SHOULDER DISLOCATION-1.pptx

How to examine

1. SHOULDER DISLOCATION PRESENTER: DR IMASIKU MODERATOR: DR MUTINTA

2. Shoulder dislocation Definition Shoulder joint anatomy Hx , Classification and clinical evaluation Diagnosis and management(reduction techniques) complications DEFINITION: shoulder dislocation is when the head of the humerus separates from the scapula at the glenohumeral joint.

3. Glenohumeral joint is a multiaxial ball and socket joint in which the head of the humerus articulates with the glenoid cavity of the scapula. GH joint is enclosed by a joint capsule that encapsulates the structures of the joint in a fibrous sheath. Synovial membrane forms the lining of the inner surface of the joint capsule & produces synovial fluid to reduce friction between the articular surfaces. Shoulder ( glenohumeral ) joint anatomy

4. Anatomy cont …

5. STABILITY OF JOINT DYNAMIC STABILIZERS Contractile tissue of the shoulder complex (tendons, muscles and tendon-muscular junctions) predominantly the rotator cuff muscles, supras.S , infra.S ., subscapularis and teres minor, maintain centralization of the humeral head during static postures and dynamic movements), proprioceptive and neuromuscular control STATIC STABILIZERS Non contractile tissue of the GH joint, important in end range-ROM(point where active mobility ends) Glenoid labrum and glenohumeral ligaments, joint capsule. MOVEMENTS OF THE JOINTS: flexion, extension, abduction, adduction, external rotation, internal rotation and circumduction

6. ANATOMY CONT … MAJOR BLOOD VESSEL : axillary artery with its branches: superior thoracic artery, thoracoacromial artery, lateral thoracic artery, subscapular artery, a. humeral circumflex artery, p. humeral circumflex artery. NERVE SUPPLY : Suprascapular, axillary, lateral pectoral nerves (branches of C5-C6 of brachial plexus)

7. HISTORY, CLASSIFICATIONS AND CLINICAL EVALUATION HX: patients may report popping sensation, sudden onset of pain with decreased range of motion or a sensation of joint rolling out of the socket post trauma. ANTERIOR DISLOCATION : acc for 96% of cases. Subcoracoid , subglenoid,luxatio erecta , subclavicular , supraglenoid , intrathoracic, fx -dislocation. Mechanism of injury is usually a blow to an abducted, externally rotated and extended extremity. It may also occur with posterior humerus force. On exam, the arm is usually abducted and externally rotated, and the acromion appears prominent, a relative hollow beneath the acromion posteriorly and a palpable mass anteriorly. There are associated injuries in up 40% of anterior dislocations including nerve damage, or tears and fractures associated with the labrum, glenoid fossa, and/or humeral head. POSTERIOR DISLOCATION : acc for 2-4% of cases. subacromial , subglenoid , supspinous . It may also be a result of violent muscle contractions (seizures, electricution ).the shoulder is typically in a position of adduction, flexion and internal rotation.

8. CLASSIFICATIONS AND CLINICAL EVALUATION CONT … On exam, the arm is usually held in adduction, and internal rotation and patient is unable to rotate externally. A palpable mass posterior to the shoulder, flattening of anterior shoulder and prominent coracoid may be observed Higher risk of associated injuries such as fractures of surgical neck or tuberosity, reverse Hill-Sachs lesions (also called a McLaughlin lesion which is an impaction fracture of anteromedial aspect of humeral head), and injuries of the labrum or rotator cuff . INFERIOR DISLOCATION : 0.5-1%. infraglenoid ( luxatio erecta ) more common in elderly. Usually caused by hyperabduction or with axial loading on the abducted arm. On exam, patient presents with characteristic “salute” the arm is held above and behind the head and patient is unable to adduct arm . The humeral head is palpable on the lateral chest wall and axilla Often associated with nerve injury, rotator cuff injury, tears in the internal capsule, and the highest incidence of axillary nerve and artery injury of all shoulder injuries.

9. DIAGNOSIS AND MANAGEMENT Clinical diagnosis. Pre-reduction imaging( AP,Scapular,axillary ) for associated Fx can be useful and should be done when trauma is known. REDUCTION OF DISLOCATED SHOULDER . -CONTRAINDICATIONS TO REDUCTION Anterior Dislocation Fractures of humeral neck can lead to avascular necrosis Subclavicular and/or intrathoracic dislocations include a subacute dislocation in an elderly patient and an associated surgical neck fracture Avoid multiple attempts in injuries that include neurovascular compromise (including brachial plexus involvement, axillary nerve, a musculocutaneous nerve, etc.).  If prompt reduction cannot occur without further injury, may need surgical help.   The suspected arterial injury may need urgent angiography first.

