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SHOULDER DISLOCATION Co NORBERT, UR-CMHS
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COLLEGE OF MEDICINE AND HEALTH SCIENCES CLIN MED α COM HEALTH DEPARTMENT ACADEMIC YEAR 2016-2017 YEAR THREE
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INTRODUCTION
Shoulder Dislocation is when the head of the humerus separates from the scapula at the glenohumeral joint. (Anon (a), 2009)
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Anatomy of Gleno Humeral Joint
• Is a synovial ball-and-socket joint • between the glenoid cavity of the scapula and the head
of the humerus.• Both articular surfaces are covered with hyaline
cartilage. • It is surrounded by the fibrous capsule that is attached
superiorly to the margin of the glenoid cavity and inferiorly to the anatomic neck of the humerus.
• The capsule is reinforced by the rotator cuff, the glenohumeral ligaments, and the coracohumeral ligaments.
•
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Shoulder joint cont’
• it Has a cavity that is deepened by the fibrocartilaginous glenoid labrum; communicates with the subscapular bursa; and allows abduction and adduction, flexion and extension, and circumduction and rotation.
• It is innervated by the axillary, suprascapular, and lateral pectoral nerves.
• Receives blood from branches of the suprascapular, anterior and posterior humeral circumflex, and scapular circumflex arteries.
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Rotator (Musculotendinous) Cuff
• May be subject to inferior or anterior dislocation• The later stretches the fibrous capsule, avulses the
glenoid labrum, and may injure the axillary nerves formed by the tendons of the supraspinatus, infraspinatus, teres minor, and subscapularis (SITS).
• fuses with the joint capsule and provides mobility. • Keeps the head of the humerus in the glenoid fossa
during movements and thus stabilizes the shoulder joint.
(Wesley Norman,2009)
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Nerves supply
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Normal(1) glenohumeral and ant. Shoulder dislocation (2)
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REASONS FOR INSTABILITY
• Shallow glenoid • Extraordinary ROM • Vulnerability of upper limb to injury • Underlying conditions : Ligament laxity
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MECHANISM OF INJURY :
DIRECT :less commonFall on abducted Extended shoulder
INDIRECT: more commonBlow from behind
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SUSCEPTIBLE POSITION
Anterior dislocation :• abduction • external rotation• extension
Posterior Dislocation : Flexion adduction internal rotation
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ASS0CIATED INJURIES :
• Humeral head & neck # • tuberosity # • glenoid # • rotator cuff tears( older age) • neurological ( axillary N.) and vascular injuries • Any pt. with weakness after shoulder dislocation
must be evaluated for rotator cuff tear
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MECHANISM OF SHOULDER AND CLAVICLE INJURY
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Special case
• In seizures & electrical shock
all the muscles are contracted , external rotators overpower internal rotators
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TYPES OF SHOULDER DISLOCATION
Shoulder dislocations are usually divided according to the direction in which the humerus exits the joint:• Anterior > 95%.
• sub coracoid (majority).• subglenoid (1/3).• subclavicular (rare).
• Posterior 2-4%. • Inferior ( luxation erecta ) < 1%.
