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What is a primary indication for operative treatment in shoulder injuries?
What is a primary indication for operative treatment in shoulder injuries?
What should be avoided to decrease the risk of recurrent anterior shoulder dislocation?
What should be avoided to decrease the risk of recurrent anterior shoulder dislocation?
What is the main focus of non-operative treatment for shoulder instability?
What is the main focus of non-operative treatment for shoulder instability?
What is recommended for the position of the arm during immobilization after reduction in shoulder injury?
What is recommended for the position of the arm during immobilization after reduction in shoulder injury?
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What is the typical duration of sling immobilization for patients under the age of 40?
What is the typical duration of sling immobilization for patients under the age of 40?
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What is a common precaution post-surgery if subscapularis was cut?
What is a common precaution post-surgery if subscapularis was cut?
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What aspect of shoulder rehabilitation is emphasized for enhancing stability?
What aspect of shoulder rehabilitation is emphasized for enhancing stability?
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Which statement about recurrent shoulder dislocations is correct for surgical intervention?
Which statement about recurrent shoulder dislocations is correct for surgical intervention?
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What is a primary goal during the first phase of rehabilitation after shoulder surgery?
What is a primary goal during the first phase of rehabilitation after shoulder surgery?
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What is a common sensation reported in patients with an axillary artery injury?
What is a common sensation reported in patients with an axillary artery injury?
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Which position is characteristic of the arm in posterior shoulder dislocation?
Which position is characteristic of the arm in posterior shoulder dislocation?
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What sign may be observed on imaging for posterior shoulder dislocation?
What sign may be observed on imaging for posterior shoulder dislocation?
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How should shoulder dislocations be managed to avoid complications like avascular necrosis?
How should shoulder dislocations be managed to avoid complications like avascular necrosis?
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What is a main feature of Luxtio Erecta?
What is a main feature of Luxtio Erecta?
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What distinguishes the Hippocratic method of closed reduction from others?
What distinguishes the Hippocratic method of closed reduction from others?
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Which technique for shoulder reduction employs gravity to aid in muscle stretching?
Which technique for shoulder reduction employs gravity to aid in muscle stretching?
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What muscle is mentioned as potentially torn during a posterior shoulder dislocation?
What muscle is mentioned as potentially torn during a posterior shoulder dislocation?
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What is associated with the mechanism of injury in posterior dislocation?
What is associated with the mechanism of injury in posterior dislocation?
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Which characteristic symptom may be observed in a patient with anterior dislocation regarding the deltoid contour?
Which characteristic symptom may be observed in a patient with anterior dislocation regarding the deltoid contour?
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What percentage of shoulder dislocations are typically anterior?
What percentage of shoulder dislocations are typically anterior?
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Which condition describes the result of forceful impaction of the humeral head against the glenoid rim during anterior dislocation?
Which condition describes the result of forceful impaction of the humeral head against the glenoid rim during anterior dislocation?
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Which test is specifically used to assess unreduced anterior shoulder dislocation?
Which test is specifically used to assess unreduced anterior shoulder dislocation?
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What characterizes a Bony Bankart lesion?
What characterizes a Bony Bankart lesion?
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In which position is the glenohumeral joint most susceptible to dislocation?
In which position is the glenohumeral joint most susceptible to dislocation?
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What is considered a common complication associated with anterior shoulder dislocation?
What is considered a common complication associated with anterior shoulder dislocation?
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Which statement accurately describes multi-directional dislocation of the shoulder?
Which statement accurately describes multi-directional dislocation of the shoulder?
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Which of the following is NOT a type of dislocation mentioned?
Which of the following is NOT a type of dislocation mentioned?
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What condition results from a tear of the anterior glenoid labrum due to an anterior shoulder dislocation?
What condition results from a tear of the anterior glenoid labrum due to an anterior shoulder dislocation?
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What is the typical posture of the arm in an anterior shoulder dislocation?
What is the typical posture of the arm in an anterior shoulder dislocation?
