Shoulder Dislocation PDF

Dislocation Of The Shoulder -Mostly anterior > 95 % of dislocations. -Posterior dislocation occurs < 5 %. -True inferior dislocation ( luxato infero ) occurs < 1%. -Multi directional dislocation due to ligament laxity and is painless. Mechanism Of Anterior Shoulder Dislocation Usually indirect fal...

Dislocation Of The Shoulder -Mostly anterior > 95 % of dislocations. -Posterior dislocation occurs < 5 %. -True inferior dislocation ( luxato infero ) occurs < 1%. -Multi directional dislocation due to ligament laxity and is painless. Mechanism Of Anterior Shoulder Dislocation Usually indirect fall. It may be direct when there is a blow on the shoulder from behind. It is caused by the arm being positioned in an excessive amount of abduction and external rotation (the glenohumeral joint is most susceptible to dislocation in the 90 degree abduction and 90 degree external rotation).  Complications of anterior shoulder dislocation -Bony: bony Bankart, Hill-Sachs Lesion, neck of humerus, Greater or lesser Tuberosity Fracture. -Soft Tissue: Soft tissue Bankart lesion, Subscapularis Tear, RCT (older pts with dislocation). -Vascular: Axillary artery injury, avascular necrosis of the head of the Humerus -Nerve: Axillary nerve neuropraxia. -Recurrent dislocation. -Shoulder stiffness with prolonged immobilization A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. Bony Bankart lesion shows besides the soft tissue damage also a fracture of the anteroinferior glenoid rim. Hill–Sachs fracture, is a cortical depression in the posterolateral head of the humerus. It results from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly. Reverse Hill Sach’s Lesion, It is defect in Antero medial part aspect of humerus head in posterior dislocation of shoulder.  Tests for anterior shoulder dislocation Dugas test (inability to touch the opposite shoulder by affected hand).This test is used if an unreduced anterior shoulder dislocation is suspected. The patient is asked to place the hand on the opposite shoulder and then attempt to lower the elbow to the chest. With an anterior dislocation, this is not possible, and pain in the shoulder results. If the pain is only over the acromioclavicular joint, problems in that joint should be suspected.  Clinical picture of anterior dislocation a. Arm held in an abducted and ER position, internal rotation and adduction may be limited. b. Loss of normal contour of the deltoid and acromion prominent posteriorly and laterally c. Humeral head palpable anteriorly d. All movements limited and painful E-Palpable fullness below the coracoid process and towards the axilla A clinician can determine if an axillary artery injury is present by looking for reduced pulse pressure or a transient coolness in the hands. Peripheral nerve injuries following an anterior dislocation is common because of the proximity of the brachial plexus.  Posterior Dislocation Rare, commonly missed, more among epileptics and electrocution which cause overpull of subscapularis and latissimus dorsi and may led to posterior dislocation. It is caused by an external blow to the front of the shoulder. There is an indirect force applied to the humerus that combines flexion, adduction, and internal rotation. This is usually the result of one falling on an out stretched hand (FOOSH injury). Imaging easily missed, lateral view is essential. An axillary view is a preferred view for diagnosis. Look for “light bulb sign. Posterior shoulder dislocation  Clinical Picture of Posterior Dislocation a. Arm is adducted and internal rotation. Clinically locked in internal rotation and unable to externally rotate the shoulder b. May or may not lose deltoid contour c. May notice posterior prominence head of humerus d. Tear of subscapularis muscle (weak or cannot internally rotate)  Luxtio Erecta Also known as inferior dislocation of shoulder. Caused by severe hyper abduction of force. Arm presents in abducted position. Reduce with in-line traction and gentle adduction.  Management Of Shoulder Dislocation Is an emergency, it should be reduced in less than 24 hours or there may be avascular necrosis of head of humerus. Reduction may closed or surgical open reduction Methods Of anterior Shoulder closed Reduction -Hippocratic method -Stimson’s gravity method -Kocher’s method  Hippocratic Method By holds the patients affected arm by wrist and applies traction at a 45 angle. At the same time provides counter traction by placing foot on the patients chest wall or having an assistant wrap a sheet around the patient.  