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PRESENTATION OF ACUTE DISLOCATION
• Pain at the injured area • Loss of normal contour of the shoulder • Empty glenoid socket • In ant . Dislocation: limitation of int. rotation &
abduction• In post. Dislocation: limitation of external
rotation • In inferior dislocation: in fully abducted position
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PHYSICAL EXAMINATION
• Flattening of shoulder • Fullness in delto-pectoral area• Axillary fold at lower level• Able to insinuate finger beneath acromion • dugas test • Callaway's test • Hamilton ruler test
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Cont,’
• Axillary N. tested for both sensory & motor components
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TESTS OF INSTABILITY
DRAWER TEST :
Positive if the translation is excessive in comparison to other side or if pt develops apprehension or pain
• For both anterior & posterior instability • LOAD SHIFT TEST – variant of drawer test
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SULCUS TEST :
• With arm in 0 and 45 degree abduction• At 45 degree – inf. Glenohumeral ligament complex• Significant if noticeable dimple / sulcus at lateral edge of
acromion• Graded from 0 to 3 • 1+ subluxation < 1 cm• 2+ 1 to 2 cm • 3+ > 2 cm
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APPREHENSION TEST
• For anterior instability • Shoulder placed in a position vulnerable to dislocate • 90 of abduction and external rotation • FULCRUM TEST & CRANK TEST – modifications of apprehension test anteriorly directed force applied to exaggerate
instability
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RELOCATION TEST
• Arm placed in abduction & ext rotation • Posteriorly directed force eliminates apprehension
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SURPRISE TEST
• Posteriorly directed force • Doesn’t experience apprehension even at abduction &
maximal ext rotation • By abruptly removing force apprehension develops• • JERK TEST • For posterior instability • After elevating the shoulder to 90 degree in plane of
scapula , axial load placed on the humerus , • Gradually adducting the shoulder , head may
subluxate / dislocate posteriorly . Adduction when removed , head reduces back .
• +ve even if elicits apprehesion
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JERK TEST
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RADIOGRAPHIC EVALUATION
ROUTINE AP VIEW
• Glenoid fossa: ellipse • In normal shoulder: humeral head will overlap glenoid shadow • Overlap if significantly altered : joint dislocation • Distance b/w ant. Glenoid rim & humeral head > 6mm
highly s/o post. Dislocation – POSITIVE RIM OR VACANT GLENOID SIGN
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Radiographic findings cont.’
• TRUE AP VIEW – beam perpendicular to scapula ( 35 – 45 degree oblique to sagittal )
• Any overlap in this view is s/o dislocation
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05/03/2023 CMCH , L3 , G4 37Inferior Shoulder Dislocation.
05/03/2023 CMCH , L3 , G4 38Normal glenohumeral joint. An anterior shoulder
dislocation.
Computed tomography
• Double-contrast axial computed tomography (CT) arthrogram of the left shoulder shows an undisplaced
• tear (arrows) of the anterior glenoid labrum. The patient had one episode of an anterior dislocation.
.
CT
• Double-contrast axial computed tomography (CT) arthrogram of the right shoulder shows a deficient anterior glenoid labrum (arrows) and medial stripping of the anterior capsular attachment (arrowhead). The patient had a recurrent anterior dislocation
CT
• Double-contrast axial computed tomography (CT) arthrogram of the right shoulder shows a small, loose body (arrow) in the axillary recess. The patient had recurrent anterior dislocations.
• Double-contrast, reconstructed, 2-dimensional coronal computed tomography (CT) arthrogram
• of the right shoulder shows a large Hill-Sachs defect (arrow) in the humeral head. A full-thickness rotator cuff tear is present, evidenced by a large amount of air in the subacromial/subdeltoid
• bursa. The remnant end of the supraspinatus tendon is seen (arrowhead).
.
COMPUTED TOMOGRAPHY
• Double-contrast axial computed tomography (CT) arthrogram of the left shoulder shows a bony Bankart glenoid fracture (arrows). The patient had one episode of an anterior dislocation
Axial, fat-suppressed, spin-echo T1-weighted magnetic resonance arthrogram of the right shoulder shows an undisplaced tear (arrow) of the anterior glenoid labrum. Part of the middle glenohumeral ligament is shown (arrowhead). The patient had one episode of anterior dislocation.
Axial, spin-echo T1-weighted magnetic resonance arthrogram of the left shoulder shows a deficient anterior labrum (arrows) and medial stripping of the anterior capsular attachment (arrowheads). The patient had recurrent anterior dislocations.
MRI
Coronal, T1WI and fast spin-echo T2-weighted conventional magnetic resonance imaging (MRI) scan of the left shoulder shows a large Hill-Sachs defect (arrows) in the superolateral humeral head. Surrounding bone marrow edema is shown. Fluid is present in the subacromial/subdeltoid bursa (arrowheads), indicative of a full-thickness rotator cuff tear. The patient had one episode of an anterior dislocation.
