Dislocation of the shoulder
- 1. DISLOCATION OF THE SHOULDER Dr. Vivek Shrivatava, BPT, MPT (Ortho) Asso.Prof LNCT University, Bhopal
- 2. Introduction • The commonest joint to Dislocate in human body. • commonly occurs in adults, and rarely in children. • Anterior dislocation > posterior dislocation
- 3. Shoulder instability Subluxation Dislocation Anterior Instability Posterior Instability Inferior Insatiability Multidirectional Instability (MDI)
- 4. Classification of Shoulder Instability Frequency • Acute • Recurrent • Fixed or Chronic Causes • Traumatic • Automatic Events • Microtrauma • Congenital • Neuromuscular condition Direction • Anterior • Posterior • Inferior • Multidirectional Degree • Dislocation • Subluxation • Transient
- 5. MECHANISM • A fall on an out-stretched hand with the shoulder abducted and externally rotated. • Direct force pushing the Humerus head out of the glenoid cavity Anterior Dislocation • Direct blow on the front of the shoulder • Electric shock or an epileptiform convulsion Posterior dislocation
- 6. Classification Anterior dislocation Posterior dislocation Luxatio erecta (inferior dislocation)
- 7. Anterior dislocation The head of the Humerus comes out of the glenoid cavity and lies anteriorly. Subclassified into three types depending on the position of the dislocated head Preglenoid: The head lies in front of the glenoid. Subcoracoid: The head lies below the coracoid process. Most common type of dislocation. Subclavicular: The head lies below the clavicle.
- 9. Posterior dislocation The head of Humerus comes to lie posteriorly, behind the glenoid
- 10. Luxatio erecta (inferior dislocation) • The head comes to lie in the subglenoid position
- 11. Pathological changes Bankart's lesion- Stripping of the glenoidal labrum along with the periosteum from the antero-inferior surface of the glenoid and scapular neck The head lie in front of the scapular neck, creating a pouch like structure. In severe injuries, a piece of bone is avulsed from antero-inferior glenoid rim, Knows as bony Bankart lesion
- 12. Bankart's lesion
- 13. Hill-Sachs lesion Depression on the postero-lateral quadrant of humeral head, It is caused by impingement of dislocated head on anterior edge of the glenoid. Rounding off of the anterior glenoid rim occurs in chronic cases as the head dislocates repeatedly over it There may be associated injuries: like fracture of greater tuberosity, rotator- cuff tear, chondral damage etc
- 15. DIAGNOSIS On basis of Presentation- Shoulder abducted and the elbow supported with opposite hand History of a fall on an out- stretched hand followed by pain and inability to move the shoulder
- 16. DIAGNOSIS On examination • Shoulder joint Symmetry • ROM • Clinical Test Radiological • X Ray • USG • MRI • CT scan
- 17. TREATMENT • Reduction under sedation or general anesthesia, followed by immobilization
- 18. TECHNIQUES OF REDUCTION OF SHOULDER DISLOCATION Kocher's manoeuvre • Traction—with The Elbow Flexed To A Right Angle Steady Traction Is Applied Along The Long Axis Of The Humerus • External Rotation—the Arm Is Rotated Externally • Adduction—the Externally Rotated Arm Is Adducted By Carrying The Elbow Across The Body Towards The Midline • Internal Rotation – The Arm Is Rotated Internally So That The Hand Falls Across To The Opposite Shoulder
- 20. TECHNIQUES OF REDUCTION OF SHOULDER DISLOCATION Hippocrates manoeuvre • Therapist exerts a firm and steady pull is on the semi abducted arm. • Therapist places one foot in the axilla against the chest wall • The head of the humerus is levered back into position using the foot as a fulcrum
- 22. COMPLICATIONS • Early complications (Injury to the axillary nerve) • Late complications (recurrent dislocation) • This results from the following causes: (i) Anatomically unstable joint e.g., in Marfan's syndrome (ii) inadequate healing after the first dislocation, or (iii) an epileptic patient
- 23. Surgical management • Putti-Platt operation • Bankart's operation • Bristow's operation • Arthroscopic Bankart repair
- 24. Putti-Platt operation • Double-breasting of the subscapularis tendon is performed in order to prevent external rotation and abduction, thereby preventing recurrences
- 25. Bankart's operation • The glenoid labrum and capsule are re-attached to the front of the glenoid rim. • This is a technically demanding procedure, but has become simpler with the use of special fixation devices called anchors
- 26. Bristow's operation • The coracoid process, along with its attached muscles, is osteotomized at its base and fixed to lower-half of the anterior margin of the glenoid. • The muscles attached to the coracoid provide a dynamic anterior support to the head of the Humerus
- 27. Arthroscopic Bankart repair • For recurrently unstable shoulder • The anchor sutures are used for repair