Shoulder dislocation with physiotherapy management

It discribes all Shoulder dislocation and its physiotherapy and surgical treatment

1. Shoulder dislocation with physiotherapy management

2. introduction This is the commonest joint in human body to dislocate. More comon in adults. Anterior dislocation is much more common.

3. Types of shoulder dislocation Aanterior Posterior Luxatio erecta( erect dislocation)

4. Anterior dislocation The most common mode of injury is fall on out stretched hand with limb in lateral rotation. In this position the head of the humerus is thrust against the thightened Anterior capsule which gets torn or avulsed from bone .

5. Lateral rotation Lateral rotation of the arm is particularly important in causing this injury rather than abduction. In this type of dislocation the position of head of humerus may slip to one of the following: Subcoracoid Subglenoid Subcvicular

6. Subcoracoid : Most common type of dislocation. The dislocated humeral head comes to lie anteriorly below the coracoid process.

7. Subcarocoid dislocation

8. Subglenoid: The head of the humerus passes through the lower part of the capsule and remain beneath the glenoid cavity. Subclavicular: Rarely, the head of humerus occupies a position just below the clavicle.

9. Subglenoid dislocation xray:

10. Recurrent anterior dislocation of shoulder It occurs by repeated dislocation of Shoulder jt. Following one episode of acute dislocation . occurs due to failure of healing of torn avulsed capsule anteriorly because of inadequate treatment during first episode. The repeated dislocations usually require less violence and therefore the subsequent dislocations occur when the arm is externally rotated And abducted during the routine movemens of playing and dressing.

11. There are two types of lesions which may occur during anterior dislocation of the shoulder: bankart’s lesion : Hill-sachs lesion :

12. 1. Bankart’s lesion The avulsion of the glenoid labrum and anterior capsule creates a pouch anterior to the neak of scapula into which the humeral head slips with every dislocation . 2 . hill- sachs lesion: It is deffect in the posterolateral quadrant of the head of tbe humerus . It caused by the anterior edge of the scapula when the dialocated head impiges against glenoid.

13. Hill-sachs lesion:

14. Hill-sachs lesion x-ray:

15. Posterior dislocation Less common Caused by direct blow on the front of the shoulder with the arm in internal rotation, e.g.during electroconvulsive therapy or epileptic attack or severe electrial shock.

16. This injury is often missed even on x-ray,so careful examination of x-ray is needed. Loss of external rotation. CT scan may be diagnostic.

17. Posterior dislocation x-ray:

18. Laxatio erecta It occurs in rare cases. Occurs when limb is strongly abducted E.g. Holding a branch of a tree with arm in wide abduction while falling down From tree. As a result of injury the head of humerus is pushed down underneath the glenoid and the arm is held

19. continued..... Fixed in wide abduction-elevation almost by the side of the head.

20. Luxatio erecta x-ray:

21. Diagnosis: ◆Presenting complaints: The pt.enters the casulty with his shoulder abducted and the elbow supported wirh opposite hand.

22. Also pain is present. inability to move the Shoulder. there may be a history of similar episodes in the past.

23. ◆ On examination: The pt. Keeps his arm abducted. the normal contour of the shoulder jt. Is lost, and it becomes flattened. on carefully inspection , fullness below the clavicle Is noticeable, due to the displaced head. It is felt by rotating the arm.

24. The pt. Resists any attempted movt. Of abduction and external rotation. This is called apprehension sign. Dugas test: Pt’s position: sitting. And instruct him to touch the opposite Shoulder and bring the elbow to the chest wall. Positive test:inability to touch the opposite Shoulder, because of pain . Which indicates anterior dislocation of humeral head.

25. Dugas test:

26. Hamilton ruler test : Because of flattni g of tbe Shoulder, it is possible to place a ruler on the lateral side of the arm. The ruler touches the acromion and lateral Condyle of humerus simultaneously. x-ray are also used for diagnosis.

27. Normal side Affected side

28. ◆treatment: It has three phases; ∆ Reduction ∆ Immobilization phase ∆ Mobilization phase

29. ◆ Reduction: It is done under sedation or general anesthesia. There are two techniques of reduction of Shoulder dislocation: Kocher’s monoeurve: Hippocrates monoeurve :

30. Kocher’s monoeurve: This is the most commonly used method. Traction- with elbow flexed to a right angle steady traction is applied along the long axis of the humerus. External rotation of the arm adduction Internal rotation of the arm

31. 1 2 2 3 4

32. Hippocrates manoeuvre: In this method surgeon applies a firm and steady pull in the semi-abducted arm. He keeps his foot in the axilla against tbe chest wall. Head of the humerus is levered back into position using the foot as a fulcrum.

33. ◆ Imobilisation : In chest arm bandage. For 3 weeks. ◆ mobilization : After bandage is removed , pt. can move the Shoulder.

