a brief overview of shoulder dislocation in a pictographical way for better understanding for postgraduates n medicos

1. Shoulder dislocation
Dr. Guru prasad
Dnb orthopaedics

2. synopsis
• Definition
• Anatomy – pathoanatomy
• Types – anterior/posterior/inferior
• Clinical features – Tests for evaluation
• Management -- Reduction techniques
• Complications

4. History:
• Shoulder dislocation is documented in Egyptian tomb
murals as early as 3000 BC, with depiction of a
manipulation for glenohumeral dislocation resembling
the Kocher technique.
• Hippocrates detailed the oldest known reduction
method still in use today. Hippocrates described 13
different techniques, generally traction / counter
traction.
A painting in the tomb of Ipuy,
1300BC, the sculptor of Ramses II
depicts a physician reducing a
dislocated shoulder, using a
similar technique Kocher
described in 1870.

6. - SURGICAL ANATOMY
- Static stabilizers- anatomic constraints to shoulder motion
- Dynamic stabilisers – normal physiological function creates a
stabilizng effect
- BONY ANATOMY – has minimal constraints – large range of
motion
Scapula – hence glenoid anterverted 30 – 40
Humeral head retroverted
¼ of head articulates with bony glenoid
LABRUM – one of the most important stabilizing structures .
- Effectively enlarges & deepens the glenoid surface by 1 cm &
50% respectively .
- Increases humeral contact to 75 %

7. • CAPSULE : loose and redundant at most positions
- At extremes – tightens , provides stability
.
• GLENOHUMERAL LIGAMENTS
- Superior , middle , inferior
• CORACOHUMERAL LIGAMENT –
-Passes in the rotator interval ( between subscapularis &
supraspinatus )

8. DYNAMIC STABILIZERS
• ROTATOR CUFF MUSCLES :
- BICEPS TENDON : along the rotator interval
• CORACO-ACROMIAL ARCH limits superior translation

12. Anterior:
• Subcoracoid (anterior):
– Humeral head sits
anterior and medial to
the glenoid, just
inferior to the coracoid.
– ~ 60% of cases.
• Subglenoid
(anteroinferior):
– humeral head sits
inferior and slightly
anterior to the glenoid,
that the humeral head
has also travelled
medially.
– ~ 30% of cases.

17. • MECHANISM OF INJURY :
• DIRECT – less common
INDIRECT – more common
• Susecptible position –
• Anterior dislocation : abd. , ext. rotation & extension
• Post. Dislocation : flexion, add . & int. rotation
• In seizures & electrical shock – all the muscles are contracted
, ext. rotators overpower int. rotators
• ASS0CIATED INJURIES :
• Humeral head & neck # , tuberosity # , glenoid # , rotator
cuff tears( older age) , neurological ( axillary N.) and vascular
injuries
• Any pt. with weakness after shoulder dislocation must be
evaluated for rotator cuff tear

22. • Presentation of acute dislocation
• Pain , typical attitude ,
• In ant . Dis- limitation of int. rotation & abd.
• In post. Disl. – “ of ext. rotation
• In inferior disl. – in fully abducted position
• PHYSICAL EXAMINATION
• Flattening of shoulder
• Fullness in delto-pectoral area
• Axillary fold at lower level
• Able to insinuate finger beneath acromion
• dugas test
• Hamilton ruler test

23. Dugas test

24. Hamilton ruler test

25. SULCUS TEST :

26. • Axillary N. tested for both sensory & motor components

27. X-Ray
• The anteroposterior x-ray will show the
overlapping shadows of the humeral head and
glenoid fossa, with the head usually lying
below and medial to the socket.

35. • CLASSIFICATION
• SEVERITY –
subluxation
dislocation
-DURATION
acute
chronic
- OCCURRENCE
single
recurrent
- MECHANISM
Traumatic / atraumatic
- DIRECTION - anterior / posterior / multidirectional

38. • NONOPERATIVE TRAETMENT
• CLOSED REDUCTION FOR ACUTE DISLOCATION
- Under i.v. analgesia + sedation
- Under intra-articular lignocaine
- If initial closed reduction unsucessful , degree of sedation &
analgesia evaluated , if not successful , under G.A for closed
/ open reduction

40. Traction-countertraction
• Note how the clinician on
the left has the sheet
wrapped around him,
allowing him to use his
body weight to create
traction. Some clinicians
employ gentle external
rotation to the affected
arm while providing
traction.

