Shoulder dislocation

Anatomy and Types

1. Shoulder Dislocation Created by-Vaibhav Kushwaha Tabish Parkar Guided By Dr.Hashini Karunadhara

2. Surface Anatomy of Shoulder Joint

3. Muscles in Shoulder Joint

4. Rotator Cuff Muscles Supraspinatus(Abduction) Infraspinatus(External Rotation) Teres Minor (External Rotation) Subscapularis(Internal Rotation)

5. Bones in Shoulder Joint

6. Bursae in Shoulder Joint Subcoracoid Bursa Subacromial Bursa Subscapular Bursa

7. Movements of Shoulder Joint Flexion Extension Abduction Adduction Lateral Rotation Medial Rotation Horizontal Flexion Horizontal Extension Circumduction

8. Shoulder Dislocation Glenohumeral Instability is the Inability to maintain the Humeral head in the glenoid fossa Most unstable large joint Mobility at the expense of stability

9. Pathology The humeral head is stabilized within the shoulder joint by the glenoid labrum, a fibro-cartilaginous rim surrounding the glenoid cuff that is attached to the tendon of the long head of the biceps muscle.   A tear or a violent stretch of these structures causes the exit of the humeral head from the glenoid, making the shoulder highly unstable.

10. A shoulder dislocation can be complete or partial. In complete dislocation the head of the humerus moves entirely out of the socket, requiring medical intervention whereas in partial dislocation , also named subluxation, the head of the humerus slips out of the socket only temporarily to often returning into place spontaneously.  Both injuries can cause pain, arm weakness and swelling.

11. Reasons for Instability Shallow glenoid Extraordinary Rotation Of Muscle Vulnerability of upper limb to injury Underlying conditions eg. ligament laxity

12. Pathoanatomy of D islocation Stretching/ tearing of capsule Avulsion of glenohumeral ligaments usually off the glenoid Labral injury Bankart lesion Impression fracture Hill- Sach lesion Rotator cuff tear

13. Clinical Picture Pain Holds injured limb with other hand close to trunk The shoulder is abducted and the elbow is kept flexed Loss of the normal contour of the shoulder Anterior bulge of head of humerus may be visible or palpable Empty glenoid socket

14. What causes a dislocated shoulder? Sports injuries. Accidents, including traffic accidents. Falling on your shoulder or outstretched arm. Seizures and electric shocks, which can cause muscle contractions that pull the arm out of place.

15. Dislocated shoulder signs and symptoms may include: Severe shoulder pain Swelling and bruising of your shoulder or upper arm Numbness and/or weakness in your arm, neck, hand, or fingers Trouble moving your arm Your arm seems to be out of place Muscle spasms in your shoulder

16. Risk Factors A previous shoulder dislocation or subluxation predisposes to a second episode of the pathology particularly in young men (incidence of 80-90%). high risk is found in athletes involved in sports such as football, rugby, hockey and skiing due to the frequent contact impacts, throwing activities and falls.  Congenital conditions causing loosening of the joints, such as  Ehlers-Danlos Syndrome  confer an intrinsic poor stability of the shoulder joint facilitating the exit of the humeral head.  Weakness of the muscles around the shoulder and core muscles due to lack of training can predispose to a dislocation. Incorrect posture and inadequate sporting technique are all contributing factors to a shoulder dislocation.

17. Diagnosis A shoulder dislocation is diagnosed clinically when significant pain, alterations in the appearance of the shoulder anatomy and impaired movement of the shoulder are present. The history of the mechanisms of injury and pre-existing conditions are discussed with the doctor and recorded Standard X-ray of the shoulder forms the first diagnostic approach to confirm the type of humeral head displacement and potentially associated injuries to the surrounding bones. Additional damage to ligaments, vessels and nerves is diagnosed by clinical examination, computer tomogram (CT) scans, magnetic resonance imaging (MRI), ultrasound and nerve conduction studies.

18. Treatment Nonoperative treatment Surgical treatment Rehabilitation

19. Nonoperative treatment closed reduction is performed usually under anaesthesia in the Emergency Department. It consists of manual reposition the humeral head in the glenoid using different methods.  This is followed by the immobilisation of the shoulder for approximately four weeks, aided by local treatment with ice and/or heat and non-steroidal antiinflammatory drugs (NSAIDs). At a later stage physiotherapy is recommended.