34. Complications: Fracture of the greater tuberosity or surgical neak of humerus. Supraspinatus tendinitis. Rotator cuff injury . Injury to the axillary nerve during reduction. Recurrent anterior dislocation of Shoulder.

35. Surgical Operation: ◆ Putti-platt operation: Procedure: in this procedure the subscapularis muscle is divided along with the anterior capsule and it is sutured back by overlapping(double breasting) both the divided edges of the subscapularis muscle along with rhe capsule. capsuloraphy Drawback of tbis procedure is there is loss of external rotation.

36. Indication: it is indicated for pts with unidirectional anterior shoulder instability. Evaluation of outcomes and biomechanics suggests that this procedure is rarely indicated. Contraindication :it only repairs anterior instability. Glenohumeral arthritis . Any limitation in external rotation preoperatively may exacerbate by this Procedure.

37. Technical consideration: Athletes and laborers requiring normal range of motion in external rotation And are limited with this procedure. This procedure also limits the use for throwers and overhead athletes . The applicability of this procedure is reduced because of loss of external rotation .

38. Bankart’s operation: Procedure:the goal of procedure is to reattach and thighten the torn labrum and ligament of the jt. This is technically demanding procedure. It becomes simpler with the use of special fixation device called anchors.

39. Bristow’s operation: Procedure : in this procedure the coracoid process along with its attached muscles, is osteomized at the base and fixed to lower half of the anterior margin of tbe glenoid. Musxles attached to the coracoid provide dynamic anterior support rto the head of humerus.

40. Arthroscopic benkart repair: Now days repair of benkart’s lesion is done arthroscopically. Minimal invasive surgery. Definite advantage. The post operative morbidity is less and rehabilitation is faster. lower complication rate than open repair procedure.

41. physiotherapy management Basic objective: To regain full range of active movements of Shoulder. Early return of movements of abduction and external rotation.

42. ∆ During immobilization: first 3 weeks only wrist and finger movements are possible because the arm is strapped to the trunk in position of adduction and internal rotation. So exercises at this phase are: * Strong resistive movement at wrist and finger. * isometric contractions can safely be instituted to the deltoid, biceps, and triceps. s

43. ∆ Mobilization: after 3 weeks After Removal of strapping the limb is supported in a sling. Elbow should be mobilized to the full extent by removing the sling intermittently. Then mobilization of the shoulder flexion-extension should be initiated as a small range pendular swinging movt. In forward stoop position.

44. continued.... Initiation of Shoulder abduction and external rotation: as this two are instrumental in causing redislocation they have to be initiated with atmost care and adequate stabilization at GH jt. Initial aim should be relaxed passive abduction up to 45 degrees.this is done in supine wirh arm in internal rotation.

45. External rotation Should also be initiated in supine with arm adducted by the side of the body, and pt have to do external rotation up to 45 degree. Relaxed passive movts. To the Shoulder should be carried out to the full or near normal range at the earliest, to avoid adhesive capsulitis. Self assisted relaxed movts. With wand in supine lying are also helpful at this stage.

46. Once good passive range is attained, regimen of strengthening is begun. Self-resisted isometric and slow isotonic movt. Should be taught as a home treatment programme. Dumbells could be used as a resistive device. 90% of full range is achieved by 6-8 weeks following dislocation. Heavy resistive exercise, passive stretching, and forced external rotation and abduction are safe after12 weeks.

47. It may be difficult in some pts. To achieve the terminal range of abduction- elevation and external rotation this could be painful and needs to be facilitated by a suitable thermotherapy adjunct. But majority of pts. get full function by 12 weeks following injury. Physiotherapy also play very important role in preventing recurrent anterior dislocation.

48. Preventive regime of Physiotherapy: Principle objective of physiotherapautic management: To strenghen the ligaments and muscles crossing the shoulder jt. to iptimum level. To regain full passive ROM of all the movts. ∆ Strenghning procedure: to be successful, it needs several repitations. Teach the Pt. Self resisted eccentric, as well as isometric contractions for all the shoulder movts.

49. The exercise should be taught in standing or sitting So they can be conveniently performed several times. Weighted dumbells or weight belts may also be used as resistive device. ∆ To achieve and maintain full range passive motion: The arc of movts. Of abduction-elevation, flexion-elevation and external rotation need to be done gradually and carefully.

50. Extra care should be taken during the terminal range of elevation and external rotation. As adequate stabilization of Shoulder girdle facilitates relaxation of gh jt, pt. Should be advised to get some assistance at home while performing these movts. Surgically managed pts:the regime of physiotherapy for the pts. treated with surgery proceed same as for ‘anterior dislocation’.

51. The main difference is the secured safety of performming movments It needs hard effort to achieve active terminal range in external rotation and elevation. Usually extreme level of external rotation remain deficient. Strong and functional shoulder can be achieved with in 10 to 12weeks.

52. Refrence: Eessentials of orthopedics and applied physiotherapy: jayant joshi;second edition Essential of orthopedics:maheshwari and mahaskar;5 th edition

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