UPPER LIMB DISLOCATION

Presented by Elias Godfrey

Supervisor Dr Swai
20th November 2017
 OBJECTIVES
By the end of this session students should be
able to;

•Describe mechanism of injury , clinical

presentations and Diagnoses of upper limb
dislocation.
•Describes managements and complication of
upper limb dislocation
 OUTLINES
• Introduction
• Shoulder dislocation
• Elbow dislocation
• Wrist (Carpals) and Fingers dislocation
• References
 Introd…Definition
• Dislocation : Loss of congruity between the
articular surfaces of a joint.Therefore
displacement usually complete

• Subluxation; partial dislocation loss of contact

of the articulating surfaces is notable but
incomplete, may proceed to complete
dislocation.
 Mechanism of Injuries of the Upper
Limb
• Mostly Indirect

• Commonly described as “ a fall on

outstretched hand “

• Type of injury depends on position of the

upper limb at the time of impact : Flexed,
Extended, adducted, abducted, pronated or
supinated
SHOULDER JOINT DISLOCATION
 SHOULDER JOINT ANATOMY
Articulation: rounded head of humerus and glenoid
cavity of the scapula (deepened by glenoid labrum-
triangular rim of fibrocartilage)

Covered by hyaline articular cartilage

Type: multiaxial Synovial ball and socket joint

Capsule: Surrounds the joint and attached medially to

margin of the glenoid cavity, laterally to anatomic neck
of humerus (part is intracapsular)
Shoulder joint
 Articulating surfaces.Ball
• spheroidal head of humerus

• 1/3rd of a sphere

• Directed medially, upwards and backwards

• Covered by hyaline articular cartilage – thickest

in center, thin at periphery
 Articulating surfaces: Socket
• Pear shaped, small and shallow glenoid cavity of
scapula

• Directed upwards, forwards and laterally.

• Hyaline articular cartilage- thin center, thick

periphery

• Fossa deepened – glenoid labrum – fibro

cartilageneous, attached to its peripheral margin
Rotator cuff muscles:
“SITS” Are short and
close to the joint;
maintain humeral head in
glenoid fossa(Important
for shoulder stability)
 Cont..
LIGAMENTS CAPSULE
 SHOULDER DISLOCATION

• The head of the humerus becomes completely

separated from the glenoid fossa of the
scapula
• May be complicated by fracture
• Is most common joint to dislocate , while
ankle being least.
 Types of shoulder dislocation

• Anterior > 95 % of dislocations

• Posterior Dislocation occurs < 5 %

• True Inferior dislocation (luxatio erecta)

occurs < 1%
 Mechanism of injury
• Usually Indirect fall on Abducted and
extended shoulder for anterior dislocation
and adduction and internal Rotation of arm in
posterior dislocation.
• May be direct when there is a blow on the
shoulder from behind(anterior dislocation )or
front for posterior dislocation.
 History Shoulder dislocations
• May be recurrent, and if so may be trivial
history

• Trauma, force/axial loading from falls and

motor bike accidents (e.g. tackler in rugby)

• Seizures
 Clinical pictures
• Patient is in pain
• Holds the injured limb
with other hand close to
the trunk
• The shoulder is abducted
and the elbow is kept
flexed
• There is loss of the normal
contour of the shoulder
 Clinical Picture
• Loss of the contour of
the shoulder may appear
as a step

• Anterior bulge of head of

humerus may be visible
or palpable

• A gap can be palpated

above the dislocated
head of the humerus
 Examination
• Neurovascular examination,including
axillary/circumflex nerve
• Wounds or other injuries
• Palpate the outer edge of the acromion
• displaced head is palpable below clavicle or
coracoid process of the axilla.
 Test for Diagnoses of Anterior
shoulder dislocation

B-Bryant’s signs;anteriorly axillary fold look

elongated
C-collaway’s signs;Axillary girth get increased
D-duga’s test ;inability to touch opposite shoulder
by affected hand.
H-hamilton ruler test;a ruler can touch acromium
process and lateral epicondlye at the same
time.
Normal X-ray(L)
Anterior dislocation
Posterior dislocation
Luxatio Erecta
 Management of Shoulder Dislocation
• Is an Emergency
• It should be reduced in less than 24 hours or
there may be Avascular Necrosis of head of
humerus
• Following reduction the shoulder should be
immobilised strapped to the trunk for 3-4
weeks and rested in a collar and cuff
 Treatment/follow up
• Sling