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What is the primary focus during the immobilization period after an upper extremity injury?
What is the primary focus during the immobilization period after an upper extremity injury?
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When is stretching permitted in the rehabilitation process?
When is stretching permitted in the rehabilitation process?
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In Phase 2 of rehabilitation, what is the primary goal?
In Phase 2 of rehabilitation, what is the primary goal?
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What type of exercises are advised to start in Phase 3 of rehabilitation?
What type of exercises are advised to start in Phase 3 of rehabilitation?
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Which of the following muscles should strengthening emphasize during rehabilitation for posterior dislocation?
Which of the following muscles should strengthening emphasize during rehabilitation for posterior dislocation?
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What movement should be avoided during the management of posterior dislocation?
What movement should be avoided during the management of posterior dislocation?
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How long should immobilization last for individuals under 40 years old after a posterior dislocation?
How long should immobilization last for individuals under 40 years old after a posterior dislocation?
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Which type of fracture is characterized as involving the anatomical neck of the humerus?
Which type of fracture is characterized as involving the anatomical neck of the humerus?
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Which of the following muscles is NOT considered part of the posterior musculature for strengthening?
Which of the following muscles is NOT considered part of the posterior musculature for strengthening?
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Study Notes
Shoulder Dislocations
- Anterior dislocations are the most common, making up over 95% of cases.
- Posterior dislocations are rare, occurring in less than 5%.
- True inferior dislocations are even rarer, occurring in less than 1%.
- Multidirectional dislocations are caused by ligament laxity and are often painless.
Mechanism of Anterior Shoulder Dislocation
- Most often caused by an indirect fall.
- Can also occur due to a direct blow to the shoulder from behind.
- Occurs when the arm is positioned in excessive abduction and external rotation, making the glenohumeral joint vulnerable.
Complications of Anterior Shoulder Dislocation
- Bony: Bankart lesion (anterior glenoid labrum injury), Hill-Sachs lesion (humeral head depression), neck of humerus fracture, greater or lesser tuberosity fracture.
- Soft Tissue: Soft tissue Bankart lesion, subscapularis tear, rotator cuff tear (more common in older patients with dislocation).
- Vascular: Axillary artery injury, avascular necrosis of the humeral head.
- Nerve: Axillary nerve neuropraxia.
- Other: Recurrent dislocation, shoulder stiffness (prolonged immobilization).
Bankart Lesion
- Anterior (inferior) glenoid labrum injury
- Bony bankart lesion involves a fracture of the anteroinferior glenoid rim, in addition to soft tissue damage.
Hill-Sachs Fracture
- Cortical depression in the posterolateral head of the humerus
- Occurs due to forceful impact of the humeral head against the anteroinferior glenoid rim during anterior dislocation.
Reverse Hill-Sachs Lesion
- Defect in the anteromedial aspect of the humeral head during posterior dislocation.
Tests for Anterior Shoulder Dislocation
- Dugas Test: inability to touch the opposite shoulder with the affected hand. The patient is asked to place the hand on the opposite shoulder and then attempt to lower the elbow to the chest. This is not possible with an anterior dislocation.
Clinical Picture of Anterior Dislocation
- Arm held in abducted and externally rotated position.
- Limited internal rotation and adduction.
- Loss of normal deltoid contour.
- Prominent acromion posteriorly and laterally.
- Humeral head palpable anteriorly.
- All movements are limited and painful.
- Palpable fullness below the coracoid process and towards the axilla.
Axillary Artery Injury
- Can be identified by reduced pulse pressure or transient coolness in the hands.
Peripheral Nerve Injuries
- Common complication due to proximity of the brachial plexus.
Posterior Dislocation
- Rare condition, often missed.
- More frequent in individuals with epilepsy or those who have experienced electrocution.
- Caused by overpull of the subscapularis and latissimus dorsi muscles.
- Occurs due to an external blow to the front of the shoulder.
- Results from a force applied to the humerus that combines flexion, adduction, and internal rotation.
