Shoulder Dislocation. s Shoulder dislocation 1. DISLOCATION - COMPLETE LOSS OF GLENOHUMERAL ARTICULATION. CAUSE- ACUTE TRAUMA 1. DISLOCATION - COMPLETE

Shoulder Shoulder DislocationDislocation

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Shoulder dislocationShoulder dislocation

1. 1. DISLOCATIONDISLOCATION- COMPLETE LOSS OF - COMPLETE LOSS OF GLENOHUMERAL ARTICULATION . CAUSE- GLENOHUMERAL ARTICULATION . CAUSE- ACUTE TRAUMA ACUTE TRAUMA

22. SUBLUXATION . SUBLUXATION - PARTIAL LOSS OF - PARTIAL LOSS OF ARTICULATION WITH SYMPTOM’S. CAUSE- ARTICULATION WITH SYMPTOM’S. CAUSE- REPITITIVE TRAUMA. REPITITIVE TRAUMA.

3.3. LAXITY LAXITY - PARTIAL LOSS OF - PARTIAL LOSS OF GLENOHUMERAL ARTICULATION BUT PAITENT GLENOHUMERAL ARTICULATION BUT PAITENT IS ASYMPTOMATIC. SHOULDER INSTABLITYIS ASYMPTOMATIC. SHOULDER INSTABLITY

Shoulder dislocationShoulder dislocation Shoulder is the most commonly dislocated Shoulder is the most commonly dislocated

joint[45%]joint[45%]

1] shallowness of glenoid socket1] shallowness of glenoid socket

2]Extraordinary ROM2]Extraordinary ROM

3] ligamentus laxity3] ligamentus laxity Humeral head 3x larger than glenoid fossaHumeral head 3x larger than glenoid fossa

glenohumeral articulation is minimally glenohumeral articulation is minimally constrained by bony anatomy aloneconstrained by bony anatomy alone

stability is conferred by a series of dynamic stability is conferred by a series of dynamic and static soft tissue restraintsand static soft tissue restraints

Shoulder dislocationShoulder dislocation

Type of dislocationType of dislocation Traumatic DislocationsTraumatic Dislocations Atraumatic dislocationAtraumatic dislocation Acquird dislocationAcquird dislocation

Traumatic dislocationTraumatic dislocation

Single force applies excessive Single force applies excessive overload to the soft tissues of the overload to the soft tissues of the joint and often damages the Glenoid joint and often damages the Glenoid Labrum (Bankart Lesion) and the Labrum (Bankart Lesion) and the joint capsulejoint capsule

Anterior [85%]Anterior [85%] Posterior[10]Posterior[10] Inferior [5]Inferior [5]

Atraumatic dislocationAtraumatic dislocation

Athelete who has jointAthelete who has joint hyperlaxity hyperlaxity and had multiple episode of joint and had multiple episode of joint subluxationsubluxation

Minor injury can results into Minor injury can results into dislocationdislocation

[Congenital hypermobility or muscle [Congenital hypermobility or muscle weakness.] weakness.]

Acquired dislocationAcquired dislocation Sports such as Sports such as

swimming, gymnastics swimming, gymnastics and baseball where and baseball where

repetitive repetitive micro-trauma, micro-trauma, poor stretching and poor stretching and motion lead to motion lead to

capsular capsular stretchingstretching. . Eventual feeling of Eventual feeling of instabilityinstability

Traumatic anterior Traumatic anterior dislocationdislocation

Mech. of injuryMech. of injury Arm in abduction and external Arm in abduction and external

rotation. Force is taken on the hand rotation. Force is taken on the hand or arm which increases the external or arm which increases the external rotation of the arm causing the head rotation of the arm causing the head of the humerus to dislocateof the humerus to dislocate

Clinical symptom:Clinical symptom: Pain [severe]Pain [severe] Hold limb with normal limb by side Hold limb with normal limb by side

of body.of body. Abduction and external rotation.Abduction and external rotation. Pt can’t touch apposite shoulder Pt can’t touch apposite shoulder

