Shoulder dislocation

dr. Irsan Abubakar, SpOT

Orthopeadic and Traumatology division
Faculty of Medicine. Syiah kuala University
Zainal Abidin General Hospital
 synopsis
• Definition
• Anatomy – pathoanatomy
• Types – anterior/posterior/inferior
• Clinical features – Tests for evaluation
• Management -- Reduction
techniques
• Complications
 History:
• Shoulder dislocation is documented in Egyptian tomb
murals as early as 3000 BC, with depiction of a
manipulation for glenohumeral dislocation resembling
the Kocher technique.
A painting in the tomb of Ipuy,
1300BC, the sculptor of Ramses II
depicts a physician reducing a
dislocated shoulder, using a
similar technique Kocher
described in 1870.

• Hippocrates detailed the oldest known reduction

method still in use today. Hippocrates described 13
different techniques, generally traction / counter
traction.
SURGICAL ANATOMY
- Static stabilizers- anatomic constraints to shoulder motion
- Dynamic stabilisers – normal physiological function creates a
stabilizng effect

BONY ANATOMY – has minimal constraints – large range of

motion
Scapula – hence glenoid anterverted 30 – 40
Humeral head retroverted
¼ of head articulates with bony glenoid
LABRUM – one of the most important
stabilizing structures .
- Effectively enlarges & deepens the glenoid
surface by 1 cm &
50% respectively .
• CAPSULE : loose and redundant at most positions
- At extremes – tightens , provides stability
.
• GLENOHUMERAL LIGAMENTS
- Superior , middle , inferior
• CORACOHUMERAL LIGAMENT –
-Passes in the rotator interval ( between subscapularis &
supraspinatus )
DYNAMIC STABILIZERS
• ROTATOR CUFF MUSCLES :

- BICEPS TENDON : along the rotator interval

• CORACO-ACROMIAL ARCH limits superior translation

 Anterior:
• Subcoracoid (anterior):
– Humeral head sits
anterior and medial to
the glenoid, just
inferior to the coracoid.
– ~ 60% of cases.

• Subglenoid
(anteroinferior):
– humeral head sits
inferior and slightly
anterior to the glenoid,
that the humeral head
has also travelled
medially.
– ~ 30% of cases.
MECHANISM OF INJURY :
• DIRECT – less common
INDIRECT – more common
• Susecptible position –
• Anterior dislocation :
abd. , ext. rotation &
extension
• Post. Dislocation : flexion,
add . & int. rotation
• In seizures & electrical
shock – all the muscles
are contracted
, ext. rotators overpower
int. rotators
• ASS0CIATED INJURIES :
• Humeral head & neck # , tuberosity # , glenoid # , rotator
CLINICAL FINDING :
• Presentation of acute dislocation
• Pain , typical attitude ,
• In ant . Dis- limitation of int. rotation & abd.
• In post. Disl. – “ of ext. rotation
• In inferior disl. – in fully abducted position

PHYSICAL EXAMINATION :
• Flattening of shoulder
• Fullness in delto-pectoral area
• Axillary fold at lower level
• Able to insinuate finger beneath acromion
• dugas test
• Hamilton ruler test
Dugas test
Hamilton ruler test
SULCUS TEST :
• Axillary N. tested for both sensory & motor
components
 X-Ray
• The anteroposterior x-ray will show the
overlapping shadows of the humeral head and
glenoid fossa, with the head usually lying
below and medial to the socket.
CLASSIFICATION
SEVERITY :
subluxation
dislocation
DURATION :
Acute
chronic
OCCURRENCE :
Single / Recurrent
MECHANISM :
Traumatic /
atraumatic
DIRECTION :
anterior / posterior /
multidirectional
NONOPERATIVE TRAETMENT
• CLOSED REDUCTION FOR ACUTE DISLOCATION
- Under i.v. analgesia + sedation
- Under intra-articular lignocaine
- If initial closed reduction unsucessful , degree of sedation &
analgesia evaluated , if not successful , under G.A for closed
/ open reduction
 Traction-countertraction
• Note how the clinician on
the left has the sheet
wrapped around him,
allowing him to use his
body weight to create
traction. Some clinicians
employ gentle external
rotation to the affected
arm while providing
traction.
 Stimson technique
• The patient is
placed prone on the
stretcher with the
affected shoulder
hanging off the
edge. Weights (10-
15 lbs) are fastened
to the wrist to
provide gentle,
constant traction.
 Scapular manipulation
• The patient sits upright and
leans the unaffected shoulder
against the stretcher. The
physician stands behind the
patient and palpates the tip
of the scapula with his
thumbs and directs a force
medially. The assistant stands
in front of the patient and
provides gentle downward
traction on the humerus as
shown. The patient is
encouraged to relax the
shoulder as much as possible.
 Milch technique
• The arm is abducted
and the physician's
thumb is used to
push the humeral
head into its proper
position. Gentle
traction in line with
the humerus is
provided with the
physician's opposite
hand.
 Spaso technique
• The arm is flexed
forward and
gentle traction
and external
rotation forces are
applied.
 Management
• The arm is rested in a sling for about three weeks
in those under 30 years of age (who are most
prone to recurrence) and for only a week in those
over 30 (who are most prone to stiffness).

