1. Shoulder Dislocation By: Hashem Bukhary

2. ANATOMY The most commonly dislocated joint in the body, Why ?  Stability is sacrificed for High Motion  Small (ball & Socket Joint)

3. Muscle That contribute to shoulder joint.

4. Glenoid Tubricle is  “Log.H Biceps Attachment”

6. The Labrum is a lignment [ bumper + deep 50% ]

7. Types: Anterior ( 90-95 % ) Posterior ( 2-5 % ) Inferior (<1%)

8. Shared Complication Recurrence “ Most Common “ (Esp: <30) Nerve Injury (Esp: Axillary) Rotator cuff or capsular tear ( Esp : Old )

9. Recurrence Recurrence rate depends on age of 1st dislocation: <20 yrs = 65-95%; 20-40 yrs = 60-70%; >40 yrs = 4-20%

10. Nerve Injury Axillary N. “Post. Crod” = Teris Minor and deltoid Mus. + skin over Shoulder  Numbness & Weakness  “ Transient Nuropraxia”  “ 5%” Musculocutaneous nerve (sensory patch on lateral forearm)

11. The "regimental badge" area  Examine pin-prick sensation to this area to assess axillary nerve sensory function.

12. Anterior Dislocation

13. Anterior Dislocation Subcoracoid (90%), Subglenoid (7%), Subclavicular(<3%)

14. Anterior Dislocation 1/ Hx and Mechanism : Traumatic VS Atraumatic  Posterior direct force OR Blow to Posterior shoulder : with position [ Abduction + Extension + Ext. Rot ] VS  Loose joint with more stretching [ Chronic pain or feeling of instability ]

15. Anterior Dislocation 1/ Hx, Ex and Mechanism : Sever Pain. Lat. outline shoulder flattened. Possible bulge under acromion. Possible Nerve / Vessel injury.

16. Anterior Dislocation 1/ Hx. Ex and Mechanism : Ass. With: (Anterio-Inferior) Labral tear [+/- Bony] = Bankart Lesion # Greater Tuberosity ( esp: > 50 yrs ) # ( Back indentation ) to Humeral “Post-Superior” Head = Hill-Sachs lesion.

17. Anterior Dislocation

18. Anterior Dislocation Labral tear only vs With Bony Lesion

19. Anterior Dislocation Post-Superior Hum. Head

20. Anterior Dislocation 2/ Special Ex: Apprehension Test ( In Supine/ abduct 90” & Ext. Rot)

21. Anterior Dislocation

22. 2/ Special Ex: Apprehension Test ( In Supine/ abduct 90” & Ext. Rot) Relocate test ( apply Post-Pushing Force )

23. Anterior Dislocation 2/ Ex:

24. Anterior Dislocation 2/ Special Ex: Apprehension Test ( In Supine/ abduct 90” & Ext. Rot) Relocate test ( apply Post-Pushing Force ) Load & Shift test.( Humeral Head draft force ) Role OUT dislocation if pt. can Touch the opposite shoulder.

25. Anterior Dislocation 3/ Radiology Finding: X ray Views = AP, Trans-scapular ” Y ”, Axillary. MRI = to evaluate Labral Tear CT = for small bony #

27. Anterior Dislocation

28. Anterior Dislocation Lateral Scapular View

29. Anterior Dislocation Lateral Scapular View

30. Anterior Dislocation Lateral “Y”

31. Anterior Dislocation Axillary

32. Anterior Dislocation

33. Anterior Dislocation Bankart BONY Lesion

34. Anterior Dislocation

35. Anterior Dislocation MRI w/ Intra Articular Contrast: Anterior Labral injury

36. Anterior Dislocation Hill-Sach injury

37. Anterior Dislocation Management : Non Operative VS Operative

38. Anterior Dislocation Management : Non Operative (Conservative) 1/ Closed reduction with: “ IV sedation and muscle relaxation Or Local Anasthesia [ 20cc + 1% Lidocan] just below to acromion process. 2/ Imoblization 1-3 wks: Avoid abduction (still Controversial for duration & position). 3/ PT for restoring Painless ROM.

39. Anterior Dislocation Methods : I: Traction-countertraction:  In Adduction – Seen in Hippocrates & Strap Methods.  In F.F. – Seen in Stimson and Spaso  In lateral elevation – Seen in the Eskimos

40. Anterior Dislocation Hippocratic method: Place heel into patient's axilla and apply traction to arm  foot acts as a a lever to PUSH the humeral head laterally. 30-40° abduction  for 1 mint.