[dugos test][dugos test]

Clinical EvaluationClinical Evaluation PE:PE:

Prominent acromion, Prominent acromion, sulcus sign, palpable sulcus sign, palpable humeral head anteriorlyhumeral head anteriorly

Neuro integrity of Neuro integrity of axillary and axillary and musculcutaneous nervesmusculcutaneous nerves

Apprehension TestApprehension Test: : reproduces sense of reproduces sense of instability and pain in instability and pain in shoulder reduced prior shoulder reduced prior to examto exam

Radiographic EvaluationRadiographic Evaluation

AP [fracture dislo]AP [fracture dislo] Axillary Axillary Special Views:Special Views:

West Point axillary: West Point axillary: for visualization of for visualization of glenoid rimglenoid rim

Hill-Sach view: Hill-Sach view: internal rotation viewinternal rotation view

Stryker Notch: view Stryker Notch: view 90% of posterolateral 90% of posterolateral humeral headhumeral head

ManagementManagement

Pre-MedicationPre-Medication

Reduction Reduction ManeuversManeuvers

Post-Reduction Post-Reduction ImmobilizationImmobilization

Pre-MedicationPre-Medication

Methods of Methods of Premedication prior to Premedication prior to ReductionReduction NoneNone Intraarticular Lidocaine Intraarticular Lidocaine

IV SedationIV Sedation Supraclavicular BlockSupraclavicular Block Suprascapular BlockSuprascapular Block

IV Sedation vs IV Sedation vs Intraarticular Lidocaine Intraarticular Lidocaine

InjectionInjection

Intra-articular Lidocaine

Injection is Preferred over

IV Sedation

Reduction ManeuversReduction Maneuvers

Is there an Ideal Method for Reduction?Is there an Ideal Method for Reduction? Over 24 Techniques DescribedOver 24 Techniques Described

Most Common Techniques Most Common Techniques Kocher (71-100%)Kocher (71-100%) External Rotation (78-90%) External Rotation (78-90%) Milch (70-89%) Milch (70-89%) Stimson (91-96%)Stimson (91-96%) Traction/CountertractionTraction/Countertraction Scapular Manipulation (79-96%)Scapular Manipulation (79-96%)

Kocher ManeuverKocher Maneuver

TEA ITEA I TractionTraction ERER AdductionAdduction arm is internally arm is internally

rotatedrotated Modified [no Modified [no

traction]traction]

Stimson method Stimson method

Traction/CountertractionTraction/Countertraction

Arm in some Arm in some abductionabduction

Traction applied to Traction applied to armarm

Assistant applies Assistant applies firm counter-firm counter-traction with sheet traction with sheet across the bodyacross the body

Hippocratic methodHippocratic method

Surgeon use foot Surgeon use foot applies on axilla for applies on axilla for countertractioncountertraction

Post-Reduction Post-Reduction ImmobilizationImmobilization

Is Is immobilization immobilization necessary? necessary?

What Method What Method

is Best?is Best?

Does immobilization Does immobilization reduce recurrence?reduce recurrence?

usually fracture associated with usually fracture associated with dislocation are reduced with dislocation are reduced with reduction of dislocation. reduction of dislocation.

