Shoulder dislocations - orthopedics.pptx

This ppt aims to help you with shoulder dislocations in a concise way. It covers the basics, types, classifications, displacements, diagnosis, evaluation and management (conservative and operative) of the shoulder dislocations.

1. DISLOCATIONS OF THE SHOULDER Dr. Saumya Kine MPT, COMT

2. DISLOCATION OF THE SHOULDER This is the commonest joint in the human body to dislocate. It occurs more commonly in adults and is rare in children. Anterior dislocation is much more common than posterior dislocation . Shoulder instability is a broad term used for shoulder problems , where head of the humerus is not stable in the glenoid . It has a wide spectrum - from minor instability or a loose shoulder to a frank dislocation. In instability, the patient may present with just pain in the shoulder , more on using the shoulder. Pain occurs due to stretching of the capsule, as the head 'moves out‘ in some direction without actually dislocating.

3. A patient with frank instability may present with an abnormal movement of the head of the humerus . This could be subluxation ( partial movement) which gets spontaneously reduced to a dislocation . Subluxation: articular surfaces only partly displaced but retain some contact b/w them. Dislocation: articular surfaces completely displaced such that all contact is lost The instability may be unidirectional or bidirectional or may be in multiple directions – anterior, inferior, posterior, where it is called multi- directional instability (MDI).

4. MECHANISM A fall on an out- stretched hand with the shoulder abducted and externally rotated, is the common mechanism of injury. Occasionally, it results from a direct force pushing the humerus head out of the glenoid cavity. A posterior dislocation may result from a direct blow on the front of the shoulder, driving the head backwards. More often, posterior dislocation is the consequence of an electric shock or an epileptic form convulsion.

5. PATHOANATOMY Classification: They are following types: Anterior dislocation : In this injury, the head of humerus comes out of the glenoid cavity and lies anteriorly. It may be further classified into three subtypes depending on the position of the dislocated head. Preglenoid : The head lies in front of the glenoid . Subcoracoid : The head lies below the coracoid process. Most common type of dislocation. Subclavicular / Infraclavicular : The head lies below the clavicle.

6. Classification: b) Posterior dislocation : In this injury, the head of the humerus comes to lie posteriorly behind the glenoid . c) Luxatio erecta (inferior dislocation): This is a rare type, where the head comes to lie in the subglenoid position. PATHOANATOMY

7. Pathological changes: The following pathological c hanges occur in the commoner, anterior dislocation: Bankart's lesion : Dislocation causes stripping of the glenoidal labrum along with the periosteum from the antero- inferior surface of the glenoid and scapular neck. In severe injuries, it may be avulsion of a piece of bone from antero- inferior glenoid rim, called bony Bankart lesion . Hill-Sachs lesion: This is a depression on the humeral head in its postero -lateral quadrant , caused by impingement by the anterior edge of the glenoid on the head as it dislocates. Rounding off of the anterior glenoid rim occurs in chronic cases as the head dislocates repeatedly over it. There may be associated injuries: like fracture of greater tuberosity, rotator-cuff tear, chondral damage etc.

8. DIAGNOSIS Presenting complaints: The patient will have his shoulder abducted and the elbow supported with opposite hand. There is a history of a fall on an out- stretched hand followed by pain and inability to move the shoulder. There may be a history of similar episodes in the past. On examination: The patient keeps his arm abducted. The normal round contour of the shoulder joint is lost, and it becomes flattened. On careful inspection, one may notice fullness below the clavicle due to the displaced head. This can be felt by rotating the arm.

9. On examination: The following are some of the signs, associated with anterior dislocation: Dugas ' test : Inability to touch the opposite shoulder. Hamilton ruler test : Because of the flattening of the shoulder, it is possible to place a ruler on the lateral side of the arm. This touches the acromion and lateral condyle of the humerus simultaneously. The diagnosis is easily confirmed on an antero - posterior X- ray of the shoulder. An axillary view is sometimes required.

10. Posterior dislocation usually occurs following a convulsion. There are few symptoms and signs. This injury is often missed even on X- ray. A clinical examination eliciting loss of external rotation, and a careful look at the X- ray may help diagnose these cases. CT scan may be diagnostic. TREATMENT Treatment of acute dislocation is reduction under sedation or general anaesthesia, followed by immobilization of the shoulder in a chest- arm bandage for three weeks. After the bandage is removed, shoulder exercises are begun.