• Then movements are begun, but combined

abduction and lateral rotation must be avoided
for at least 3 weeks.

• Throughout this period, elbow and finger

movements are practised every day.
OPERATIVE TREATMENT
• SURGICAL STABILISATION FOR ANT . INSTABILITY
in – failed appropriate nonoperative treatment
- recurrent dislocation at young age
- irreducible dislocation
- open dislocation
- unstable joint reduction
- 1st dislocation in young pt with high demand activity
surgical options
- arthroscopic surgery
- open tech. with soft tissue repair
- open tech. with bony augmentation
Open procedures :

• BANKART OPERATION
- MC performed surgery
- Ant. Labral defect identified , mobilized & reattached to
original anatomic site with suture anchor .
- Capsular reconstruction also recommended
- Subscapularis tendon is split at junction of upper 2/3rd
&
lower 2/3rd
 BRISTOW OPERATION

- Suturing of coracoid process with the conjoint tendon to the

ant. Portion of scapular neck through a transversely
sectioned subscapularis M.

- The transferred short head of biceps & corachobrachialis –

strong buttress across the anterior & inferior aspects of joint

- Tendon also holds the lower half of subscapularis M. thus

prevents slipping over the humeral head when abducted
• PUTTI-PLAT OPERATION

- Subscapularis and capsule incised vertically

- Lateral leaf sutured to the labrum & medial leaf imbricated
- Subscapularis is advanced laterally
- Gross limitation of ext. rotation
- Rarely indicated
• ARTHROSCOPIC PROCEDURES
• ADVANTAGES & DISADVANATAGES
 POSTERIOR DISLOCATION OF THE
SHOULDER

• Posterior dislocation is rare, accounting for

less than 2% of all dislocations around the
shoulder.
 Clinical features
• The diagnosis is frequently missed – partly
because reliance is placed on a single
anteroposterior x-ray (which may look almost
normal) and partly because those attending to
the patient fail to think of it.

• There are, in fact, several well-marked clinical

features.
• The arm is held in internal rotation and is
locked in that position.

• The front of the shoulder looks flat with a

prominent coracoid, but swelling may obscure
this deformity; seen from above, however,
the posterior displacement is usually
apparent.
 X-Ray
• In the anteroposterior film the humeral head,
because it is medially rotated, looks abnormal in
shape (like an electric light bulb) and it stands
away somewhat from the glenoid fossa (the
‘empty glenoid’ sign).

• An axillary view is essential; it shows posterior

subluxation or dislocation and sometimes a deep
indentation on the anterior aspect of the humeral
head.
 Posterior shoulder
dislocation reduction

• The underlying approach to

the traction-countertraction
technique demonstrated in
this photograph is similar to
that employed in the
reduction of anterior
dislocations. The notable
difference is positioning.
Note that the patient is
upright and the clinician
providing traction is
standing in front of the
patient.
 INFERIOR DISLOCATION OF THE
SHOULDER (LUXATIO ERECTA)
• Inferior dislocation is rare but it demands early
recognition because the consequences are
potentially very serious.

• Dislocation occurs with the arm in nearly full

abduction/elevation.

• The humeral head is levered out of its socket and

pokes into the axilla; the arm remains fixed in
abduction.
Mechanism of injury and pathology
• The injury is caused by a severe hyper-
abduction force.

