Shoulder dislocation

Types of shoulder Dislocation:

1. Anterior

2. Posterior

3. Luxatio erecta (inferior dislocation)

Anterior Dislocation: head is dislocated anterior to the glenoid

Most common among all dislocations of shoulder

Mostly traumatic

MOI: happens in hyperabduction and external rotation

Posterior dislocation: head is dislocated posterior to glenoid

Most frequent cause is – epilepsy, electric shock, electroconvulsive

therapy

MOI: flexion, adduction and internal rotation

Luxatio erecta: head is quite inferior to the glenoid

Occurs due to holding an object while vertical fall

Shoulder in hyperabduction at the time of presentation

Recurrent dislocation:

It could be in any direction: ant/post/inferior

Acute anterior dislocation

Mechanism of injury:

1. Direct contact

2. Anteriorly directed force in an abducted and externally rotated shoulder

Clinical features:

1. Pain, swelling over shoulder

2. Inability to use arm

3. Arm held in slight abduction and external rotation

Specific signs in a DISLOCATED shoulder

A: Axillary concavity reduced

B: Bryant’s test: anterior axillary fold is at lower level when compared

to normal side

C: Callaway’s test: Increased anteroposterior diameter of axilla

C: Contour of shoulder lost due to flattening

D: Duga’s test: inability to touch opposite shoulder

H: Hamilton ruler test: a ruler placed on lateral aspect of arm touches

the acromion. (it fails to touch on normal side)

H: Hollow posterior aspect

I: Increased length of arm compared to normal side.

R: Regimental badge sign: loss/decrease in sensation over axillary nerve

distribution area over upper lateral aspect of arm

Diagnosis:

1. Plain xray of shoulder: AP and axillary view

2. MRI to detect Bankart and hill sach’s lesion

Treatment of acute anterior dislocation: Reduction of dislocation in

sedation/GA

Various manoeuvres for reduction

1. Kocher’s method: traction-counter traction method

2. Hippocratic method: Leg in axilla method

3. Stimson’s method: Gravity method

Essential pathological lesion in a traumatic anterior dislocation of shoulder is

1. Bankart lesion: detachment of anteroinferior labrum with capsule

2. Hill Sach’s lesion on posterolateral aspect of head of humerus

Kocher’s method:

Quite popular

Uses traction-counter traction method with following sequence

TEAI: traction-countertraction----external rotation---adduction---internal

rotation

Can led to fracture of humerus due to rotational stress

Hippocratic method:

The examiner pushes his leg into the axilla (countertraction) of patient

and pulls arm towards himself (traction).

Now almost obsolete

Stimson’s method:

Used in patients who present with old unreduced anterior dislocation of

shoulder between 3-6 weeks

Patients is asked to lie prone on the couch and weight is applied over his

forearm which acts like traction. Edge of bed is like counter traction

Complications of shoulder dislocations

1. Associated fracture of greater/lesser tuberosity/shaft/neck of

humerus

2. Axillary nerve palsy

3. Rotator cuff tear in elderly patients

4. Recurrent dislocation

Recurrent Anterior dislocation

Recurrent anterior dislocation is not uncommon

C/F:

1. Apprehension test

2. Relocation-release test

Investigation:

1. MRI of shoulder

2. CT scan to assess the glenoid bone loss and Hill sachs size

Treatment of recurrent anterior dislocation

1. Arthroscopic / open Bankart repair: the torn anteroinferior labrum is re-

sutured onto the glenoid margin arthroscopically

2. Latarjet Procedure:

The tip of coracoid (2cm) is taken off from coracoid along with the

attachment of coracobrachialis and short head of biceps and is fixed

onto the anterior glenoid margins with two screws.

It is performed when the anteroposterior diameter of glenoid is eroded

more than 21%

Procedures of historical importance

1. Puttiplatt procedure

Double breasting of subscapularis

It prevents dislocation by limiting ER of shoulder

2. Bristow’s procedure:

Similar to Latarjet.

Here tip of coracoid is fixed with single screw over glenoid margin.

Latarjet is preferred over Bristows.

Recent advances:

“Remplissage” is performed for large hill sachs lesions.

It is a procedure wherein the tendon of Infraspinatus is sutured over the

large Hill sachs defect to prevent engagement of Hill sachs lesion with

glenoid margin.