Coronal, fat-suppressed, spin-echo T1-weighted magnetic resonance arthrogram image of the right shoulder shows a loose body (arrow) in the axillary recess. The patient had a previous dislocation.
Axial, spin-echo T1-weighted magnetic resonance arthrogram of the right shoulder shows an undisplaced tear (arrow) of the anterior glenoid labrum, which remains attached to the inferior glenohumeral ligament (arrowhead). The patient had recurrent anterior dislocations.
Axial, spin-echo T1-weighted magnetic resonance arthrogram of the right shoulder shows an anterior labroligamentous periosteal sleeve avulsion lesion (arrows), seen as a rolled-up mass anterior to the neck of the scapula. The patient had recurrent anterior dislocations.
MR images in a 31-year-old male dancer obtained 4 days after acute first-time anterior shoulder dislocation. A, Oblique coronal fat-suppressed T2-weighted image shows a small Hill-Sachs fracture (arrow) with prominent bone marrow edema. Effusion is present. B, On more anterior oblique coronal fat-suppressed T2-weighted image, the inferior labral-ligamentous complex (open arrow) is detached and displaced from the inferior glenoid rim. The humeral attachment site (solid arrow) is unremarkable. The cuff is intact. C, On axial gradient-echo image, the anteroinferior labral-ligamentous complex (open arrow) is displaced from the glenoid rim, and the attached periosteum (solid arrow) is stripped medially along the glenoid neck. No glenoid rim fracture is present.
Acute first-time anterior shoulder dislocation: T1-weighted MR images in a 26-year-old man with shoulder pain after a single anterior dislocation. MR arthrography was performed 2 months after known dislocation owing to persistent pain and limitation. A, Axial fat-suppressed image demonstrates an intact anterior labrum (arrow). B, ABER image demonstrates an avulsion of the anterior labrum with an intact glenoid periosteum and capsule (arrow), highlighting the mechanical advantage of having the shoulder in this position during imaging.
MR images of acute ALPSA in a 24-year-old man who sustained a first episode of anterior shoulder dislocation 3 weeks prior to imaging. A, Fat-suppressed T2-weighted and, B, axial fat-suppressed intermediate-weighted images demonstrate a Hill-Sachs lesion (white arrow) with marrow edema and associated anteroinferior labral tear with anteromedially displaced fragment (open arrow). Note stripping and edema of the scapular periosteum with developing granulation tissue (black arrow).
MR images of acute recurrent anterior shoulder dislocation with Bankart fracture in a 64-year-old man. A, Sagittal and, B, C, coronal fat-suppressed T2-weighted images demonstrate extensive periarticular posttraumatic swelling ( ) with high-grade ☆partial thickness tears of the subscapularis myotendinous junction (white arrow) and humeral muscular insertion (open arrow) as well as strains of the supraspinatus (SST), infraspinatus (IST), teres minor (Tmi), latissimus dorsi (LD), triceps (T), and teres major (Tma) muscles. Glenohumeral and subacromial subdeltoid effusions ( ), as well as humeral avulsion of the ★inferior glenohumeral ligament (HAGL ▲) and a detached and mildly displaced Bankart fracture (black arrow). D, Sagittal T1-weighted image demonstrates a displaced Bankart fracture fragment. The defect in the anteroinferior glenoid rim is somewhat ill defined. E, Three-dimensional MR reconstruction demonstrates the amount of glenoid bone loss, glenoid fracture margin (white arrow), and adjacent fracture fragment (open arrow) to a better extent than the conventional MR images. F, Three-dimensional MR reconstruction of the humeral head demonstrates a mildly displaced avulsion fracture of the greater tuberosity at the insertion of the supraspinatus tendon (black arrow), as well as an impacted Hill-Sachs lesion (white arrow).
