The shoulder dislocation:

Definition:
 It is separating the head of the humerus from the
glenoid cavity of scapula.
 It is most common joint dislocated.
 It is can be complete {dislocation}or
partial{subluxation}.
Causes:
1) trauma as {motor cycle accidents}.
2) Falls as {from ladder,……}.
3) Sport injuries as {football - hockey}.
4) Brachial plexus injury.
5) Poor stretching exercise.
6) Neurological disorders as {hemiplegia,……}.
7) congenital.
Classification:
 It is classified according to the direction of displaces
and mechanism of injury as:
1) Anterior dislocation:
_It is most common type which over 85% of shoulder
dislocation is anteriorly.
_Usually occurs when the arm is over abduction and
external rotation.
_The humeral head palpable anteriorly.
_The axillary nerve is most common injured with this
type.
2) Posterior dislocation:

_10% of shoulder dislocation is posteriorly.

_Usually occurs when the arm is over abduction and
internal rotation.
_The humeral head palpable posteriorly.
3) inferior dislocation:
 _5% of shoulder dislocation is inferiorly.
_Usually occurs when the arm is excessive abduction
and pushing the hand inferiorly.
_There is increase space between the head of the
humerus and acromion process in the scapula.
4) Multi directional dislocation:
_Includes:
A)Anterior – inferior.
B)Posterior – inferior.
Clinical pictures:
A)The Early signs:
1-Seven lain.
2-Bruising.
3-Tenderness.
4-Swelling and warmth.
5-Redness.
6-Visibly deformity.
 7-Inability to use the shoulder.
8-Muscle spasm in the muscles that surrounded the
shoulder joint.
B)The Later signs:
1-Weakness of the shoulder girdle muscle.
2-The weakness maybe extend to the elbow and grip
muscle.
3-Decrease the neuromuscular co-ordination in the
upper limp.
4-Contractures of the soft tissues that surrounded the
shoulder joint.
5-Joint stiffness.
6-Hand edema.
*Complication:
 1-Tearing of the muscles, tendons, ligaments, capsule,
cartilage or labrum.
2-Bcachial plexus injury especially the axillary nerve
injury:
 Loss of sensation or numbness in the deltoid muscle
region.
 Paralysis or paresis of the deltoid and teres minor
muscles.
3-Axillary blood vessels injury.
4-Recurrent shoulder dislocation after primary
dislocation.
*Diagnosis:
1-History of injury.
2-Clinical pictures.
3-Physical examination and special testing.
4-X-ray.
5-US.
6-MRI.
7-Arthrogram.
*Treatment:
A)Non operative management:
_Closed reduction.
 _ Immobilization with sling.
_ Medication as:
1) NSAIDS.
2) narcotics for 5-7 days.
_ PT.
B) Operative management:
_ Open reduction.
_ Repair the surrounded structures injuries.
_ Immobilization with splint.
_ Medications.
_ PT.
*Physiotherapy:
_The program will vary in length depending to several
factors:
1) Severity of injury.
2) Acute versus chronic condition.
3) ROM / strength status.
4) Performance / activity affected.
The physiotherapy aims and procedures during all
stages management:
A. Stage 1 { 1-2 weeks }:
1-Reduce the pain and inflammation signs by:
_ Rest with support as shoulder sling.
 The sling used for 1-4weeks dependent to the
condition and inflammatory signs.
_ Cold back.
_ US{mechanical effect}.
_ Compression by bandage.
_ Elevation to prevent the hand edema.
_ Can use taping.
2-Avoid the positions of the shoulder that increase the
risk of recurrent dislocation as:
 Abduction and external rotation.
 Abduction and internal rotation.
 Pull the upper limb downward.
3-Exercise for the joints awayfrom the shoulder as:
A)Elbow motion:
_The exercise is passive and progress to active.
_You can not training the elbow flexion above 130
degree .
B)Wrist and grip strengthening exercise.
B-stage 2 { 3-4weeks }:
_Same the procedures of stage 1 but you are added
the following:
1-Elbow strengthening by:
_Free active exercise or active resisted exercise with
low resistance.
2-Shoulder motion:
_Begin with codman pendulum exercise.
_Passive ROM exercise but:
A)You cannot training the shoulder flexion above 140
degree.
B)You cannot training the shoulder external rotation
above 40 degree.
_Isometric exercise for shoulder joint with elbow 90
degree flexion which includes.
 Shoulder flexion, internal rotation and external
rotation.
Note: you are must the stability the head of the
humerus during isometcic exercise.
C- Stage 3 { 4-8weeks }:
1-Reduse the pain and improvement the healing by:
_TENS/DDC.
_ IF.
_ US
_ Liser therapy.
_ Stop cold back.
_Stop sling if there is not axillary nerve in jury.
2-Strengthening exercise for elbow and wrist.
3-Shoulder exercise as:
_Passive ROM exercise but no above 160 degree
shoulder flexion and 70 degree external rotation.
_Theraband exercise permit concentric and
eccentric strength of the shoulder muscle includes
flexion, abduction, internal and external rotation.
_Progressive to light isotonic dumbbell exercise for
same shoulder muscle.
 _Initiate deltoid strengthening in the 90 degree
elevation.
_Use F.S for strength the deltoid muscle if it is not
contraindication.
D- Stage 4 { 8-12weeks }:
1-TENS / DDC if are allow to use.
2-Improvement the healing and relaxation of the
soft tissues contractures by:
_S.W.D or M.W.D if are not contraindication.
_Moist heat therapy if are not contraindication.
3-Improvement the shoulder strength by:
_Strengthening exercise for rotator cuff scapula
muscle and deltoid muscle.
4-Restore the normal ROM by:
_Stretching exercise.
_Hold-relax technique PNF.
5-Improvement the co-ordination by:
_PNF pattern with theraband or weight.
_Co-ordination exercise.
6-Improvment the endurance by:
_dumbbell exercises.
_Shoulder wheel.
7-Correct shoulder posture by:
_Mirror way.
_Weight in the unaffected upper limb.
8-Restore the normal ROM by:
_Stretching exercise.
_Hold-relax technique PNF.
9-Education the patient to home program as:
_Self stretching exercise.
_Theraband exercise.
 _Wight bearing exercise.

Doctor{Ahmed al-jobarii}