Glenohumeral Dislocation: Class, Complications and Management

August 21, 2003Emergency XR Rounds

Simon Pulfrey (with much gleaned from Dave Dyck)

Objectives

• Types of dislocations• Review radiographic anatomy• Types of radiographic views• Key issues of physical exam• Reduction strategies• “Common” complications• Pre and Post radiograph discussion• Follow-up/discharge issues

Normal

Glenohumeral Joint Dislocation

• Anterior• Posterior• Inferior (Luxatio Erecta)• Superior

Anterior

• Most common – 94-97% of GH dislocation• 4 Types

– Subcoracoid– Subglenoid 99%– Subclavicular– Intrathoracic

Case 1

• 29 y male, fell mountain biking - forced abduction injury to left arm, about 4 hours ago In severe pain. No prior injuries.

• Holding arm in slight abduction and external rotation with right hand.

• Refuses to adduct or internally rotate L arm.• L shoulder appears “squared-off”

What neurovascular exam will you do?

• Neuro• Median, Ulnar, &

Radial• Axillary N

– Shoulder pin prick & deltoid motor activity

– Injured in 5-54% of cases

– Usually >50yrs

• Vascular• Axillary• Brachial • Radial

? Need for pre-reduction x-rays

• Shuster, Abu-Laban, and Boyd – Banff say NO

• BUT – most others say YES!• Maybe NO in patient with recurrent

shoulder dislocation and non-traumatic mechanism.

• Is there a fracture prior to reduction?

To classify glenohumeral dislocations

• Mechanism – Traumatic vs Non-traumatic• Frequency – Primary vs Recurrent• Anatomic position of humeral head

Diagnostic Strategies

• 1- True AP

2. Axillary

Transcapular or “Y” View

How to manage?

• Analgesia? • None, procedural sedation, intraarticular LA

injection• Reduction strategy• Incidence of neurovasc complications

increase with time• The ideal method is simple, quick &

minimally traumatic

Reduction methods

• Stimson – Hanging weights. Not sedated.• Cooper&Miltch – forward elevation,

flexion and abduction.• Traction-counter traction• Liedelmeyer – External rotation and

abduction.• All have similar success rates• Hippocratic and Krocher are quite traumatic

Post-Reduction Issues

• Neurovascular status• Re-radiograph? – 2 small studies –Harvey et al

Am J Emerg Med 1992, Hendey et al Am J Emerg Med, 1996 suggest maybe not. Rosen says do.

• Need to consider every case – recurrent, trauma, age, difficulty with reduction, comorbidities…

Post reduction:

Hill-Sachs

Post reduction

Bankhart

Complications of anterior glenohumeral dislocation and

reduction• Neurovascular – neuropraxic and recover in

days-weeks• Fractures

– Hill-Sachs – 11-50% of ant dislocations. May be higher if consider minor compression fractures

– Bankart – ant glenoid rim #. 5% of cases.– Avulsion # of greater tuberosity in 10-15%.

Complications of anterior glenohumeral dislocation and

reduction• Rotator cuff injury – 10-15% will have tear.

Higher incidence in those >40yrs.• Capsulolabral avulsions in those of younger

years

Infraglenoid Dislocation + Hill-Sachs Fracture

Luxatio Erecta:

Luxatio Erecta

• 0.5%• Usually axial load on abducted arm or

indirect trauma• Presents with 100-160 deg of abduction• Humeral shafts lies parallel to spine of

scapula (infglenoid lies against chest wall)• Usually need ortho help• Wary buttonhole problem

Posterior Dislocation: -trough sign. Reverse Hill-Sach# on ante-medial hh. -Lightbulb/drum stick

Posterior Dislocation

• Rare. 2%. • Commonly missed (50%!)• Seizures, fall on flexed and adducted arm,

direct blow• Deceptively normal-appearing AP XR• Increased importance of clinical exam

Clinical Findings:

• Arm adducted and internally rotated• The anterior shoulder is flat and the

posterior aspect full• Prominent coracoid• The patient won’t allow abduction or

external rotation

Rim sign: ant glenoid rim and articular surface of hh increased (usu>6mm)

Summary• Reduce ASAP• Wary neurovascular status, fractures & rotator

cuff injuries• Consider necessity of pre & post reduction films

on an individual basis• Know well three methods of reduction• Suspect posterior dislocations in appropriate pts