Chronic multidirectional instability in a 41-year-old woman with apprehension, disability, and provocative testing positive for instability and without previous dislocation or major traumatic event. At conventional MR imaging of the shoulder 5 weeks earlier at an outside institution, findings were interpreted as negative for labral-ligamentous injury. On this oblique coronal fat-suppressed T1-weighted arthrographic MR image, contrast material outlines the anterior band of the inferior glenohumeral ligament (black arrow), which is ruptured and retracted from its humeral attachment site. Contrast material leaks from the joint into the quadrilateral space (white arrow). Capsulorrhaphy was performed arthroscopically.
Chronic ALPSA in a young baseball player with clinical findings of anteroinferior instability and no history of prior dislocation. A, B, Axial and, C, sagittal fat-suppressed T1-weighted MR arthrograms demonstrate a medially displaced anteroinferior labral tear (black arrows) and stripped off scapular periosteum with scar tissue annealing the fragment and periosteum to the inferomedial scapular neck (white arrows).
MR images in a 24-year-old extreme athlete who denied previous dislocation or major shoulder trauma. A, Axial, fat-suppressed T1-weighted MR arthrogram shows increased signal intensity at the labral chondral junction (black arrow), as well as a nondisplaced posteroinferior labral tear and a contrast agent–filled chondral defect with a GLAD lesion (white arrow). A small subchondral cyst is found adjacent to the posterior tear (open arrow). B, On ABER fat-suppressed T1-weighted MR arthrogram, tear of the anteroinferior labral chondral is made conspicuous (arrow). At the time of initial MR imaging, the patient elected to continue competition, forgoing surgical intervention. Repeat MR imaging 2.5 years later was performed due to disability preventing further competition. C, Axial fat-suppressed T1-weighted MR arthrogram shows a Bankart lesion and marked displacement of the anteroinferior labral-ligamentous complex (arrow) from the glenoid rim. D, ABER fat-suppressed T1-weighted MR arthrogram demonstrates progression to a GLAD injury in the anteroinferior labrum with detachment and displacement of a large labral chondral fragment (arrow). Arthroscopic stabilization procedure was performed. The posteroinferior labral chondral GLAD lesion appears to have healed in the interval.
(A-C): Bony Bankart lesion in a 28-year-old male with recurrent anterior shoulder dislocation. Axial TSE T1W fat-saturated MRA image (A) shows an absent anteroinferior labrum with bony injury (arrow). Sagittal TSE T1W fat-saturated MRA (B) and sagittal MRA image (C) 5 mm medial to B, show the full extent of the bony Bankart lesion (arrow).
(A-C): Perthes lesion. A 16-year-old male presented with post-traumatic recurrent anterior shoulder dislocation. TSE T1W fat-saturated axial MRA image (A) and TSE T1W fat-saturated oblique axial MRA image with arm in ABER position (B) show intercalation of intra-articular contrast beneath the anterior labrum (small arrow) with an intact scapular periosteum (long arrow); this suggests a diagnosis of Perthes lesion. TSE T1W fat-saturated oblique sagittal MRA image (C) shows the extent of the lesion (arrows).
ALPSA lesion in three different patients with anterior shoulder instability. TSE T1W fat-saturated coronal MRA images (A,B) and axial MRA image (C) show the anteroinferior labrum and antero-inferior glenohumeral ligament rolled back medially along the scapular neck (arrow)
GLAD lesion in an 18-year-old male student. TSE T2W fat-saturated axial conventional MRI image (A) and coronal TSE T1W fat-saturated MRA images (B,C) show anterior-inferior labral injury (long arrow) with an articular cartilage defect (small arrow).
