Shoulder Dislocation

Dr Saseendar S, MS Ortho, DNB Ortho, MNAMS,

Dip SICOT(Belgium), FISOC(US), FASM (Sing),

Consultant Arthroscopy and Sports Medicine,

Chettinad Super Speciality Hospital,

Chennai

Synopsis

Introduction

Definition

Types

Anterior/ Posterior/ Inferior◦ Mechanism

◦ Subtypes

◦ Evaluation

◦ Clinical findings

◦ Management

◦ Complications

Recurrent

Introduction

Most unstable large joint

Mobility at the expense of stability

Definition

Glenohumeral instability is the inability

to maintain

the humeral head in

the glenoid fossa

Reasons for instability

Shallow glenoid

Extraordinary ROM

Vulnerability of upper limb to injury

Underlying conditions eg. ligament

laxity

Directions of instability

Anterior

◦ 97% of recurrent dislocations

subcoracoid - abd, extension and external

rotation

subglenoid

subclavicular

intrathoracic

Posterior◦ 3% of recurrent

◦ Seizures, shock, fall on flexed + adducted arm

subacromial

subglenoid

subspinous

Inferior

Superior

Bilateral

Dislocation of the Shoulder

Mostly Anterior > 95 % of dislocations

Posterior Dislocation occurs < 5 %

True Inferior dislocation (luxatio erecta) occurs < 1%

Habitual - Non traumatic dislocation may present as Multi directional dislocation due to generalized ligamentous laxity and is Painless

Mechanism

Usually Indirect fall on Abducted and

extended shoulder

May be Direct when there is a blow

on the shoulder from behind

Pathoanatomy of dislocation

Stretching/ tearing of capsule

Avulsion of glenohumeral ligaments

usually off the glenoid

Labral injury

◦ Bankart lesion

Impression fracture

◦ Hill-Sach lesion

Rotator cuff tear

Clinical Picture

Pain

Holds injured limb with

other hand close to

trunk

The shoulder is

abducted and the elbow

is kept flexed

Clinical Picture

Loss of the normal

contour of the shoulder -

appears as a step

Anterior bulge of head

of humerus may be

visible or palpable

Empty glenoid socket

Anterior Shoulder dislocation

Usually also inferior

Radiograph

Radiograph

Anterior Dislocation of Shoulder

Management

Emergency

Should be reduced in < 24 hours or

else AVN of head of humerus

Immobilised strapped to the trunk for

3-4 weeks and rested in a collar and

cuff

Management

Reduction◦ Closed

◦ Open

Maneouvers

Traction-countertraction method

Hippocrates method

Stimpson’s technique

Kocher’s technique

Traction-countertraction

Traction-countertraction

Hippocrates Method

Hippocrates Method

Hippocrates Method

Stimpson’s technique

Kocher’s Technique

Complications of anterior Shoulder

Dislocation : Early

Nerve – Axillary

Artery – Axillary

Ligaments

Bone - Associated fracture

◦ Neck of humerus

◦ Greater or lesser tuberosity

◦ Hill Sach

◦ Bankart

Axillary nerve injury

Bankart lesion – Soft tissue

Bankart lesion - Bony

Hill-Sachs lesion

Hill-Sachs lesion

Complications of anterior shoulder

Dislocation : Late

Avascular necrosis of the head of the Humerus (high risk with delayed reduction)

Heterotopic calcification ( used to be called Myositis Ossificans )

Recurrent dislocation

Posterior dislocation

5-10% of shoulder dislocations

Shoulder is in adduction flexion and

internal rotation

Mechanism

Indirect

◦ Electric shock

◦ Seizure episode

Direct

◦ Force on the anterior shoulder

Shoulder AP view

Scapular Y-view

Closed Reduction

Traction to adduct arm in the line of

deformity

Gentle lifting of humeral head into the

glenoid fossa

Operative treatment

Failed closed

Displaced fracture

Recurrence

Large defect

◦ Reverse Hill Sachs

Reverse Hill-Sachs

Complications

Neurological

◦ Axillary

◦ Nerve to infraspinatus

Vascular

Fractures

Recurrence

Inferior Dislocation

Luxatio erecta

Mechanism

Hyperabduction force

Radiograph

Reduction

Operative

Buttonholing

Complications

High

◦ Vascular

◦ Neurological

◦ Ligaments

◦ Fractures

Evaluation of recurrent

atraumatic instability

History

◦ Trauma?

◦ Sports

◦ Throwing or overhead activities

◦ Voluntary subluxation

◦ “Clunk” or knock

◦ Fear

◦ Hx of dislocations and energy associated

Physical

◦ Demonstrate dislocation/subluxation ?

◦ Laxity tests

◦ Stability tests

Generalised ligament laxity

Management

Conservative

◦ Acute episode

◦ Immobilisation

◦ Physiotherapy – Strengthening exercises

Operative reconstruction

◦ Soft-tissue reconstruction

◦ Bony reconstruction

Information contained in this presentation are intended for academic purpose only for the students of orthopaedic surgery.

The guidelines mentioned cannot be used absolutely for management of patients.

I am not responsible for any controversies that arise out of this presentation.

For clarifications/ suggestions please contact ssaseendar@yahoo.co.in or call at 91-9500366970.