20. Surgical treatment Surgery is performed if a closed reduction is not successful or when a traumatic dislocation is associated with injuries to the labrum (e.g. Superior Labral Tear from Anterior to Posterior also named SLAP tear) or glenoid (Bankart lesion), damage of the humeral head (Hill-Sachs lesion) or the ligaments of the rotator cuff. These secondary pathologies produce significant shoulder instability and require surgical repair to prevent further dislocations. Various approaches are available including arthroscopic surgery and open surgery. After surgery the shoulder is immobilised for 3-4 weeks prior to commence physical therapy

21. Rehabilitation Physiotherapy is a key form of treatment following a shoulder dislocation whether or not surgery has occurred. Strengthening the muscles around the shoulder is essential for supporting the joint stability provided by the shoulder ligaments. Therapy also aims at restoring the range of motion of the shoulder following initial immobilisation . Physiotherapy consists of a number of approaches: Use of a sling Massage Joint mobilisation Ice/heat treatment Physical exercise (pendular movements) Education in sport and daily activities Ergonometric postural correction  Return to sport plan In case of persistent pain and/or movement restrictions the patient can be treated with  antiinflammatory treatment (NSAIDs) and local steroid injection

22. Prevention Take care to avoid falls. Wear protective gear when you play contact sports. Exercise regularly to maintain strength and flexibility in your joints and muscles.

23. Types of Shoulder Dislocation

24. Types of Dislocation of the Shoulder Mostly Anterior > 95 % of dislocations Posterior d islocation occurs < 5 % True Inferior dislocation ( luxatio erecta ) occurs < 1% Superior dislocation occurs <1% Habitual - Non traumatic dislocation may present as Multi directional dislocation due to generalized ligamentous laxity and is Painless

25. Anterior Dislocation 97% of recurrent dislocations It is the most common  dislocation   cause inability to abduct the arm. loss in the round contour of the shoulder. The most severe cases of anterior dislocation of the shoulder are associated with injury to the axillary artery and the axillary nerve.

26. Anterior Dislocation of Shoulder

27. Posterior Dislocation 3% of shoulder dislocations caused by an external blow to the front of the shoulder. This type of shoulder dislocation can be the consequence of a high-energy trauma and a fall due to seizures. dislocations may also have concurrent labral or rotator cuff pathology

28. Mechanism Indirect Electric shock Seizure episode Direct Force on the anterior shoulder

29. Shoulder AP view

30. Shoulder PA or Scapular Y-view

31. Inferior dislocation Inferior dislocation  is rarely seen. It is also called Luxatio Erecta It occurs when the humerus is displaced below the joint. It is caused by a traumatic impact pushing the shoulder downwards.

32. Superior dislocation Superior dislocation  is the least frequent type of dislocation (1%). It occurs when the humeral head is driven upward through the rotator cuff.  It can be associated with fracture of the humerus , clavicle and acromion.

33. Complications of Shoulder Dislocation arise in Trauma Condition

34. Complications of Shoulder Dislocation : Early Damage to Axillary Nerve Axillary Artery And Ligaments Bone - Associated fracture Neck of humerus Greater or lesser tuberosity Hill Sach lesion Bankart lesion

35. Hill-Sachs lesion   Hill – Sachs lesion , or  Hill – Sachs  fracture, is a cortical depression in the posterolateral head of the humerus . It results from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly.

36. Bankart Lesion A  Bankart lesion  is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.

37. Complications of 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

38. Maneouvers Traction- countertraction method Hippocrates method Stimpson’s technique Kocher’s technique

39. Traction-countertraction

40. Hippocrates Method c

41. Stimpson’s technique

42. Reference Gray_s Anatomy for Students 3rd Ed Moore - Clinically Oriented Anatomy 7th Ed by allmedicalstuff.com https://medlineplus.gov/dislocatedshoulder.html https://www.physio-pedia.com/Shoulder_Dislocation http://pathologies.lexmedicus.com.au/pathologies/shoulder-dislocation-and-luxation