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 SYMPTOM’S. CAUSE- REPITITIVE 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 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

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 micro-trauma, 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 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

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 30-40 degrees of lateral or in the plane of the scapula Axillary: arm is abducted 70-90 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

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 Intraarticular Lidocaine Injection with 15-20 cc of Lidocaine through a posterior approach (aspirate obtains hemarthrosis= in the joint)

IV Sedation vs Intraarticular Lidocaine Injection 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 Immobilization: Arm tied to torso (internal rotation)

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.

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 (85-90%)

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: limited ER

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