41. Anterior Dislocation Better to flex the Elbow 90° to relax the biceps muscle. Most effective for Subglenoid dis. Brach. Plex and vessel injuries are common  No longer use nowadays.

42. Anterior Dislocation Strap Method: With elbow 90° Assistant stabilizes body with a folded sheet wrapped across the chest while the surgeon applies gentle steady traction along the axis of the arm in 30-40° abduction.

43. Anterior Dislocation Strap Method: Simple, safe, effective, quick, and may be less painful. However, they require adequate space and at least two persons. Towels or sheets can cause friction injury to the fragile skin of the elderly.

44. Anterior Dislocation Management : Stimson (Hanging Arm) : Pt. lies prone with arm hanging over table edge. Hang about 5-7 kg weight on wrist for  20-30 min.  Never let pt. Grap the wit  due to engagement Long. Head of Biceps.

45. Anterior Dislocation Management : Stimson (Hanging Arm) : If Still not occur spontaneously  Gentle longitudinal traction (with elbow at 90°) and internal or external rotation are applied to the arm or direct pressure applied on the humeral head.

46. Anterior Dislocation Management : Stimson (Hanging Arm) : * Best for elderly or obese pt. *BUT : Slow, time consuming, fatiguing, unsuitable for tall patients, Painful Position.

47. Anterior Dislocation Spaso’s Method: “Reverse Stimson” Pt. supine position: grasp the affected arm at the wrist or forearm and lift gently vertically  Traction, externally rotate. If still  palpate and gently push the humeral head posteriorly with the opposite hand.

48. Anterior Dislocation Spaso’s Method “Reverse Stimson”  Simple, effective, atraumatic.  Safe reduction technique.  Requiring minimal force and a single operator only.

49. Anterior Dislocation  Chair Method: Pt. sit upright on a chair with a well-padded backrest. Using the backrest as fulcrum in the axilla  gentle downward traction with external rotation is applied to the wrist.

50. Anterior Dislocation Self-reduction method:  With 90° flexed ipsilateral knee pt. leans backward with neck in hyperextension, extending the elbows and hip. So Shoulder rotating the scapula around a vertical axis.  Success = 60% ; SubCoracoid  Less successful >60 years of age, subclavicular and especially subglenoid dislocations.

51. Anterior Dislocation Eskimo (Hanging Pt.) Grasp the dislocated arm, pulled upwards and lifted the shoulder a couple of centimeters off the ground. Still not work  Press the humeral head towards its socket. Simple, No facilities needed. Can be by nonmedical personnel.

52. Anterior Dislocation Management : II. Leverage “Force” : exemplified by Kocher and Milch

53. Anterior Dislocation Milch Methods: With Arm ( F.F & abduction & Pt. Supine or 30°): I.Put hand over dislocat. shoulder (to support the top) & Thumb is under the dislocated humeral head to hold it in place. II. The elbow of the affected arm may be put into 90° flexion  left hand gently abducts the arm into the overhead position ( abducted & ext. rotated)  Direct pressure with thumb to humeral head over the glenoid rim with Axial traction may be applied.

54. Anterior Dislocation Milch Methods: Relatively painless, safe, and free from complications & requires little sedation. However, the manoeuvres are complex. It has been claimed to have a very high success rate.

55. Anterior Dislocation Kocher’s Methods: With longitudinal traction to humerus, and arm slightly away from pt.  1/ Elbow flexed to 90° with pressed (adducted) against the body & to full external rotation until resistance. 2/ Elbow is lifted & adducted arm across the chest wall to midline. 3/ The affected hand is then placed on the opposite shoulder (internally rotated).

56. Anterior Dislocation Kocher’s Methods: Not for: Obese, Old Increased risk of: ( Recurrent dislocation, Spiral fractures of the humerus and axillary nerve injuries when compared to other techniques)  Not Common

57. Anterior Dislocation Management : III. Scapular manipulation & direct pressure or pulsion

58. Anterior Dislocation Scapular manipulation methods: Manipulates the scapula so that the glenoid rotates down to meet the humeral head. In prone pt. = shoulder in 90° of F.F. and ext. rotation. Suspended maintained hanging 5-7 Kg weight to the wrist / manual traction for 5- 10 minutes.

59. Anterior Dislocation Scapular manipulation methods: +ve / simple, easy, fast, effective, safe, atraumatic, need No Sedation. -ve / Hard to countere prone position, difficult in obese patients.

60. Anterior Dislocation Shoulder reduction in the elderly (Direct Pressure or pulsation ) Stand behind the seated patient Put flexed forearm into the axilla of the affected shoulder.  Gentle traction on the flexed forearm Pt. + pulls in lateral direction and upward the head of the humerus into the socket. It is simple, atraumatic, direct and effective.

