Shoulder dislocation: Types and Management Methods of Reduction

A Brief overview of Anatomy, Radiographics and Closed Reduction Maneuvers

1. Shoulder Dislocation Types and Management Methods of Reduction Dr. Uzair Ahmed

2. 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. 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.

3. Epidemiology ~1.7% population Bimodal distribution: Men in 20-30 yo (M:F 9:1) Women 61-80 (M:F 1:3) Less in children as their epiphyseal plate is weaker and tends to fracture before dislocating. More common in elderly as the collagen fibres have fewer cross links weaker capsule / tendons / ligaments.

4. Anatomy: Glenohumeral stability depends on both passive and active mechanisms, including : Passive : Joint conformity Vacuum effect of limited joint volume . Adhesion and cohesion owing to the presence of synovial fluid. Scapular inclination : zero to thirty degrees Glenoid labrum Bony restraints Coracoid, Acromian and Glenoid Fossa Ligamentous and capsular restraints Joint capsule Superior, middle and inferior GLENOHUMERAL LIGAMENTS CORACOHUMERAL LIGAMENT

5. . ■ Active: Biceps, long-head Rotator cuff Scapular stabilizing muscles

6. Pathoanatomy of shoulder dislocations: Stretching/ tearing of capsule Avulsion of glenohumeral ligaments usually off the glenoid Labral injury Bankart lesion Impression fracture Hill- Sach lesion Rotator cuff tear

7. BANKARTS LESION Seen in anterior dislocation. Stripping of glenoid labrum along with periosteum . Antero inferior Surface of glenoid and sca p ular neck. Avulsion of anteroinferior Glenoid rim causes Bony Bankart Lesion.

8. CT Reconstruction

9. HILL SACHS LESION Depresson on humeral head in its postero lateral quadrant Due to impingment by the anterior edgeof glenoid on the head as it dislocates

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

11. Mechanism of Injury COMMONEST :Fall on an outstretched hand wiith the shoulder abducted and externally rotated. POSTERIOR DISLOCATION:by direct blow from the front of the shoulder or from epileptiform convulsions or electric Shock.

12. ANTERIOR DISLOCATION POSTERIOR DISLOCATION

13. Clinical Picture Pain Holds injured limb with other hand close to trunk The shoulder is abducted and the elbow is kept flexed

14. 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

15. POSTERIOR SHOULDER DISLOCATION (adducted and internally rotated arm) ANTERIOR DISLOCATION (Slight abducted and internal rotated arm) INFERIOR DISLOCATION

16. Radiographic Evaluation Trauma series of the affected shoulder: Anteroposterior (AP ), Scapular-Y , and A xillary views taken in the plane of the scapula

17. VELPEAU AXILLARY VIEW If a standard axillary cannot be obtained because of pain, the patient may be left in a sling and leaned obliquely backward 45 degrees over the cassette. The beam is directed caudally, orthogonal to the cassette, resulting in an axillary view with magnification.

18. West Point axillary: This is taken with patient prone with the beam directed cephalad to the axilla 25 degrees from the horizontal and 25 degrees medial. It provides a tangential view of the anteroinferior glenoid rim.

19. Stryker notch view : The patient is supine with the ipsilateral palm on the crown of the head and the elbow pointing straight upward. The x-ray beam is directed 10 degrees cephalad , aimed at the coracoid. This view can visualize 90% of posterolateral humeral head defects.

20. Computed tomography may be useful in defining humeral head or glenoid impression fractures,loose bodies, and anterior labral bony injuries ( bony BANKARTS LESION ) Single- or double-contrast arthrography may be utilized to evaluate rotator cuff pathologic processes . Magnetic resonance imaging may be used to identify rotator cuff, capsular, and glenoid labral ( Bankart lesion) pathologic processes.

21. Anteri o r:  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.

22. Other  POSTERIOR:  Different mechanisms: seizure, electrocution.  Present with flattened anterior shoulder and prominent coracoid.  Can easily go unrecognised.  INFERIOR: ‘luxation erecta’  Hyperabduction injury.  High rate of vascular, nervous, ligament, tendon injuries.

23. Anterior Dislocation of Shoulder

24. Inferior Dislocation

25. Posterior Dislocation

26. 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

27. Reduction Maneuver's Traction- countertraction method Hippocrates method Stimpson’s technique Kocher’s technique Milch Technique Scapular Manipulation

28. 1. 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.

29. Traction-countertraction

30. Traction-countertraction

31. 2. Hippocrates Method

32. Hippocrates Method

33. Hippocrates Method

34. 3. Stimpson’s 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.

35. 4. KOCHERS MANOUEVRE I)Traction –with the elbow flexed at right angle ,steady traction applied along long axis of humerus II)External Rotation III)Adduction IV)Internal Rotation

36. 5. 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.

37. 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.

38. POST REDUCTION:  Ortho f/u in ~1/52.  COMPLICATIONS:  Recurrent dislocation:  approx 50 – 90% patients under 20  Approx 5 to 10% of patients over age 40  ? Ways to prevent redislocation: position of immobilization, increasing the duration of immobilization, physical therapy, and operative repair.  Mobilisation:  <30 – immobilise 3 weeks.  >30 – begin mobilisation after one week.  Position: internal rotation and adduction vs. 10 degrees external rotation (anatomically sound but evidence not support benefit).