• Analgesia

• Orthopaedic clinic
Methods of Reduction of shoulder
Dislocation
• Hippocrates Method ( A form of anesthesia or
pain abolishing is required )

• Stimpson’s technique ( some sedation and

analgesia are used but No anesthesia is
required )
• Kocher’s technique is the method used in
hospitals under general anesthesia and
muscle relaxation
Hippocrates Method
Stimpson’s technique
Kocher’s Technique
 Complications of Shoulder
Dislocation : Early
• Neuro vascular injury ( rare )

• Axillary nerve injury

• Associated Fracture of neck of humerus or

greater or lesser tuberosities
 Axillary Nerve Injury
• Also called circumflex nerve
• It is a branch from posterior
cord of Brachial plexus
• It hooks close round neck of
humerus from posterior to
anterior
• It pierces the deep surface
of deltoid and supply it and
the part of skin over it
Axillary nerve injury
Complications of shoulder Dislocation :
Late
• Avascular necrosis of the head of the
Humerus (high risk with delayed reduction)
• Heterotopic calcification ( used to be called
Myositis Ossificans )

• Recurrent dislocation
Xray Lt shoulder shows Heterotopic ossification
DISLOCATION OF ELBOW
 Anatomy
• Elbow Joint includes
-ulnohumeral joint
-radiocapitellar joint
-proximal radioulnar joint
• joint type; pivot joint - the radiohumeral
articulation while the ulnohumeral
articulation is a hinge joint
Parts of Elbow joint
 Stability of elbow joint
• elbow static stabilizers (primary)
– ulnohumeral joint ,anterior bundle of the MCL
– LCL complex (includes the LUCL)
• static stabilizers (secondary)
– radiocapitellar joint ,joint capsule
– origins of the common flexor and extensor tendons
• dynamic stabilizers
– muscles that cross the elbow joint, which apply
compressive (stabilizing) force;anconeus,brachialis
and triceps
 Anatomy of elbow
MCL LCLC
 Epidemiology
– Elbow dislocations are the most common major
joint dislocation second to the shoulder
• most common dislocated joint in children
– account for 10-25% of injuries to the elbow
– posterolateral is the most common type of
dislocation (80%)
• demographics
– predominantly affects patients between age 10-20
years old
 Types of Dislocation of Elbow
• Anatomic description 
– based on anatomic location of olecranon relative to
humerus
• posterolateral -most common
• Simple vs. complex
– simple  
• elbow dislocation with no associated fracture 
• accounts for 50-60% of elbow dislocations
– complex  
• elbow dislocation with associated fracture
 Mechanism of injury
• Pathophysiology mechanism for
posterolateral dislocation
– usually a combination of
• axial loading
• supination/external rotation of the forearm
• valgus posterolateral force 
– posterior dislocations may involve more than one
injury mechanism
 Clinical picture
• Symptoms pain and swelling
• Physical exam  important to assess
– the status of the skin - evaluate for open injuries
– presence of compartment syndrome
– neurovascular status
– status of wrist and shoulder
• concomitant injuries occur in 10-15% of elbow
dislocations
Normal Xray of Elbow
Xray Elbow show Posterior Elbow
Dislocation
 Reduction Techniques
• Is an Emergency
• closed reduction with splinting ensure patient
has sufficient analgesia to allow for adequate
muscle relaxation
• reduction maneuver requires a combination of:
– inline traction to improve coronal displacement
– forearm supination to shift the coronoid under the
trochlea
– elbow flexion while placing direct pressure on tip of
olecranon
 Cont..
• a palpable "clunk" can be appreciated after most
reductions
• assess post reduction stability 
– elbow is often unstable in extension 
– elbow is often unstable to valgus stress
• test by stressing elbow with forearm in pronation to lock
the lateral side
• place post-reduction posterior mold splint in
flexion and appropriate forearm rotation
– splint in at least 90° of elbow flexion
 Cont..
• obtain post-reduction radiographs