61. Anterior Dislocation Conclusion Acute anterior shoulder dislocation is a common presentation to emergency departments. Most dislocations can be reduced in the emergency department using simple methods. The success rates and complication rates of the various techniques are summarised in Table. Because No single shoulder reduction technique is infallible, the So physician should be proficient in several methods in case of failed first attempts.

62. Anterior Dislocation

63. Management : Arthroscopic VS open Bankart repair +/- capsular shift Arthroscopic  1 st time traumatic shold. Dislo with Bankart lesion confirmed MRI ( athlete younger than 25 yrs )  Equally efficacious as open But less pain & more Motion preservation.

64. Anterior Dislocation Management : Hill-Sachs bony reconstruction Indication Engaging Hill-Sachs lesions By : Arthroplasty or Allograft reconstruction

65. Anterior Dislocation Management : ALLWAYS: obtain post-reduction x-rays check post-reduction NVS Shoulder rehabilitation (dynamic stabilizer strengthening)

66. Posterior Dislocation

67. 1/ Hx and Mechanism : Up to 60-80% are missed on initial presentation due : Poor physical exam and radiographs.  FOOSH OR Blow to Anterior shoulder: with position [ Adduction + Flexed Arm+ Int. Rot ]

69. Posterior Dislocation Ass. With: 3 E's ( Epileptic seizure, EtOH, Electrocution) Reverse bony Bankart lesion: avulsion of the posterior glenoid labrum from the bony glenoid rim. # Lesser Tuberosity Reverse Hill-Sachs lesion (75% of cases).

70. Posterior Dislocation 2/ Ex: Jerk Test ( Add + FF ) Load-and-shift Test Most Reliable Sign : Shoulder being Locked in Internal. Rot.

71. Posterior Dislocation 3/ Radiology Finding: Dislocation: AP view: partial vacancy of glenoid fossa (vacant glenoid sign) humeral head may resemble a lightbulb due to internal rotation (lightbulb sign). axillary view: humeral head is posterior. trans-scapular view: humeral head is posterior to centre of "Mercedes-Benz sign'’

72. Posterior Dislocation The humeral head is Much SYMETRICAL + and the Joint space WIDER

73. Posterior Dislocation

74. Missed Post. Dislocation

75. Posterior Dislocation

76. 4/ Management : Non-operative Management: Reduction (under anaesthesia) Immobilisation : in 20 ° of external rotation (up to 6/52) Activity restriction Exercise rehabilitation & P.T.

77. A 35-year-old male injured his right shoulder while playing basketball. Came to ER with significant pain and his shoulder abducted at 140 degree. He is unable to lower his arm. Radiographs will most likely show that his glenohumeral joint has dislocated in what direction? 1.Anterior. 2.Posterior. 3.Inferior. 4.Superior. 5.Lateral.

78. Inferior Dislocation “Luxatio Erecta”

79. Inferior Dislocation 1/ Hx and Mechanism : Forceful hyperabduction of the shoulder. Happens when the humerus anchor-on/“pushed over” with the Acromion and the Humeral Head delivered out the glenoid Cavity. The Greatest type w/ Axillary Nr injured But it will usually spontaneously recovers.

80. Inferior Dislocation 1/ Hx and Mechanism : Pt presnt : "locked" in abduction of varying degrees. “hyperabducted Arm, with the elbow flexed and forearm resting on top of or behind the head”

81. Inferior Dislocation Sulcus Sign ( Inf. Force w/ arm @ side)  inc. Acr-Hum interval

82. Inferior Dislocation Sulcus Test Grading Scheme Grade 1  not over glen. Rim = Acro.humeral interval <1cm Grade 2  over but spo.reduc = Acro.humeral interval 1-2cm Grade 3  locked over gle.rim = Acro.humeral interval >2cm

83. Inferior Dislocation So all view needed : AP, Lat Y, Axillary. Axillary X-ray: usually looks Normal. MRI  Obtained after shoulder is relocated to assess shoulder injuries  Capsulolabral pathology & rotator cuff tears (common)

84. Inferior glenohumeral dislocation with arm fully abducted

85. Inferior Dislocation Non-OP. Rx: Closed reduction and immobilization: Pt. w/ good response to non-operative treatment inactive elderly patients initial reduction and immobilization followed by ROM exercises physical therapy focusing on rotator cuff strengthening

86. Inferior Dislocation Operative. Rx: reconstruction with arthroscopic or open repair For capsulolabral damage / or rotator cuff tear Especially active younger patients By: repair vs reconstruction of shoulder pathology

87. Thank You