Presentation on theme: "Management of Acute Shoulder Dislocation"— Presentation transcript:
1 Management of Acute Shoulder Dislocation An overviewHeather CampionSports Medicine Conference1/22/08
2 Incidence Shoulder is the most commonly dislocated joint Traumatic DislocationsAnterior 96%Posterior 2-4%Diverse group of patients experience dislocations;M and Fyoung and oldactive and inactiveShoulder dislocations make upto 45% of all dislocationsMechanism of Injury:-Indirect trauma to the upper extremity with the shoulder abducted, extended, and in external rotation-Direct anteriorly directed trauma to the posterior shoulder
3 Anatomic Consideration Glenohumeral stabilization mechanismsPassive: joint conformity, vacuum effect, ligamentous and capsular restraints, labrumActive: long head of Biceps and Rotator CuffPathoanatomy of shoulder dislocationsBankart Lesion: avulsion of anteroinferior labrumHill-Sachs Lesion: posterolateral humeral head defectAssoc. RCT: more common in older patientsThe anteroinferior capsule limits anterior subluxation of the abducted shoulder.The inferior glenohumeral ligament is of primary importance to prevent anterior dislocation.Bony Bankart includes anteroinferior labrum avulsion with a glenoid rim fractureHill-Sachs Lesions are see in 27% acute anterior dislocations, 74% recurrent dislocationsAssociated RCT in pts >40yo 35-40%, >60yo ~80%
4 Clinical Evaluation PE: Prominent acromion, sulcus sign, palpable humeral head anteriorlyNeuro integrity of axillary and musculcutaneous nervesApprehension Test: reproduces sense of instability and pain in shoulder reduced prior to examNeuro exam: Test axillary sensation over deltoid and musculcutaneous sensation over anterolateral forearmAxillary nerve injury in 9-18% of anterior dislocationsApprehension Test: placement of shoulder into abduction, extension, and ER
5 Radiographic Evaluation AP vs true APAxillary vs Valpeau AxillarySpecial Views:West Point axillary: for visualization of glenoid rimHill-Sach view: internal rotation viewStryker Notch: view 90% of posterolateral humeral headTrue AP xray taken at degrees of lateral or in the plane of the scapulaAxillary: arm is abducted degrees with beam pointed into axilla with cassette superior to shoulder (can try technique of having pt grab IV pole with ipsilateral hand and roll IV poll laterally to obtain xrayValpeau Axillary: If standard axillary cannot be obtained, patient is left in a sling and leaned obliquely backward 45 degrees over a cassette, beam is directed caudallyWest Point: Pt is prone with beam directed to the axilla 25 D downward and on the horizontal 25 D medial. Helps to identify Bankart Lesion.Hill-Sach View: Place shoulder in maximal internal rotation to visualize a posterolateral defectStryker Notch:Pt is supine with the ipsilateral palm on the crown of the head and the elbow pointed upward. The xray beam is pointed 10 D off the vertical at the coracoid. This can visualize 90% of the posterolateral head defects (Hill-Sach lesion) CT scan: once reduction is complete for surgical preoperative planning if nec -->concern for fraccture/comminution/bony Bankart
7 Pre-Medication Methods of Premedication prior to Reduction None Intraarticular LidocaineIV SedationSupraclavicular BlockSuprascapular BlockIntraarticular Lidocaine Injection with cc of Lidocaine through a posterior approach (aspirate obtains hemarthrosis= in the joint)
8 IV Sedation vs Intraarticular Lidocaine Injection Level 1 RCT: Miller et al JBJS 2002Prospective Randomized study put isolated shoulder dislocation patients (#30) into 2 groupsVariety of Outcome Measures:Reduction SuccessComplicationsPainTime to reduce/Time in the ERCost
