1. Shoulder Dislocation

2. s

4. Shoulder dislocation
1. DISLOCATION- COMPLETE LOSS OF GLENOHUMERAL ARTICULATION . CAUSE- ACUTE TRAUMA
2. SUBLUXATION - PARTIAL LOSS OF ARTICULATION WITH SYMPTOM’S. CAUSE- REPITITIVE TRAUMA.
3. LAXITY - PARTIAL LOSS OF GLENOHUMERAL ARTICULATION BUT PAITENT IS ASYMPTOMATIC. SHOULDER INSTABLITY

5. 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 dislocations make upto 45% of all dislocations
Mechanism 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

6. Shoulder dislocation Type of dislocation Traumatic Dislocations
Atraumatic dislocation
Acquird dislocation

7. 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]

8. 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.]

9. 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

10. 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

11. 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]

12. 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
Neuro exam: Test axillary sensation over deltoid and musculcutaneous sensation over anterolateral forearm
Axillary nerve injury in 9-18% of anterior dislocations
Apprehension Test: placement of shoulder into abduction, extension, and ER

13. 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
True AP xray taken at degrees of lateral or in the plane of the scapula
Axillary: 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 xray
Valpeau 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 caudally
West 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 defect
Stryker 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

14. Management Pre-Medication Reduction Maneuvers
Post-Reduction Immobilization

15. Pre-Medication Methods of Premedication prior to Reduction None
Intraarticular Lidocaine
IV Sedation
Supraclavicular Block
Suprascapular Block
Intraarticular Lidocaine Injection with cc of Lidocaine through a posterior approach (aspirate obtains hemarthrosis= in the joint)

16. IV Sedation vs Intraarticular Lidocaine Injection
Injection is Preferred over
IV Sedation

17. 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%)

18. Kocher Maneuver TEA I Traction ER Adduction arm is internally rotated
Modified [no traction]

19. Stimson method

20. Traction/Countertraction
Arm in some abduction
Traction applied to arm
Assistant applies firm counter-traction with sheet across the body

21. Hippocratic method
Surgeon use foot applies on axilla for countertraction

22. Post-Reduction Immobilization
Is immobilization necessary?
What Method
is Best?

24. 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
Immobilization: Arm tied to torso (internal rotation)

25. 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
Questions yet to be answered:
The best position for immobilization -- > how much ER?
2. The optimum duration of immobilization has not bee determined.

26. Complication of ant.shoulder dislocation
Early
Rotator cuff tear
Nerve injury
Vascular injury
Fracture dislocation

27. 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

28. 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

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

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

32. 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.

33. 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

34. Inferior shoulder dislocation[luxatio erecta]
Xrays –AP
LAT

35. Inferior shoulder dislocation[luxatio erecta]
Treatment
Traction and counter traction.
Immobilised for 3 wks

36. 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 (85-90%)

37. 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

38. Recurrent shoulder dislocation

39. Bony bankart

40. Hillsach lesion – posteriolateral indentation of humeral head.
Enganging lesion is indication of surgery

41. Recurrent shoulder dislocation

42. 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)

43. 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

44. Recurrent shoulder dislocation

45. Recurrent shoulder dislocation
Shoulder Stabilisers – Static
Intracapsular pressure
Labrum: increases depth of the glenoid by 50%
Ligaments – main static restraints
capsule

46. Recurrent shoulder dislocation

47. Shoulder Stabilisers
Dynamic
Rotator cuff and biceps

48. Recurrent shoulder dislocation

49. Recurrent shoulder dislocation

50. Recurrent shoulder dislocation

51. Recurrent shoulder dislocation

52. 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.

53. 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

54. 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

55. Bankart repair

56. Bankart repair

57. 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

58. Latarjet procedure

59. Latarjet procedure

60. Putti-plat operation:
limited ER

61. Thanks