(A-B): Coronal TSE T1W MRI (A) and axial TSE T1W fat-saturated MRA (B) images show a comminuted greater tuberosity fracture (arrow) in this 38-year-old male presenting with
traumatic shoulder instability
(A-B): Reverse Hill-Sachs and reverse Bankart lesion in a 34-year-old male who had multidirectional instability with a posterior dislocation at presentation. Axial TSE T1W fat-saturated MRA images (A,B) show a reverse Hill-Sachs lesion (long arrow) as a bony defect in the anterior humeral head. A posterior labral tear is indicated with a thick arrow. The patient also had an anterior labral tear (small arrow in B) and a Hill-Sachs lesion from previous anterior dislocations. A Bennett lesion is seen as ossification, posteriorly along the scapular neck (long arrow in B)
Morphologic abnormality of the posteroinferior glenoid in a patient with posterior instability. Axial GRE MEDIC T2W MRI image (A) and axial CT arthrogram image (B) reveal the "lazy J" deformity; better appreciated on CT scan
MRI of shoulder after dislocation with Hill-Sachs lesion and labral Bankart's
lesion.
Dual post-traumatic findings - Note the presence of both a Hill-Sachs deformity of the posterolateral humeral head and a partial thickness supraspinatus tendinous tear.
Combined tendinous injuries from a single, devastating shoulder injury. Displaced tendon of long head of biceps muscle (Fig A), Subscapularis tendinous avulsion and Teres minor tendon partial tear (Fig B), Posterior capsular disruption (Fig C) and Supraspinatus tendinous disruption (Fig D).
Bankart and Hill-Sachs lesions in anterior shoulder dislocation. (A) T1-weighted oblique coronal and (B) STIR axial MR images of the shoulder show a bony Bankart lesion with detachment of the anteroinferior labrum from the underlying glenoid, involving the bony margin (impaction fracture) (arrows). STIR axial (C) and oblique sagittal (D) MR images show a Hill-Sachs lesion with posterolateral humeral head compression fracture with bone edema as the humeral head comes to rest against the anteroinferior part of the glenoid. These types of lesions frequently occur in collision-sports
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Management
• Emergency • Should be reduced in ˂ 24 hours • Immobilized strapped to the trunk for 3-4 weeks and rested in a
collar and cuff
REDUCTION
Closed reduction Open reduction / surgery
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Maneuvers
• traction- counter traction method• Hippocrates method • Stimpson’ s technique • Kocher’ s technique
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Hippocrates method
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Stimpson’ s technique
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Kocher’ technique
• Step I : flex elbow traction • Step II : external rotation • Step III : adduction • Step IV : internal rotation
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MILCH TECHNIQUE
• Pt in supine / prone position • With moderate traction • arm abducted & externally rotated • humeral head is manually manipulated back into joint
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DEFINITIVE NONOPERATIVE TREATMENT
reduction confirmed by radiographs exact protocol for immobilization : controversial simple sling : preferred immobilization , protection and rehabilitation strengthening of rotator cuff M. , deltoid & scapular stabilizers
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OPERATIVE TREATMENT
SURGICAL STABILISATION FOR ANT . INSTABILITY in failed appropriate non operative treatment recurrent dislocation at young age irreducible dislocation open dislocation unstable joint reduction 1st dislocation in young pt with high demand activity
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SURGICAL OPTIONS
arthroscopic surgery open tech. with soft tissue repair open tech. with bony augmentation
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Surgery cont.’