Immobilization for 3-4 weeks after Immobilization for 3-4 weeks after shoulder dislocation does NOT shoulder dislocation does NOT change the prognosis compared with change the prognosis compared with immediate mobilizationimmediate mobilization

Internal vs External Internal vs External RotationRotation

Level II RCT: Itoi JBJS 2007Level II RCT: Itoi JBJS 2007 ER for 3 weeksER for 3 weeks

Recurrence rate: 32%Recurrence rate: 32% IR for 3 weeksIR for 3 weeks

Recurrence rate: 60%Recurrence rate: 60% P = 0.007P = 0.007

Complication of Complication of ant.shoulder dislocationant.shoulder dislocation

Early Early Rotator cuff tearRotator cuff tear Nerve injuryNerve injury Vascular injuryVascular injury Fracture dislocationFracture dislocation

Late complicationLate complication

StiffnessStiffness Unreduced disloction [undiagnos in Unreduced disloction [undiagnos in

unconcious and old pts. ]unconcious and old pts. ]

closed reduction done upto 6 wks and closed reduction done upto 6 wks and open reduction done after 6wks in open reduction done after 6wks in young pts. Willful neglect in old ptsyoung pts. Willful neglect in old pts

Recurrent dislocationRecurrent dislocation

Post. Shoulder Post. Shoulder dislocationdislocation

The arm is in flexion and adduction. The arm is in flexion and adduction. Force is taken on the hand, causing Force is taken on the hand, causing the head of the humerus to be push the head of the humerus to be push out the glenoid posteriorly.out the glenoid posteriorly.

h/o convulsion or electric shockh/o convulsion or electric shock

Clinical sign and symptomClinical sign and symptom Diag is often missedDiag is often missed Internal rotationInternal rotation Flat front of shoulderFlat front of shoulder Prominent corocoidProminent corocoid Frominent post aspect of shoulder Frominent post aspect of shoulder

Radiology Radiology AP- electric bulb AP- electric bulb

apperence and empty apperence and empty glenoid sign.glenoid sign.

Lat – post Lat – post displacementdisplacement

Treatmet Treatmet Under GA reduction by pulling arm Under GA reduction by pulling arm

in adduction to dis engage head then in adduction to dis engage head then lateraly rotate while pushing head lateraly rotate while pushing head anteriorly.anteriorly.

Immobilization in ext rotation and Immobilization in ext rotation and abduction for 3 wks.abduction for 3 wks.

Inferior shoulder Inferior shoulder dislocation[luxatio dislocation[luxatio

erecta]erecta]Arm is in excessive abduction and a Arm is in excessive abduction and a

force is taken on the hand pushing force is taken on the hand pushing the head of the humerus inferiorly the head of the humerus inferiorly out of the glenoid. out of the glenoid.

Clinical featuresClinical features

limb in abductionlimb in abduction


erecta]erecta]

Xrays –APXrays –AP LATLAT


erecta]erecta]Treatment Treatment Traction and counter traction.Traction and counter traction.

Immobilised for 3 wksImmobilised for 3 wks

Recurrent shoulder Recurrent shoulder dislocationdislocation

Anterior dislocations account for ~95% of Anterior dislocations account for ~95% of shoulder dislocationsshoulder dislocations

Typically occurs in athletes who are < 25 years Typically occurs in athletes who are < 25 years oldold

Males are much more commonly affected than Males are much more commonly affected than are females (85-90%)are females (85-90%)


Pathology most commonly found in shoulders Pathology most commonly found in shoulders following a dislocation is a Bankart lesionfollowing a dislocation is a Bankart lesion Disruption of the labrum and the Disruption of the labrum and the

contiguous anterior band of the inferior contiguous anterior band of the inferior glenohumeral ligamentous complex glenohumeral ligamentous complex (IGHLC)(IGHLC)

Bankhart lesion occurs > 85% of the timeBankhart lesion occurs > 85% of the time


Bony bankartBony bankart

Hillsach lesion – Hillsach lesion – posteriolateral posteriolateral indentation of indentation of humeral head.humeral head.