- Often occurs due to a fall onto an outstretched hand (FOOSH injury).
- Imaging is important for diagnosis.
- Lateral view is essential.
- Axillary view is preferred to diagnose posterior dislocation.
- "Light bulb sign" may be observed on imaging.
Clinical Picture of Posterior Dislocation
- Arm is adducted and internally rotated.
- Shoulder is locked in internal rotation and unable to externally rotate.
- May or may not have loss of deltoid contour.
- Posterior prominence of the humeral head may be evident.
- Tear of the subscapularis muscle (weak or unable to internally rotate).
Luxatio Erecta (Inferior Dislocation)
- Also known as inferior dislocation of the shoulder.
- Caused by severe hyperabduction force.
- Arm is presented in abducted position.
- Reduced with in-line traction and gentle adduction.
Management of Shoulder Dislocation
- Prompt reduction is crucial (within 24 hours) to prevent avascular necrosis of the humeral head.
- Reduction can be performed closed (non-surgical) or open (surgical).
Methods of Closed Reduction for Anterior Shoulder Dislocation
- Hippocratic Method: Traction applied to the wrist at a 45-degree angle while providing counter-traction.
- Stimson’s Gravity Method: Patient lies prone with the affected arm hanging over the edge of the bed. Weight is applied to the elbow or wrist. Takes 15-20 minutes for reduction.
Operative Treatment for Shoulder Dislocation
- Indications for Surgery: Irreducible shoulder (soft tissue interposition), displaced greater tuberosity fractures, glenoid rim fractures larger than 5 mm, recurrent dislocations (3 or more in a year), dislocations at rest or during sleep.
- Goal of Non-Operative Treatment: Reduce pain and edema, protect static stabilizers, strengthen dynamic stabilizers, increase overall shoulder stability.
- Strengthening focus: Rotator cuff muscles and scapular muscles (lower trapezius and serratus anterior).
Precautions After Shoulder Surgery
- If the subscapularis was cut, avoid resisted internal rotation for 4-6 weeks.
- External rotation initially limited to 30 degrees, increasing to 45 degrees at 6 weeks.
- Avoid provocative positions: external rotation, abduction, distraction, extension.
Rehabilitation for Shoulder Dislocation
-
Phase 1 (up to 6 weeks): Goal is to maintain anterior-inferior stability.
- Immobilization after reduction (closed or open).
- Traditional immobilization in internal rotation, but external rotation is now advocated by some for better glenoid labrum healing.
- AROM exercises for elbow, wrist, and hand.
- Pain reduction.
- Isometrics for rotator cuff and biceps muscles.
- Codman Exercises (pendulum exercises).
- AAROM for external rotation (0-30°) and forward elevation (0-90°).
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Phase 2 (6-12 weeks): Goal is to restore adequate motion, specifically in external rotation.
- AAROM to achieve full range of motion.
- Passive stretching of the posterior joint capsule.
- No strengthening or repetitive exercises until full ROM is achieved.
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Phase 3 (12-24 weeks): Successful return to sports or physical activities of daily living.
- Strengthening exercises, impairment-based.
- Pain-free motion exercises.
- Focus on rotator cuff and scapular stabilizers, then larger muscles (deltoids, latissimus dorsi, pectorals).
- Functional exercises including proprioceptive training.
Posterior Dislocation Management
- Follows the same progression as anterior, with modifications:
- Posterior glide is contraindicated.
- Avoid posterior capsule stretch (avoid active external rotation or passive internal rotation).
- Avoid flexion with adduction and internal rotation.
- Immobilization for 3-6 weeks (under 40 years) or 2-3 weeks (over 40 years).
- Strengthening focuses on posterior musculature (infraspinatus, teres minor, posterior deltoid).
Fractures of the Humerus
- Proximal Humerus: Includes the surgical and anatomical neck, greater and lesser tuberosities.
- Shaft of Humerus
- Distal Humerus: Fractures of the condyle, epicondyles, supracondylar fracture.
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