46. Stimson technique
• The patient is
placed prone on the
stretcher with the
affected shoulder
hanging off the
edge. Weights (10-
15 lbs) are fastened
to the wrist to
provide gentle,
constant traction.

48. Scapular manipulation
• The patient sits upright and
leans the unaffected shoulder
against the stretcher. The
physician stands behind the
patient and palpates the tip
of the scapula with his
thumbs and directs a force
medially. The assistant stands
in front of the patient and
provides gentle downward
traction on the humerus as
shown. The patient is
encouraged to relax the
shoulder as much as possible.

49. Milch technique
• The arm is abducted
and the physician's
thumb is used to
push the humeral
head into its proper
position. Gentle
traction in line with
the humerus is
provided with the
physician's opposite
hand.

50. Spaso technique
• The arm is flexed
forward and
gentle traction
and external
rotation forces are
applied.

51. Management
• The arm is rested in a sling for about three weeks
in those under 30 years of age (who are most
prone to recurrence) and for only a week in those
over 30 (who are most prone to stiffness).
• Then movements are begun, but combined
abduction and lateral rotation must be avoided
for at least 3 weeks.
• Throughout this period, elbow and finger
movements are practised every day.

52. • OPERATIVE TREATMENT
• SURGICAL STABILISATION FOR ANT . INSTABILITY
in – failed appropriate nonoperative treatment
- recurrent dislocation at young age
- irreducible dislocation
- open dislocation
- unstable joint reduction
- 1st dislocation in young pt with high demand activity
surgical options
- arthroscopic surgery
- open tech. with soft tissue repair
- open tech. with bony augmentation

53. • Open procedures
• BANKART OPERATION
- MC performed surgery
- Ant. Labral defect identified , mobilized & reattached to
original anatomic site with suture anchor .
- Capsular reconstruction also recommended
- Subscapularis tendon is split at junction of upper 2/3rd &
lower 2/3rd

54. BRISTOW OPERATION
- Suturing of coracoid process with the conjoint tendon to the
ant. Portion of scapular neck through a transversely
sectioned subscapularis M.
- The transferred short head of biceps & corachobrachialis –
strong buttress across the anterior & inferior aspects of joint
- Tendon also holds the lower half of subscapularis M. thus
prevents slipping over the humeral head when abducted

55. • PUTTI-PLAT OPERATION
- Subscapularis and capsule incised vertically
- Lateral leaf sutured to the labrum & medial leaf imbricated
- Subscapularis is advanced laterally
- Gross limitation of ext. rotation
- Rarely indicated

56. • ARTHROSCOPIC PROCEDURES
• ADVANTAGES & DISADVANATAGES

57. POSTERIOR DISLOCATION OF THE
SHOULDER
• Posterior dislocation is rare, accounting for
less than 2% of all dislocations around the
shoulder.

59. Clinical features
• The diagnosis is frequently missed – partly
because reliance is placed on a single
anteroposterior x-ray (which may look almost
normal) and partly because those attending to
the patient fail to think of it.
• There are, in fact, several well-marked clinical
features.

61. • The arm is held in internal rotation and is
locked in that position.
• The front of the shoulder looks flat with a
prominent coracoid, but swelling may obscure
this deformity; seen from above, however, the
posterior displacement is usually apparent.

62. X-Ray
• In the anteroposterior film the humeral head,
because it is medially rotated, looks abnormal in
shape (like an electric light bulb) and it stands
away somewhat from the glenoid fossa (the
‘empty glenoid’ sign).
• An axillary view is essential; it shows posterior
subluxation or dislocation and sometimes a deep
indentation on the anterior aspect of the humeral
head.

65. Posterior shoulder
dislocation reduction
• The underlying approach to
the traction-countertraction
technique demonstrated in
this photograph is similar to
that employed in the
reduction of anterior
dislocations. The notable
difference is positioning.
Note that the patient is
upright and the clinician
providing traction is
standing in front of the
patient.

66. INFERIOR DISLOCATION OF THE
SHOULDER (LUXATIO ERECTA)
• Inferior dislocation is rare but it demands early
recognition because the consequences are
potentially very serious.
• Dislocation occurs with the arm in nearly full
abduction/elevation.
• The humeral head is levered out of its socket and
pokes into the axilla; the arm remains fixed in
abduction.