Enganging lesion Enganging lesion is indication of is indication of surgerysurgery



Classification Classification Instability can be classified by:Instability can be classified by:

direction of instability (anterior, direction of instability (anterior, posterior, multidirectional)posterior, multidirectional)

degree of instability (subluxation, degree of instability (subluxation, dislocation)dislocation)

etiology (traumatic, atraumatic, overuse)etiology (traumatic, atraumatic, overuse) timing (acute, recurrent, fixedtiming (acute, recurrent, fixed))


TUBS or “Torn LooseTUBS or “Torn Loose”” T raumatic aetiology, U nidirectional instability, B T raumatic aetiology, U nidirectional instability, B

ankart lesion is the pathology, S urgery is ankart lesion is the pathology, S urgery is requiredrequired

AMBRI or “Born LooseAMBRI or “Born Loose”” A traumatic: minor trauma, M ultidirectional A traumatic: minor trauma, M ultidirectional

instability may be present, B ilateral: instability may be present, B ilateral: asymptomatic shoulder is also loose, R asymptomatic shoulder is also loose, R ehabilitation is the treatment of choice, I nferior ehabilitation is the treatment of choice, I nferior capsular shift: surgery required if conservative capsular shift: surgery required if conservative measures failmeasures fail



Shoulder Stabilisers – Static Shoulder Stabilisers – Static

Intracapsular pressureIntracapsular pressure Labrum: increases depth of the glenoid Labrum: increases depth of the glenoid

by 50%by 50% Ligaments – main static restraintsLigaments – main static restraints capsule capsule


Shoulder StabilisersShoulder Stabilisers

DynamicDynamic Rotator cuff and bicepsRotator cuff and biceps






How many number How many number of of dislocation is indication of surgery.dislocation is indication of surgery.

Frist dislocation in Frist dislocation in young pateint young pateint specially sports person.specially sports person.

Two time dislocation is definit Two time dislocation is definit indication of surgery.indication of surgery.


Open surgeryOpen surgery done for old and done for old and multiple recurrent dislocation due multiple recurrent dislocation due plastic deformation of tissue or larg plastic deformation of tissue or larg bony defects.bony defects.

Arthroscopic surgery Arthroscopic surgery is done is done fresh case of recurrent dislocation.fresh case of recurrent dislocation.

Advantage Advantage


Anatomic Repairs Anatomic Repairs

Restoring normal anatomy is guiding principle in Restoring normal anatomy is guiding principle in surgery to correct anterior shoulder instabilitysurgery to correct anterior shoulder instability If the labrum has been detached, it is reattached to If the labrum has been detached, it is reattached to

the anterior glenoid rimthe anterior glenoid rim If the capsule has been stripped off the glenoid If the capsule has been stripped off the glenoid

neck, the capsule is reattached to the bony glenoid neck, the capsule is reattached to the bony glenoid rimrim

If greater than one-third of the glenoid fossa is If greater than one-third of the glenoid fossa is involved, a bone block procedure such as a Bristow involved, a bone block procedure such as a Bristow or iliac crest bone graft may be consideror iliac crest bone graft may be considereded

Bankart repairBankart repair

Bankart repairBankart repair


Nonanatomic Repairs [open]Nonanatomic Repairs [open] Bristow and latarjet Bristow and latarjet

Transfer coracoid process to anteroinferior Transfer coracoid process to anteroinferior glenoidglenoid

Sling effect and bone blockSling effect and bone block

Putti-Platt -Putti-Platt -Subscapularis is cut and shortaned Subscapularis is cut and shortaned

Magnusen-StackMagnusen-Stack subscapularis tendon is detached from its subscapularis tendon is detached from its

insertion on the lesser tuberosity, transferred insertion on the lesser tuberosity, transferred laterally to the greater tuberositylaterally to the greater tuberosity

Latarjet procedureLatarjet procedure

Latarjet procedureLatarjet procedure

Putti-plat operation:Putti-plat operation:

Putti-plat operation:Putti-plat operation: limited ERlimited ER

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Shoulder Dislocation. s Shoulder dislocation 1. DISLOCATION - COMPLETE LOSS OF GLENOHUMERAL ARTICULATION. CAUSE- ACUTE TRAUMA 1. DISLOCATION - COMPLETE