Shoulder Dislocation

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Shoulder Dislocation
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Shoulder dislocation

• 1. DISLOCATION- COMPLETE LOSS OF GLENOHUMERAL
  ARTICULATION . CAUSE- ACUTE TRAUMA
• 2. SUBLUXATION - PARTIAL LOSS OF ARTICULATION
  WITH SYMPTOMS. CAUSE- REPITITIVE TRAUMA.
• 3. LAXITY - PARTIAL LOSS OF GLENOHUMERAL
  ARTICULATION BUT PAITENT IS ASYMPTOMATIC.
  SHOULDER INSTABLITY

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Shoulder dislocation

• Shoulder is the most commonly dislocated
  joint45
• 1 shallowness of glenoid socket
• 2Extraordinary 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

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Shoulder dislocation

• Type of dislocation
• Traumatic Dislocations
• Atraumatic dislocation
• Acquird dislocation

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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
• Posterior10
• Inferior 5

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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.

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Acquired dislocation

• Sports such as swimming, gymnastics and baseball
  where repetitive micro-trauma, poor stretching
  and motion lead to capsular stretching. Eventual
  feeling of instability

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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

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• Clinical symptom
• Pain severe
• Hold limb with normal limb by side of body.
• Abduction and external rotation.
• Pt cant touch apposite shoulder dugos test

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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

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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

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Management

• Pre-Medication
• Reduction Maneuvers
• Post-Reduction Immobilization

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Pre-Medication

• Methods of Premedication prior to Reduction
• None
• Intraarticular Lidocaine
• IV Sedation
• Supraclavicular Block
• Suprascapular Block

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IV Sedation vs Intraarticular Lidocaine Injection
Intra-articular Lidocaine Injection is Preferred
over IV Sedation
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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)

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Kocher Maneuver

• TEA I
• Traction
• ER
• Adduction
• arm is internally rotated
• Modified no traction

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Stimson method
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Traction/Countertraction

• Arm in some abduction
• Traction applied to arm
• Assistant applies firm counter-traction with
  sheet across the body

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Hippocratic method

• Surgeon use foot applies on axilla for
  countertraction

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Post-Reduction Immobilization

• Is immobilization necessary?
• What Method
• is Best?

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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

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Internal vs External Rotation

• Level II RCT Itoi JBJS 2007
• ER for 3 weeks
• Recurrence rate 32
• IR for 3 weeks
• Recurrence rate 60
• P 0.007

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Complication of ant.shoulder dislocation

• Early
• Rotator cuff tear
• Nerve injury
• Vascular injury
• Fracture dislocation

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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

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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

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• Clinical sign and symptom
• Diag is often missed
• Internal rotation
• Flat front of shoulder
• Prominent corocoid
• Frominent post aspect of shoulder

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• Radiology
• AP- electric bulb apperence and empty glenoid
  sign.
• Lat post displacement

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• 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.

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Inferior shoulder dislocationluxatio 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

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Inferior shoulder dislocationluxatio erecta

• Xrays AP
• LAT

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Inferior shoulder dislocationluxatio erecta

• Treatment
• Traction and counter traction.
• Immobilised for 3 wks

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Recurrent shoulder dislocation

• Anterior dislocations account for 95 of
  shoulder dislocations
• Typically occurs in athletes who are lt 25 years
  old
• Males are much more commonly affected than are
  females (85-90)

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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 gt 85 of the time

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Recurrent shoulder dislocation
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Bony bankart
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• Hillsach lesion posteriolateral indentation of
  humeral head.
• Enganging lesion is indication of surgery

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Recurrent shoulder dislocation
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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)

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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

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Recurrent shoulder dislocation
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Recurrent shoulder dislocation

• Shoulder Stabilisers Static
• Intracapsular pressure
• Labrum increases depth of the glenoid by 50
• Ligaments main static restraints
• capsule

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Recurrent shoulder dislocation
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Shoulder Stabilisers

• Dynamic

• Rotator cuff and biceps

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Recurrent shoulder dislocation
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Recurrent shoulder dislocation
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Recurrent shoulder dislocation
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Recurrent shoulder dislocation
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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.

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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

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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

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Bankart repair
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Bankart repair
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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

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Latarjet procedure
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Latarjet procedure
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Putti-plat operation

• Putti-plat operation
• limited ER

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• Thanks