• With the humerus as the lever and the

acromion as the fulcrum, the humeral head is
lifted across the inferior rim of the glenoid
socket; it remains in the subglenoid position,
with the humeral shaft pointing upwards.
• Soft-tissue injury may be severe and includes
avulsion of the capsule and sur-rounding
tendons, rupture of muscles, fractures of the
glenoid or proximal humerus and damage to
the brachial plexus and axillary artery.
 Clinical features
• The startling picture of a patient with his arm
locked in almost full abduction should make
diagnosis quite easy.

• The head of the humerus may be felt in or

below the axilla.

• Always examine for neurovascular

damage.
 X-ray
• The humeral shaft is shown in the abducted position with
the head sitting below the glenoid.

• It is important to search for associated fractures of the

glenoid or proximal humerus.

– NOTE: True inferior dislocation must not be confused with

postural downward displacement of the humerus, which results
quite commonly from weakness and laxity of the muscles
around the shoulder, especially after trauma and shoulder
splintage; here the shaft of the humerus lies in the normal
anatomical position at the side of the chest.
– The condition is harmless and resolves as muscle tone is
regained.
 Treatmen
•
t
Inferior dislocation can usually be reduced by pulling
upwards in the line of the abducted arm, with counter-
traction downwards over the top of the shoulder.

• If the humeral head is stuck in the soft tissues, open

reduction is needed. It is important to examine again,
after reduction, for evidence of neurovascular injury.

• The arm is rested in a sling until pain subsides and

movement is then allowed, but avoiding abduction for
3 weeks to allow the soft tissues to heal.
 Complications
• EARLY COMPLICATIONS
• Rotator cuff tear:
– This commonly accompanies anterior dislocation,
particularly in older people.

– The patient may have difficulty abducting the arm

after reduction; palpable contraction of the
deltoid muscle excludes an axillary nerve palsy.

– Most do not require surgical attention, but young

active individuals with large tears will benefit from
early repair.
• Nerve injury:
– The axillary nerve is most commonly injured; the patient is
unable to contract the deltoid muscle and there may be a
small patch of anaesthesia over the muscle.

– The inability to abduct must be distinguished from a

rotator cuff tear.

– The nerve lesion is usually a neuropraxia which recovers

spontaneously after a few weeks; if it does not,
then surgery should be considered as the results of
repair are less satisfactory if the delay is more than a
few months.
– Occasionally the radial nerve, musculocutaneous
nerve, median nerve or ulnar nerve can be
injured.

– Rarely there is a complete infra-clavicular brachial

plexus palsy.

– This is somewhat alarming, but fortunately it

usually recovers with time.
• Vascular injury:
– The axillary artery may be damaged, particularly in
old patients with fragile vessels.

– This can occur either at the time of injury or

during overzealous reduction.

– The limb should always be examined for signs of

ischaemia both before and after reduction.
• Fracture-dislocation
– If there is an associated fracture of the proximal humerus,
open reduction and internal fixation may be necessary.

– The greater tuberosity may be sheared off during

dislocation.

– It usually falls into place during reduction, and no special

treatment is then required.

– If it remains displaced, surgical reattachment is

recommended to avoid later subacromial impingement.
 • LATE COMPLICATIONS
• Shoulder stiffness
– Prolonged immobilization may lead to stiffness of the shoulder,
especially in patients over the age of 40.

– There is loss of lateral rotation, which automatically limits

abduction.

– Active exercises will usually loosen the joint.

– They are practised vigorously, bearing in mind that full

abduction is not possible until lateral rotation has been
regained.

– Manipulation under anaesthesia or arthroscopic capsular

release is advised only if progress has halted and at least 6
months have elapsed since injury.
• Recurrent dislocations
• Unreduced dislocation
– Surprisingly, a dislocation of the shoulder sometimes
remains undiagnosed.

– This is more likely if the patient is either unconscious or

very old.

– Closed reduction is worth attempting up to 6 weeks after

injury; manipulation later may fracture the bone or tear
vessels or nerves.

– Operative reduction is indicated after 6 weeks only in the

young, because it is difficult, dangerous and followed by
prolonged stiffness.
–
Thank you all…