9 IV Sedation vs Intraarticular Lidocaine Injection No significant difference between:Reduction SuccessReduction TimePain ScoreStatistical Significance:Pts tx with intraarticular Lidocaineleft the ER earlierFewer ComplicationsLower Cost with LidocaineReduction Success: Stimson technique reduction in 14/16 w/ lido, 11/14 w/ IV Sed. All 5 that could not be reduced initially were reduced with scapular manipulationReduction Time: 11.4 w/ Lidocaine, 8.5 w/ IV SedationPain Score: 7.0 +/- 2.6 w/ Lidocaine, 7.4 +/- 2.5 for IV SedationER time: 75 min +/- 48 minutes w/ Lido, 185 min +/- 26 min for IV Sed (p<0.01)Other studies have shown incidence of respiratory depression with IV Sedation UseCost: Lidocaine: $0.52, IV Sedation: $97.64
10 IV Sedation vs Intraarticular Lidocaine Injection Injection is Preferred overIV Sedation
11 Reduction Maneuvers Is there an Ideal Method for Reduction? Over 24 Techniques DescribedMost Common TechniquesKocher (71-100%)External Rotation (78-90%)Milch (70-89%)Stimson (91-96%)Traction/CountertractionScapular Manipulation (79-96%)
12 Kocher Maneuver Arm is adducted and flexed at the elbow Externally rotate arm until resistance is feltThe ER arm is flexed forward as far as possibleThe arm is internally rotated
13 External Rotation Arm aducted to body Forearm flexed to 90 degrees Traction on forearmGentle and gradual external rotation until reduction
14 Milcher Technique Patient is supine One hand on shoulder, with thumb on dislocated humeral headOther arm slowly abducts shoulder to overhead positionHead is gently pushed over glenoid rim to reduce dislocated shoulder
15 Stimson Technique Patient is supine Affected arm hanging down over the edge10 lbs weight applied to wristWait for relaxation and auto-reduction
16 Traction/Countertraction Arm in some abductionTraction applied to armAssistant applies firm counter-traction with sheet across the body
17 Scapular Manipulation Patient is proneShoulder flexed to 90 degrees hanging with elbow flexed and humerus in external rotation5-15lbs of traction on armOne hand on superior scapula pushing laterallyOther hand on inferior angle pushing medially
18 Milch vs Kocher RCT (Beattie 1986) Randomization by date 111 patients No premedicationOutcome: Successful ReductionResults: No difference in manuever for successful reductionGreater success with Milch’s technique in pts <40yoGreater success with Kocher approach, especially in people with a heavier build
19 Is there a best Reduction Maneuver? Unknown: More Research NeededRecommend learning three techniques and gaining experience with them each
20 Post-Reduction Immobilization Is immobilization necessary?What Methodis Best?
21 Does immobilization reduce recurrence? Level I RCT: Hovelius JBJS 2008Prospective multi-center study257 primary anterior shoulder dislocations25 year follow upResults:Immobilization for 3-4 weeks after shoulder dislocation does NOT change the prognosis compared with immediate mobilizationImmobilization: Arm tied to torso (internal rotation)
22 Internal vs External Rotation Level II RCT: Itoi JBJS 2007Basis: MRI has shown that coaptation of the Bankart lesion is better with the arm in ER than in IRThought: If the Bankart heals recurrence is less likely198 primary shoulder dislocations randomized to ER or IR immobilization for 3 weeksFollowed for a minimum of 2 yearsLevel 2: low compliance, instructional bias, short f/uER: with wire-mesh splint, held arm in 10 D of ERIR: sling and swatheCompliance 40% for IR pts, 68% for ER ptsMiller et al, Journal of Shoulder Elbow Surgery 2004, measured contact forces between the Bankart lesion and the glenoid in cadaveric shoulders. Showed that the greater the external rotation, the greater the amount of contact force.Itoi et al placed patient’s in 10 D of ER because of concerns of patient comfort with increased ER.
23 Internal vs External Rotation Level II RCT: Itoi JBJS 2007ER for 3 weeksRecurrence rate: 32%IR for 3 weeksRecurrence rate: 60%P = 0.007Questions yet to be answered:The best position for immobilization -- > how much ER?2. The optimum duration of immobilization has not bee determined.
24 Conclusion Premedicate with Intraarticular Lidocaine Learn multiple reduction maneuversIf you decide to immobilize, immobilize in ER