Stimpson’s Technique The patient is kept in prone position on bed. The affected shoulder is supported and the arm is left to hang over the edge of the bed. A weight is attached to the elbow or wrist. It is usual to begin with 2kg up to 10 kg may be applied. Gravity stretches the muscles and reduction occurs. Gentle internal humeral rotation may be applied. This method takes 15 to 20 minutes.  Operative Treatment Operative Indications Irreducible shoulder (soft tissue interposition). Displaced greater tuberosity fractures. Glenoid rim fractures bigger than 5 mm. Other indications for operative intervention include three or more recurrent dislocations in a year and dislocations that occur at rest or during sleep. The non operative treatment options for anterior, posterior, and multidirectional glenohumeral instability all center on the same core issues. The immediate goals are to decrease pain and edema, protect the static stabilizers, and strengthen the dynamic stabilizers. The ultimate aim is to increase overall shoulder stability, which is facilitated via exercises designed to enhance joint proprioception and address kinetic chain deficits. N.B: Strengthening of the rotator cuff muscle and scapular muscle (mainly lower trapezius and serratus anterior is the main target in any program. After either intervention the management is similar. However, if it is a surgical procedure, knowing what type of surgery was performed as well as the precautions post surgery. Typical precautions are: If subscapularis was cut, no resisted internal rotation for 4-6 weeks. External rotation usually limited to 30 degrees initially, then 45 degrees at 6 weeks. Avoid provocative positions of the shoulder that risk recurrent of anterior shoulder dislocation: External rotation Abduction Distraction Extension, which puts additional stress on anterior structures.  Rehabilitation Phase 1 (up to 6 weeks): Goal is to maintain anterior-inferior stability After reduction (closed or open), immobilization is done. It has traditionally been thought to be immobilized with internal rotation, but according to Miller, immobilization has been beneficial in external rotation because there is more contact force between the glenoid labrum and the glenoid. The rationale for placement of the arm in external rotation centers on the fact that the Bankart lesion is forced to separate from the glenoid when the arm is placed in internal rotation, which may be detrimental to healing. In contrast, the authors describe how placing the arm in external rotation approximates the lesion to its correct anatomic position, allowing for a better healing process. Immobilization After Reduction There is currently no consensus on the duration of immobilization in a sling. But, typical time periods in a sling range for 3-6 weeks if under the age of 40 and 1-2 weeks if older than the age of 40. During the immobilization period, the focus is on AROM of the elbow, wrist and hand and reduction of pain. Isometrics can be incorporated for the rotator cuff and biceps musculature. Codman Exercises (Pendulum exercises) AAROM for external rotation (0-30º) and forward elevation (0-90º) Isometric exercises Phase 2 (6-12 weeks): Goal is to restore adequate motion, specifically in external rotation AAROM to achieve full range of motion When stretching is permitted, passively stretch the posterior joint capsule through the use of joint mobilizations or self-stretching. No strengthening or repetitive exercises should start until achievement of full range of motion. Phase 3 (12-24 weeks): Successful return to sports or physical activities of daily living. Begin strengthening exercise, strengthening exercises should be impairment- based. Typically begin strengthening exercise in a pain-free motion with exercises for stability. A possible progression could begin by focusing on the rotator cuff musculature and scapular stabilizers, which include trapezius, serratus, levator scapulae, and rhomboids. Then, progress to the larger musculature such as the deltoids, latissimus dorsi, and pectorals. Start focusing on functional exercises include proprioceptive training  Elastic band exercises examples Endurance and strength exercises Posterior Dislocation Management for posterior dislocation follows the same progression as anterior protocol, except for the following guidelines: a. Posterior glide is contraindicated, Avoid posterior capsule stretch by avoiding active ER or passive IR. b. Avoid flexion with adduction and internal rotation c. Immobilized 3-6 weeks if less than 40 years of age and 2-3 weeks if greater than 40 years of age d. Strengthening will focus primarily on posterior musculature such as: infraspinatus, teres minor and posterior deltoid  Fractures Of The Humerus -Proximal Humerus (includes surgical and anatomical neck, greater and lesser tuberosity). -Shaft of Humerus. -Distal humerus (fracture of condyle, epicondyles, supra condylar fracture).