymnastics
and baseball where
repetitive microtrauma, poor
stretching and motion
lead to capsular
stretching.
Eventual
feeling of instability
Traumatic anterior dislocation
 Mech.
of injury
Arm in abduction and external rotation. Force is
taken on the hand or arm which increases the
external rotation of the arm causing the head of
the humerus to dislocate





Clinical symptom:
Pain [severe]
Hold limb with normal limb by side of body.
Abduction and external rotation.
Pt can’t touch apposite shoulder [dugos test]
Clinical Evaluation

PE:



Prominent acromion, sulcus
sign, palpable humeral head
anteriorly
Neuro integrity of axillary
and musculcutaneous nerves
Apprehension Test:
reproduces sense of
instability and pain in
shoulder reduced prior to
exam
Radiographic Evaluation



AP [fracture dislo]
Axillary
Special Views:



West Point axillary: for
visualization of glenoid rim
Hill-Sach view: internal
rotation view
Stryker Notch: view 90% of
posterolateral humeral head
Management

Pre-Medication

Reduction Maneuvers

Post-Reduction
Immobilization
Pre-Medication

Methods of Premedication
prior to Reduction





None
Intraarticular Lidocaine
IV Sedation
Supraclavicular Block
Suprascapular Block
IV Sedation vs Intraarticular
Lidocaine Injection
Intra-articular Lidocaine
Injection is Preferred over
IV Sedation
Reduction Maneuvers

Is there an Ideal Method for Reduction?


Over 24 Techniques Described
Most Common Techniques






Kocher (71-100%)
External Rotation (78-90%)
Milch (70-89%)
Stimson (91-96%)
Traction/Countertraction
Scapular Manipulation (79-96%)
Kocher Maneuver
TEA I





Traction
ER
Adduction
arm is internally
rotated
Modified [no traction]
Stimson method
Traction/Countertraction

Arm in some abduction

Traction applied to arm

Assistant applies firm
counter-traction with
sheet across the body
Hippocratic method

Surgeon use foot applies on
axilla for countertraction
Post-Reduction Immobilization

Is immobilization
necessary?

What Method
is Best?
Does immobilization
reduce recurrence?

usually fracture associated with dislocation are
reduced with reduction of dislocation.
 Immobilization
for 3-4 weeks after shoulder
dislocation does NOT change the prognosis
compared with immediate mobilization
Internal vs External Rotation

Level II RCT: Itoi JBJS 2007

ER for 3 weeks


IR for 3 weeks


Recurrence rate: 32%
Recurrence rate: 60%
P = 0.007
Complication of ant.shoulder
dislocation
Early
 Rotator cuff tear
 Nerve injury
 Vascular injury
 Fracture dislocation
Late complication
Stiffness
 Unreduced disloction [undiagnos in unconcious
and old pts. ]
closed reduction done upto 6 wks and open
reduction done after 6wks in young pts. Willful
neglect in old pts
 Recurrent dislocation

Post. Shoulder dislocation


The arm is in flexion and adduction. Force is
taken on the hand, causing the head of the
humerus to be push out the glenoid posteriorly.
h/o convulsion or electric shock
Clinical sign and symptom
 Diag is often missed
 Internal rotation
 Flat front of shoulder
 Prominent corocoid
 Frominent post aspect of shoulder
Radiology
 AP- electric bulb apperence
and empty glenoid sign.
 Lat – post displacement



Treatmet
Under GA reduction by pulling arm in
adduction to dis engage head then lateraly rotate
while pushing head anteriorly.
Immobilization in ext rotation and abduction for
3 wks.
Inferior shoulder
dislocation[luxatio erecta]
Arm is in excessive abduction and a force is taken
on the hand pushing the head of the humerus
inferiorly out of the glenoid.
Clinical features
limb in abduction
Inferior shoulder
dislocation[luxatio erecta]


Xrays –AP
LAT
Inferior shoulder
dislocation[luxatio erecta]
 Treatment
Traction and counter traction.
Immobilised for 3 wks
Recurrent shoulder dislocation

Anterior dislocations account for ~95% of shoulder
dislocations

Typically occurs in athletes who are < 25 years old
Males are much more commonly affected than are females (8590%)

Recurrent shoulder dislocation

Pathology most commonly found in shoulders
following a dislocation is a Bankart lesion
 Disruption of the labrum and the contiguous
anterior band of the inferior glenohumeral
ligamentous complex (IGHLC)

Bankhart lesion occurs > 85% of the time
Recurrent shoulder dislocation
Bony bankart


Hillsach lesion –
posteriolateral
indentation of humeral
head.
Enganging lesion is
indication of surgery
Recurrent shoulder dislocation
Recurrent shoulder dislocation
 Classification

Instability can be classified by:
 direction of instability (anterior, posterior,
multidirectional)
 degree of instability (subluxation, dislocation)
 etiology (traumatic, atraumatic, overuse)
 timing (acute, recurrent, fixed)
Recurrent shoulder dislocation
TUBS or “Torn Loose”


T raumatic aetiology, U nidirectional instability, B
ankart lesion is the pathology, S urgery is required
AMBRI or “Born Loose”

A traumatic: minor trauma, M ultidirectional instability
may be present, B ilateral: asymptomatic shoulder is also
loose, R ehabilitation is the treatment of choice, I
nferior capsular shift: surgery required if conservative
measures fail
Recurrent shoulder dislocation
Recurrent shoulder dislocation
 Shoulder




Stabilisers – Static
Intracapsular pressure
Labrum: increases depth of the glenoid by 50%
Ligaments – main static restraints
capsule
Recurrent shoulder dislocation
Shoulder Stabilisers
Dynamic
Rotator cuff and biceps
Recurrent shoulder dislocation
Recurrent shoulder dislocation
Recurrent shoulder dislocation
Recurrent shoulder dislocation
Recurrent shoulder dislocation
 How
many number of dislocation is
indication of surgery.


Frist dislocation in young pateint specially
sports person.
Two time dislocation is definit indication of
surgery.
Recurrent shoulder dislocation
 Open
surgery done for old and multiple
recurrent dislocation due plastic deformation of
tissue or larg bony defects.
 Arthroscopic

surgery is done fresh case of
recurrent dislocation.
Advantage
Recurrent shoulder dislocation
 Anatomic

Repairs
Restoring normal anatomy is guiding principle in surgery to
correct anterior shoulder instability
 If the labrum has been detached, it is reattached to the
anterior glenoid rim
 If the capsule has been stripped off the glenoid neck, the
capsule is reattached to the bony glenoid rim
 If greater than one-third of the glenoid fossa is involved, a
bone block procedure such as a Bristow or iliac crest bone
graft may be considered
Bankart repair
Bankart repair
Recurrent shoulder dislocation
 Nonanatomic
Repairs
[open]
 Bristow and latarjet



Transfer coracoid process to anteroinferior glenoid
Sling effect and bone block
Putti-Platt -Subscapularis is cut and shortaned
Magnusen-Stack

subscapularis tendon is detached from its insertion on the
lesser tuberosity, transferred laterally to the greater tuberosity
Latarjet procedure
Latarjet procedure
Putti-plat operation:


Putti-plat operation:
limited ER
Thanks