Shoulder Dislocation

HUSNA NAJIHAH BINTI DZULKARNAIN1213828

Shoulder dislocation

• An emergency!• Failure to reduce a dislocated shoulder

successfully within the first 24 hours carries the risk that it will be impossible to achieve a stable closed reduction.

• Neurovascular injury can occur.

Types of shoulder dislocation

Anterior dislocation (>95 %)Posterior dislocation (2-4 %)

Inferior dislocation (Luxatio Erecta) (<1 %)

Anterior dislocation

Mechanism of injury:• Abduction+ external

rotation + extension injury

• Direct blow from the posterior aspect of the shoulder.

• A fall from an outstretched hand

Posterior Dislocation

– Fall on to the flexed, adducted arm

– A direct blow on the front of the shoulder

– Can occur during a fit or convulsion or with an electric shock

Associated Injuries

Anterior Dislocation

• Bankart lesion

• Hill Sach lesion

Posterior Dislocation

• Reverse Bankart

• Reverse Hill Sach lesion

History

Complain of:1) Pain over shoulder area2) Inability to move the

arm from its current position

3) Numbness of the arm.4) Visibly displaced

shoulder

+ Mechanism of injury

Physical Examination

Investigation

• X-ray findings:

AP x-ray • overlapping shadows of the

humeral head and glenoid fossa - the head is below and medial to the socket

Lateral x-ray• humeral head out of line with

the socket.

AP view

Axillary ViewEmpty glenoid sign

Posterior dislocation

AP viewElectric light bulb head

Complication

EARLY

LATE

• Rotator Cuff Tear (38 %)

• Axillary nerve injury (12%)

• Axillary artery (1-2%)• Fracture-dislocation

• Shoulder Stiffness• Unreduced

Dislocation• Recurrent Dislocation

Management

Closed reduction – sedation or general anaesthesia

If failed: open reduction

Surgical procedures for associated injuries (Bankart operation etc).

Hippocratic Maneuver- traction and countertraction

1. Patient supine on bed2. Gently increasing

longitudinal traction is applied to the arm with shoulder in slight abduction

3. Assistant applies firm countertraction to the body

Kotcher’s Method - no traction

1. The elbow is bent to 90⁰ and held close to the body

2.The arm is slowly rotated 75⁰ laterally

3.The point of the elbow is lifted forwards

4.Finally, the arm is rotated medially

http://emedicine.medscape.com/article/109130-technique#c4

Stimson’s Technique – Gravitational traction

1.Patient is left prone with the arm hanging over the side of the bed.

2.10 – 15 lb weight suspended from wrist

3.With muscle relaxation secondary to analgesia, and gravitational traction, the shoulder may reduce within 15 or 20 minutes.

Management for Post-reduction

• Post reduction x-ray for confirmation and exclude fracture

• Patient fully awake, test for active abduction (exclude axillary nerve and rotator cuff tear)

• Also test for other nerves (median, radial, ulnar) and vessels injury (pulse).

• Immobilization by using arm sling for about 3 weeks (<30 years old) or a week (>30 years old) .

• Plan for rehabilitation

Surgery

• Indication:– Failed closed reduction.– Fracture of greater tuberosity that is displaced

greater than 1cm postreduction.– Glenoid rim fractures that are displaced greater

than 5mm.

References

• Harries M., Williams C.,Stanish W.D., Michelle L.J, Oxford Textbook of

Sports Medicine,1998, Oxford Medical Publication.• Simon R.R., Koenigsknetch S.J., Emergency Orthopedics of the

Extremities, 2001, McGraw Hill.• Medscape