10. Posterior Dislocation Delayed presentation to the emergency department (more than 6 weeks) Multipart or displaced fracture/dislocations Inferior Dislocation Humeral neck or shaft fractures should be done in a surgical setting Any potential of vascular injury

11. Reduction techniques for anterior shoulder dislocation Scapular Manipulation   (80% to 100% successful) Upright or prone Stand behind patient and use one thumb over tip of scapula and push medially while pushing acromion inferiorly with the other thumb Assistant simultaneously provides traction by grabbing patient’s wrist with one hand and flexed elbow with other hand and pushing down on elbow

12. External Rotation Technique   ( hennepin ). Easy and can do alone With patient supine, elbow flexed to 90 degrees, elbow held with one hand, and wrist is held with another hand Slowly allow the arm of the patient to fall to the side, externally rotating the forearm, as the arm externally rotates, reduction occurs. Reduction usually occurs with arm externally rotated between 70 to 110 degrees.

13. Milch Technique   (add Milch technique if external rotation unsuccessful) Patient is supine, fingers over the shoulder with thumb in axilla to stabilize Arm is externally rotated and then abducted over patient’s head while maintaining external rotation with simultaneously placing direct pressure over the humeral head

14. Cunningham Technique Patient is seated with examiner seated in front of patient, and the patient places ipsilateral hand on top of examiner’s shoulder The clinician rests one arm in patient’s elbow crease and uses the other hand to massage the patient’s biceps, deltoid, and trapezius muscles Have patient relax and instruct to pull their shoulder blades together and straighten their back

15. REDUCTION TECHNIQUES Stimson Technique No assistant needed and no need for conscious sedation Patient is prone with affected arm hanging off the side of bed with 5 lb (2.3 kg) to  15 lb (6.8 kg) of weight Reduction is usually achieved within 30 minutes Traction Countertraction A sheet is wrapped under the axilla, and one assistant provides continuous traction at the wrist or elbow while the other provides countertraction with the sheet from the opposite side

16. Stimson and traction- countertraction

17. Reduction techniques Spaso Technique Patient is supine while examiner grasps wrist or distal forearm and lifts vertically with gentle vertical traction and external rotation Fares Technique Patient is supine with upper extremity at their side The examiner holds patient’s wrist and gently pulls the arm to provide traction The arm is abducted while continuously moving arm in anteriorly and posteriorly in small oscillating movements (about 10 cm) If shoulder has not reduced by 90 degrees of abduction, add external reduction

18. Reduction techniques Fulcrum Technique Patient is supine or sitting, and a rolled towel or sheet is placed in axilla The distal humerus is adducted with simultaneous posterolateral force on the humeral h Requires increased force, may have increased complications Kocher’s: the elbow is bent to 90° and held close to the body; no traction should be applied. The arm is slowly rotated 75 degrees laterally, then the point of the elbow is lifted forwards, and finally the arm is rotated medially. This technique car- ries the risk of nerve, vessel and bone injury and is not recommended. Hippocratic Technique: place heel into patients axilla and apply traction to the arm, foot acts as a lever to push the humeral head laterally.

19. Reduction techniques

20. REDUCTION TECHNIQUES Ater reduction limb is immobilized for 2-5 weeks. Younger patients with hx of reccurent dislocation may require longer period of immobilization. Neurovascular exam Post-reduction imaging Follow up with orthopedics COMPLICATIONS ANTERIOR DISLOCATION: early: Hills- sachs lesion, bankart lesion, greater tuberosity fratures , acromion or coracoid fx ., soft tissue injuries rotator cuff tear, Vascular injuries, nerve injuries. Late: shoulder stiffness, unreduced dislocation.recurrent dislocation. POSTERIOR DISLOCATION: Fractures, reccurence , anterior subluxation.

21. THANKYOU. References: Abrams R, Akbarnia H. Shoulder Dislocations Overview. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Miniato MA, Anand P, Varacallo M. Anatomy, Shoulder and Upper Limb, Shoulder. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Kammel KR, El Bitar Y, Leber EH. Posterior Shoulder Dislocations. [Updated 2022 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan- . Apleys System of orthopaedics and fractures 9 th edition