68. Mechanism of injury and pathology
• The injury is caused by a severe hyper-
abduction force.
• With the humerus as the lever and the
acromion as the fulcrum, the humeral head is
lifted across the inferior rim of the glenoid
socket; it remains in the subglenoid position,
with the humeral shaft pointing upwards.

69. • Soft-tissue injury may be severe and includes
avulsion of the capsule and sur-rounding
tendons, rupture of muscles, fractures of the
glenoid or proximal humerus and damage to
the brachial plexus and axillary artery.

71. Clinical features
• The startling picture of a patient with his arm
locked in almost full abduction should make
diagnosis quite easy.
• The head of the humerus may be felt in or
below the axilla.
• Always examine for neurovascular damage.

73. X-ray
• The humeral shaft is shown in the abducted position with
the head sitting below the glenoid.
• It is important to search for associated fractures of the
glenoid or proximal humerus.
– NOTE: True inferior dislocation must not be confused with
postural downward displacement of the humerus, which results
quite commonly from weakness and laxity of the muscles
around the shoulder, especially after trauma and shoulder
splintage; here the shaft of the humerus lies in the normal
anatomical position at the side of the chest.
– The condition is harmless and resolves as muscle tone is
regained.

74. Treatment
• Inferior dislocation can usually be reduced by pulling
upwards in the line of the abducted arm, with counter-
traction downwards over the top of the shoulder.
• If the humeral head is stuck in the soft tissues, open
reduction is needed. It is important to examine again,
after reduction, for evidence of neurovascular injury.
• The arm is rested in a sling until pain subsides and
movement is then allowed, but avoiding abduction for
3 weeks to allow the soft tissues to heal.

77. Complications
• EARLY COMPLICATIONS
• Rotator cuff tear:
– This commonly accompanies anterior dislocation,
particularly in older people.
– The patient may have difficulty abducting the arm
after reduction; palpable contraction of the deltoid
muscle excludes an axillary nerve palsy.
– Most do not require surgical attention, but young
active individuals with large tears will benefit from
early repair.

78. • Nerve injury:
– The axillary nerve is most commonly injured; the patient is
unable to contract the deltoid muscle and there may be a
small patch of anaesthesia over the muscle.
– The inability to abduct must be distinguished from a
rotator cuff tear.
– The nerve lesion is usually a neuropraxia which recovers
spontaneously after a few weeks; if it does not, then
surgery should be considered as the results of repair are
less satisfactory if the delay is more than a few months.

80. – Occasionally the radial nerve, musculocutaneous
nerve, median nerve or ulnar nerve can be
injured.
– Rarely there is a complete infra-clavicular brachial
plexus palsy.
– This is somewhat alarming, but fortunately it
usually recovers with time.

81. • Vascular injury:
– The axillary artery may be damaged, particularly in
old patients with fragile vessels.
– This can occur either at the time of injury or
during overzealous reduction.
– The limb should always be examined for signs of
ischaemia both before and after reduction.

82. • Fracture-dislocation
– If there is an associated fracture of the proximal humerus,
open reduction and internal fixation may be necessary.
– The greater tuberosity may be sheared off during
dislocation.
– It usually falls into place during reduction, and no special
treatment is then required.
– If it remains displaced, surgical reattachment is
recommended to avoid later subacromial impingement.

83. • LATE COMPLICATIONS
• Shoulder stiffness
– Prolonged immobilization may lead to stiffness of the shoulder,
especially in patients over the age of 40.
– There is loss of lateral rotation, which automatically limits
abduction.
– Active exercises will usually loosen the joint.
– They are practised vigorously, bearing in mind that full
abduction is not possible until lateral rotation has been
regained.
– Manipulation under anaesthesia or arthroscopic capsular
release is advised only if progress has halted and at least 6
months have elapsed since injury.

84. • Recurrent dislocations

88. • Unreduced dislocation
– Surprisingly, a dislocation of the shoulder sometimes
remains undiagnosed.
– This is more likely if the patient is either unconscious or
very old.
– Closed reduction is worth attempting up to 6 weeks after
injury; manipulation later may fracture the bone or tear
vessels or nerves.
– Operative reduction is indicated after 6 weeks only in the
young, because it is difficult, dangerous and followed by
prolonged stiffness.
–

89. • Thank you all…