Shoulder disloaction

Shoulder disloaction by Bipul Borthakur

1. ANTERIOR RECURRENT SHOULDER DISLOCATION Dr . Bipul Borthakur (PROF.) Dept. of Orthopaedics, SMCH

2. Introduction most unstable and frequently dislocated joints in the body 50% of all dislocations 2% incidence in the general population

3. Anatomy Comprises of glenoid cavity of scapula and humoral head Factors providing stability of joint – Static stabilisers Glenoid cavity Glenoid labrum - increases the depth of glenoid cavity by 50% Negative intra-articular pressure Glenohumeral ligament complex

4. Dynamic stabilisers rotator cuff- Supraspinatus infraspinatus teres minor subscapularis Muscles around the shoulders

5. Mechanism of injury Anterior dislocation- abduction and external rotation of arm E.g - throwing of ball

6. Classification Based on direction of force - Anterior dislocation – most common (95%) humeral head dislocated anteriorly according to position of humeral head it is subdivided into Subcoracoid Subglenoid Subclavicular intrathoracic

7. Classification Posterior dislocation- 5% Inferior dislocation- rare

8. Risk factor Factors that influence the probability of recurrent dislocations are- Age- youngr the age more the chance of recurrence, Return to contact or collision sports. hyperlaxity, a significant bony defect in the glenoid or humeral head.

9. Pathoanatomy No essential lesion for every dislocation. There are pathological changes in stabilizing components. Hyperlaxity of the capsule- due to collagen vascular disease or microtrauma. Tears of the capsulolebral complex. Bony defect of the glenoid or humerol head.

10. Ligament injury or laxity. There are secondary changes wth repeated dislocation. Like Erosion of the anterior glenoid rim, stretching of the anterior capsule subscapularis tendon, and fraying and degeneration of the glenoid

11. Bankert lesion humeral head is forced anteriorly out of the glenoid cavity Tears the fibrocartilaginous labrum from almost the entire anterior half of the rim of the glenoid cavity and the capsule and periosteum from the anterior surface of the neck of the scapula. This traumatic detachment of the glenoid labrum has been called the Bankart lesion . Single most imp factor in ant recurrent dislocation

12. Classification Based on duration- Acute dislocation- less than 6 weeks duration Chronic dislocation- more than 6 weeks Recurrent dislocation

13. History The history important in recurrent instability of the shoulder joint The amount of initial trauma, if any, should be determined. High-energy traumatic collision sports and motor vehicle accidents are associated with increased risk of glenoid or humeral bone defects. Recurrence with minimal

14. history of repeated microtrauma. Position at which dislocation occurs.

15. Clinical feature Pain may be absent. Swelling Attitude of the shoulder- shoulder abducted and external rotation ( anterior dislocation) Prominent acromion Loss of contour Loss of range of motion .

16. Physical examination Both shoulders should be thoroughly examined, with the normal shoulder used as reference. Asymmatry or atrophy of shoulder, Tenderness over ant and post. Capsule and rotator cuff and AC joint. Examination of rotator cuff and muscles Neurovascular examination.

17. Clinical tests Duga’s test – difficulty to touch the opposite shoulder Callaway’s test – increase circumference of the axilla compared to opposite side Hamilton ruler test – normally ruler placed over the lateral aspect of arm will not touched acromion & lateral epicondyle simultaneously but here it can

18. HAMILTON RULER TEST CALLAWAY’S TEST DUGA’S TEST

19. Shift and load test one hand placed along the edge of the scapula to stabilize it and grasping the humeral head with the other hand and applying a slight compressive. Anterior and posterior translation is measured.

20. Sulcus test Done in 0 and 45 degree abduction. Done by pulling distally and observing for sulcus.

21. Apprehension test Positive reaction indicated by an apprehension reaction by patient

22. Other tests Anterior drawer test- done in various degree od abduction and external rotation. Jobes relocation test. Beighton hyperlaxity scale .

23. investigations X-rays shoulder– AP AXILLARY SCAPULAR Y VIEW Special views West point view – to see the Bankart’s lesion Stryker notch view – to see the Hill Sach’s lesion AP in internal rotation- bankert lesion.

24. West point view

25. Styrker notch view

26. NORMAL DISLOCATION

27. CT scan CT with three dimensional view m ost sensitive test for detecting and measuring bone deficiency or retroversion of the glenoid or humerus . also indicated for evaluating recurrences that occur with trivial trauma, low angle instability, and failed surgical procedures .

28. MRI- imp. For shoft tissue pathology. Arthrgraphy - xray or CT arthrography can show capsular laxity, tear, soft tissue abnormality and bony abnormality . Examination under anaesthesia sometime help in clinical diagnosis.

29. treatment Mostly surgical Non operative treatment done in case- Old low demanding patient Hyperlaxity due to collagen vascular disease Muscle strengthening and avoiding vulnarbale position

30. TREATMENT Reduction technique Hippocratic technique

31. Treatment Stimson (gravity aided) technique

32. Treatment Kocher’s maneuver – TEAI T – TRACTION E – EXTERNAL ROTATION A – ADDUCTION I – INTERNAL ROTATION

33. Surgical Treatment Lots of operative procedure have been described But no single best procedure Choice of procedure depends on-( has a low recurrence rate has a low complication rate has a low reoperation rate,

34. 4 ) does no harm ( arthritis) 5 ) maintains motion 6 ) is applicable in most cases 7 ) allows observation of the joint 8 ) corrects the pathological condition 9 ) is not too difficult.

35. Can be done open or arthroscopy Repairable defects – arthroscopic procedures Bankart and capsular plication preferred Open procedure Jobe capsulolabral reconstruction or NEER capsular shift preferred. For glenoid bony defect – Laterjet procedure

36. Humeral head defect- Moderately sized treated with arthroscopic remplissage procedure and bankart repair Larger defect(35-45%)- Laterjet procedure

37. Bankart operation Subscapularis and shoulder capsule open vertically Lateral leaf of capsule reattach to anterior glenoid rim Medial leaf of capsule imbricated

38. Laterjet procedure Coracoid process is devided at the junction of horizontal and vertical portion Vertical part is transferred to antero - inferior part of glenoid rim Additional iliac graft can be done for bony defect Post OP care immobilization in a sling for 2 weeks Forward flexion is begun thereafter External rotation started at 6 weeks

39. Laterjet procedure Post OP care immobilization in a sling for 2 weeks Forward flexion is begun thereafter External rotation started at 6 weeks Strengthening exercise at 8 weeks

40. THANK YOU