• Open preferred over arthroscopy in • Procedures involving isolation & fixation of
bony fragment • Large hill- sachs lesion • Substantial glenoid defect • HAGL lesion : humeral avulsion of gleno -
humeral ligament
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ARTHROSCOPIC PROCEDURES
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PROCEDURE
Begins with complete examination of joint Glenoid bony defect > 25 % convert to open Two anterior portals : one immediately superior to
subscapularis , other superior edge of rotator interval Accessory inferior portal also can be used Capsulolabral complex identified , advanced to anatomical
position , suture anchor inserted into rim . no instrument should enter the joint inferior to subscapularis –
nearby axillary nerve Pre op exam – consistent with rotator interval laxity ( + ve
sulcus sign ) – rotator interval closure Capsular redundancy addressed simultaneously
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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
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Bankart procedure
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LATERJET PROCEDURE
For anterior stabilization with ass. Glenoid def. with engaging hill-sachs lesion The graft lengthens the articular arc to prevent hill-
sachs lesion from engaging Coracoid process is transferred to the glenoid rim ,
extraarticularly & fixed with two screws
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LATERJET PROCEDURE
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LATERJET PROCEDURE
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LATERJET PROCEDURE
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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
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BRISTOW OPERATION
coracoid process must be near ( < 5mm from glenoid rim ) but not over the rim
Used when previous procedures resulted in dysfunctional subscapularis & backup procedure when secure capsulolabral reconstruction is not obtained
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BRISTOW OPERATION
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BRISTOW OPERATION
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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
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PUTTI-PLAT OPERATION
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PUTTI-PLAT OPERATION
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MAGNUSON & STACK OPERATION
Ant. Capsulomuscular wall tightened by advancing the capsule & tendon of subscapularis M laterally on the humerus
Adv : simple & good success rate Disadv : cant correct labral or capsular defect
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MAGNUSON & STACK OPERATION
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EDEN – HYBBINETTE PROCEDURE•
• Places tricortical iliac graft • Intraarticularly or extraarticularly
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WEBER SUBCAPITAL OSTEOTOMY-
- For large posterior defects in humeral head - To rotate the hill sachs lesion more posterolaterally
-by increasing humeral retroversion - it doesn’t encounter the glenoid during normal rotation
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PECTORALIS MAJOR transfer for subscapularis deficiency
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For severe capsular deficiency
Reconstruction with : Semitendinosus autograft Hamstring tendon Iliotibial band fascia Achilles tendon
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Grafting
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Cont.’
Large engaging hill-sachs lesion involving 20 – 30 % of humeral head acute – disimapction & bone grafting chronic – transfer of infraspinatous tendon - 30 – 40 % - fresh frozen allograft / humeral
rotational osteotomy + imbrication of ant. Capsule and subscapularis tendon
- > 45 % prosthetic replacement
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TREATMENT FOR MULTIDIRECTIONAL INSTABILITY
In most cases generalized ligamentous laxity - Primary treatment : non operative strengthening of
dynamic stabilizers - Surgical only if failed conservative treatment disability
frequent & significant not a voluntary dislocator Primary abnormality : loose redundant inferior pouch - Detach the capsule from the humeral neck & shift to
opposite side - Approach : ant / posterior depends on direction of greatest
instability
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NEER TECH OF CAPSULAR SHIFT
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O’BRIEN TECH OF CAPSULAR SHIFT
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MANAGEMENT OF POSTERIOR INSTABILITY
- initial management : conservative - surgery in failed conservative , habitual dislocation ruled out
& emotionally stable 1. posterior capsulorrhaphy 2. neer inferior capsular shift through posterior approach - 3. posterior capsular tendon retensioning 4. posterior glenoid osteotomy – if glenoid retroversion > 20
degree 5. mclaughlin procedure - if reverse hill-sachs lesion –
subscapularis tendon into the defect ( modified – along with tuberosity )
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POSTERIOR CAPSULAR RETENSIONING
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Mclaughlin operation
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MODIFIED Mc LAUGHLIN PROCEDURE
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NEER INFERIOR CAPSULAR SHIFT – POSTERIOR APPROACH
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GLENOID OSTEOTOMY
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Supportive management
• Wound care• analgesics• Antibiotics • Enough rest • Avoid movement of affected joint • Nutritional support with balanced diet• Avoid lifting heavy objects
Oxygenate and Resuscitate Before You Operate
“Failure to promptly recognize and treat simple life-threatening injuries is the tragedy of trauma, not the inability to handle the catastrophic or complicated injury.”(F.William Blaisdell)
GOOD JUDGMENT COMES FROM EXPERIENCE
EXPERIENCE COMES FROM BAD JUDGMENT
• THIS IS THE END OF OUR PRESENTATION
• HAVE A NICE DAY : LADIES AND GENTLEMEN