11. TECHNIQUES OF REDUCTION OF SHOULDER DISLOCATION K OCHER’S manoeuvre : Mo st commonly used method. Ste ps (TEA M ) are as follows: Traction : with the elbow flexed to a right angle steady traction is applied along the long axis of the humerus External rotation : the arm is rotated externally Adduction : the externally rotated arm is adducted by carrying the elbow across the body towards the midline; and Internal rotation : the arm is rotated internally so that the hand falls across to the opposite shoulder. After Treatment: After the reduction, the arm should be fastened to the chest with a body bandage for a minimum period of three weeks. Failure to do this leads to the development of recurrent dislocation of the shoulder due to the faulty healing of the capsular rent.

12. H IPPOCRATES manoeuvre: In this method, a firm and steady pull on the semi- abducted arm is applied by keeping foot in the axilla against the chest wall. The head of the humerus is levered back into position using the foot as a fulcrum. Stimson’s gravity method / with weights

13. Early complications: Injury to the axillary nerve may occur resulting in paralysis of the deltoid muscle, with a small area of anaesthesia over the lateral aspect of the shoulder. The diagnosis is confirmed by asking the patient to try to abduct the shoulder. Though shoulder abduction may not be possible because of pain, one can feel the absence of contraction of the deltoid. Treatment is conservative, and the prognosis is good. Late complications: The shoulder is the commonest joint to undergo recurrent dislocation . This results from the following causes: anatomically unstable joint inadequate healing after the first dislocation an epileptic patient.

14. RECURRENT DISLOCATION OF SHOULDER (RDS) This is a very common complication of anterior dislocation of shoulder and accounts for greater than 80% of dislocations of the upper extremity. ( One in every three anterior dislocation of shoulder becomes recurrent dislocation of shoulder) Causes Failure to immobilize the shoulder for 3 to 4 weeks after initial dislocation. Size and nature of damage at the time of initial dislocation. Greater the trauma, lower the incidence. Younger the patient, less is the recurrence.

15. CLINICAL FEATURES Usually, the patient gives history of a previous episode of traumatic dislocation. After that, there could be one or two instances of repeated dislocations during abduction. The clinical features and the presentation will be like in anterior dislocation of shoulder but the far less severity. There could be wasting of deltoid, supraspinatus and infraspinatus muscles. Clinical Tests: 3 tests help to identify instability of the shoulder prone to develop RDS: The sulcus test with the arm hanging at the side stabilize the scapula from behind and pull the humerus down. A large gap appears beneath the acromion. This suggests inferior laxity and is a test for superior glenohumeral and coracohumeral ligaments. The apprehension test: This is a provocative test where if the arm is placed in abduction, extension and external rotation and if a force is applied, the patient becomes apprehensive and resists the provocation. Relocation test: The joint can be dislocated and relocated back into its position by manual pressure.

16. TREATMENT Putti- Platt operation : Double- breasting of the subscapularis tendon is performed in order to prevent external rotation and abduction, thereby preventing recurrences. ( Subscapularis tendon and capsule is overlapped and tightened ) Bankart's operation : The glenoid labrum and capsule are re- attached to the front of the glenoid rim. This procedure has become simpler with the use of special fixation devices called anchors. (Detached anterior structures are attached to the rim of the glenoid cavity with suture )

17. Bristow's operation : In this operation, the coracoid process, along with its attached muscles, is osteotomized at its base and fixed to lower- half of the anterior margin of the glenoid . The muscles attached to the coracoid provide a dynamic anterior support to the head of the humerus . (Transplantation of coracoid’s process with its attachments to the anterior rim of glenoid ) Arthroscopic Bankart repair: With the development of arthroscopic techniques, it has become possible to stabilise a recurrently unstable shoulder arthroscopically. Initially it was considered suitable for cases where number of dislocations has been less than 5. But, with present day arthroscopic techniques, it is possible to stabilise most unstable shoulders arthroscopically. Apart from being a more cosmetic option, the rehabilitation after arthroscopic repair is faster and better. It is a technically demanding operation, and the anchor sutures used for repair are expensive.