3. Objective of the seminar
1 ….able to know how to diagnose properly
2….. Able to know which x rays are important for dx of sh
oulder dislocation
3…. able to know the techniques of closed reduction
4. Introduction
Shoulder dislocation
is a complete symptomatic dissociation of the articular surfaces of the humeral head
and glenoid without spontaneous reduction.
About 2 to 4% of shoulder injury
about 45 to 50% all dislocation
Unstable joint
Treated both non operatively and operatively
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5. Seen 17 to 23 per 100,000 per year
Bimodal
males in the 21 to 30 year age range
for women in the 61 to 80 year age range
Recurrence all ages is 50%
89% in the 14 to 20 year age group.
71.8% of dislocations occurring in men.
There was no difference based on race.
Most dislocations (58.8%) occurred during a fall, w
hereas 48.3% occurred during sports activities
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9. Coracoacromial ligament
limit the extent of
anterosuperior
superior
posterosuperior translation of the hu
meral head
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14. Anterior dislocation
represent 96% of shoulder dislocations
arm in abduction and external rotation
Rarely direct blow
Young <30
Older age
had associated injurys
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15. History
Mechanism of injury
Limb position
Previous Hx
Medical condition
age, occupation, hand dominance, level of sporting o
r recreational activity
16. Physical examination
Anterior dislocation
Limb position
squaring of the shoulder
prominence of the acromion
sulcus
neurovascular examination
Axillary nerve
musculocutaneous nerve
test contraction of the biceps or brachialis
test sensation of the lateral antebrachial cutaneous distribution on the lateral aspect
of the forearm.
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17. Apprehension Tests and fulcrum test
getting ready to dislocate
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18. Based on humeral head location
subcoracoid
Subglenoid
Subclavicular
intrathoracic
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19. Posterior dislocation
represent 2% to 4% of shoulder dislocations
50% to 60% missed on initial examination
Indirect
adduction, flexion, and internal rotation
Electric shock or convulsive mechanisms
Direct
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20. subacromial
subspinous, and
Subglenoid
Rare dislocation type
inferior dislocation
Superior dislocation
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21. posterior dislocation
does not present with striking deformity
traditional sling position
palpable mass posterior to the shoulder
flattening of the anterior shoulder
coracoid prominent
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22. Other test
Dugas test
Callaway s sign- axillary
girth
Hamilton ruler test
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25. imaging
Trauma series x ray
AP
Scapular Y view
axillary
Other special view
West point axillary
glenoid defect
Stryker notch view
humeral head defects
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29. X ray features
Anterior dislocation
Fracture dislocation
Greater tuberosity
Bankart lesion
Hill-sachs defect
Loss of elliptical over lap
Head relatively
large,
anterior ,
medial and inferior to glenoid fossa
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34. CT scan
Fracture difficult to interpret x ray
Estimation glenoid bone loss
Pre op planning
MRI
Sub acute and chronic instablity
Capsuloligamentous structure
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35. management
Non operative
Operative
Traumatic/ a traumatic
Initial /recurrent
Young/old
Pain
Demand
Medical condition
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36. Instability severity score
variable parameter score
age >20
>20
2
0
Degree of sport
participation
Competitive
recreational
2
0
Type of sport participation Contact
other
1
0
Shoulder hyper laxity Hyper laxity
normal
1
0
Hill sachs on AP x ray Visible
Not visible
2
0
Glenoid contour loss on AP
x ray
Loss of contour
No lesion
2
0
Total = 10
< 6…recurrence is 1o%
> 6….recurrence 70%
…advised to undergo open
37. Closed reduction
Better with in 24 hr
Almost all acute traumatic dislocation except
Humeral neck fracture
Compound dislocation
Vascular injury
Indicator of success
Adequate analgesia
Early reduction
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38. Techniques
optimal technique should be quick, effective, simple to perform and should
require minimal force, analgesia and assistance
simple traction–countertraction
Stimson technique
Scapular manipulation technique
Kocher maneuver
Milch technique
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40. Stimson technique
Prone
Manual traction
5Ib weight
15 to 20 min
traction injury to a nerve
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41. Milch technique
relies on shoulder position than traction
supine or prone
abducted and externally rotated to overhead
90/90 ABD/ER
Thumb pressure to humeral head
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42. Kocher
Traction
ER
Adduction
arm is internally rotated
Complication high
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43. Scapular manipulation technique
Prone position or sitting
Traction
Manually fix superior and medial scapula
push inferior tip scapula medially
Glenoid face inferiorly
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44. Posterior dislocation
Under GA reduction
Traction in flexion adduction and internal rotation
Disengage head external rotate while pushing head anteriorly
Closed reduction is often difficult
Post reduction
Stability
Radiographs
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45. Common pitfalls of closed reduction of shoulder dislocati
ons are
o Displacement of fracture
o Acute instability
o Recurrent instability
46. Common Causes of shoulder irreducibility
Soft tissue entrapment
(Biceps , subscapularis , labrum)
Bony fragments
( glenoid , GT , hill sachs)
48. Early passive motion
ER or IR exercises at lower degrees of abduction and avoid exercises at 90
° of abduction in the 1st 6 wk
isometrics exercise –avoid muscle atrophy
Full range of active and passive motion by 8 to 10 wks.
Return to sport 4 to 6 month
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49. Operative
Indications
failed appropriate non operative therapy
recurrent dislocation at a young age
irreducible dislocation
open dislocation, and
unstable joint reduction
poor function and pain
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51. Common operations performed
LATERJET PROCEDURE
Bankart procedure
lesser tuberosity transfer
transfer of the upper one-third of the subscapularis
RECONSTRUCTION OF ANTERIOR GLENOID USING ILIAC C
REST BONE AUTOGRAFT
52. Surgical approach
Anterior approach to shoulder
work-horse for open reduction
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58. Post op management
Goal
to restore pain-free range of motion
shoulder muscle strength
Decrease recurrence
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59. post-operative rehabilitation
3-6 weeks: shoulder immobilizer or sling
6-10 weeks: limit on abduction and external rotation
10-16 weeks: gradual range of motion
>16 weeks: strengthening
>10 months: contact sports
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60. complication
Recurrence
Bone injury
Soft tissue injury
Neurovascular injury
Infection
Loss of ROM
AVN
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61. Summery
shoulder is the most unstable and commonly dislocated major joint of the
body
Stability mainly from capsuloligament struc
High recurrence rate
Majority treated non operatively
Rehabilitation is important in both non operative and operative
management
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Glenoid labrum- it depeens cavity by 50 perc and increases head coverage to 75 perc.
-The average depth of the glenoid in the anterior/posterior direction is 2.5 mm compared to 9 mm in the superior/inferior
10
dislocation is defined as a complete symptomatic
dissociation of the articular surfaces of the humeral head
and glenoid without spontaneous reduction.
subluxation is a symptomatic dissociation
of the articular surfaces with spontaneous reduction
19
20
21
22
25
Lightbulb sign… int rotation
Trough line sign ..vertical line in the medial humeral head due to impactionof z humeral head
Mouzopoulus sign .. Int rotation of z humeral head allows z GT& LT to form a M shape
Moloneys arch ….acute angle of scapulohumeral arch