– if joint is concentric, immobilize (5-10 days) and
start early therapy
– obtain repeat radiographs at 3-5 days and 10-14
days to confirm reduction
• Rehabilitation initial
– immobilize for 5-10 days
– immobilization for >3 weeks results in poor final
ROM outcomes
 COMPLICATIONS
• Early stiffness loss of terminal extension is the
most common complication after closed
treatment of a simple elbow dislocation  
• Varus Posteromedial instability
– injury to the LCL and fracture of the anteromedial
facet of the coronoid 
• Neurovascular injuries
– brachial artery injuries (rare) typically associated
with open dislocations, ulnar nerve injury typically
results from stretch ,median nerve injury (rate)
typcially associated with brachial artery injury
 Cont..
• Compartment syndrome
• Damage to articular surface
• Recurrent instability
• Heterotopic ossification
– may require excision to improve elbow range of
motion 
• Contracture/stiffness
– correlated with immobilization beyond 3 weeks
• DISLOCATION OF WRIST (CARPAL BONES)
AND FINGERS
Carpal Bones
Cont..
 Dislocation of wrist
• A dislocated wrist is a dislocation of any of the
eight small bones called carpal bones which
make up the wrist. A wrist dislocation will
occur as a result of a traumatic event or fall
onto the wrist.
• Symptoms usually include severe pain with an
obvious deformity in the wrist. Tingling in the
thumb, index and middle fingers which
suggests associated median nerve damage..
 CAUSES
• There are a number of ways in which the carpal
bones dislocate and the lunate bone is usually
involved in most of them.
• A dislocation of the carpal bones will involve
severe ligament damage and if left untreated
can result in permanent disability.
• Two significant dislocations are anterior (front)
dislocation of the lunate and perilunar
dislocation of the lunate.
 Treatments
• Carpal dislocations usually require surgical
treatment .The wrist is then immobilised in a
cast for 8 weeks to allow time for the injury to
heal.
• Once out of the plaster cast a full
rehabilitation program with wrist
strengthening exercises should be done to
restore the hand and wrist to full normal
functioning and help prevent any future injury
Carpal dislocations
 Complications
• wrist arthrist,
• persistent pain,
• stiffness of the the joint,
• instability of the carpal bones.
Anatomy of hand
 Finger Dislocation:
• A finger dislocation is a joint injury in which
the finger bones move apart or sideways so
the ends of the bones are no longer aligned
normally.
• Finger dislocations usually happen when the
finger is bent backward beyond its normal
limit of motion.
 Cont..
• Distal interphalangeal joints(DIP); Most caused by
trauma, and there is often an open wound in the
location of the dislocation.
• Proximal interphalangeal joints(PIP) ;A dislocation in
one of these joints is also known as a jammed finger
or coach's finger.
• Metacarpophalangeal joints(MCP) ;Because these
joints are very stable they are less common
dislocated than the other two types. When do occur,
they are usually of either the index finger or little
finger (pinky).
Radiology
 Symptoms
A dislocated finger is
• painful
• swollen
• Deformity
• its surface skin may be cut, scraped or
bruised.
 Cont..
• Managements; Non-operatives: Closed
Reduction Operatives; Surgery
• Complications:
Redislocation,
chronic swelling,
coronal plane deformities
pin tract infections(for op Rx).
 References
• Rockwood and Green 9th Edition
• Orthobullet
• Gudena, R., K. P. Iyengar, et al. (2011). "Irreducible shoulder
dislocation - a word of caution." Orthopaedics &
traumatology, surgery & research 97(4): 451-453
• Chechik, O., M. Khashan, et al. (2011). "[Primary anterior
shoulder dislocation]." Harefuah 150(2): 117-12.
• Caudevilla Polo, S., E. Estebanez de Miguel, et al. (2011).
"Humerus axial traction with acromial fixation reduction
maneuver for anterior shoulder dislocation." Journal of
Emergency Medicine 41(3): 282-284