Shoulder Dislocation Past Paper PDF 2024/2025

Ministry of Higher Faculty Of Medicine Education and Research Ibn El Jazzar Sousse University of Sousse SHOULDER DISLOCATIONS ORTHOPEDICS DCEM 1...

Ministry of Higher Faculty Of Medicine Education and Research Ibn El Jazzar Sousse University of Sousse SHOULDER DISLOCATIONS ORTHOPEDICS DCEM 1 SELF-LEARNING MODULE Dr. Sofien BENZARTI 2024 / 2025 Orthopedics 2024-2025 Dr BENZARTI. S Pre-test 1) The factors involved in the recurrence of antero-internal dislocation of the shoulder are: A Ligamentous hyperlaxity B Age less than 20 years C Lesions of the upper gleno-humeral ligament D Failure to comply with immobilization deadlines after reduction of a dislocation E Fracture of the upper edge of the glenoid 2) An anterior dislocation of the glenohumeral joint can be complicated by: A. Subscapular nerve injury B. Fracture of the greater tubercle C. Compression of the axillary artery D. Posterosuperior osteochondral impaction of the humeral head E. Rotator cuff tear 3) What is the most suggestive clinical sign of a posterior shoulder dislocation? A. Emptiness of the glenoid B. Arm in abduction and external rotation C. Limitation of external rotation D. Filling of the deltopectoral groove E. Elastic resistance during adduction or bringing the arm closer to the body's axis Answers : 1- A-B-D 2- B-C-D-E 3- C Orthopedics 2024-2025 Dr BENZARTI. S OBJECTIVES: 1) List the main types of shoulder dislocations. The student should be able to identify the most common traumatic injuries of the shoulder: scapulohumeral dislocation, acromioclavicular dislocation, and sternoclavicular dislocation. 2) Describe the injury mechanisms and the anatomopathological varieties of each type of shoulder dislocation. The student should be able to describe the injury mechanisms involved in each type of traumatic shoulder dislocation, as well as the different anatomopathological forms. 3) Make a positive diagnosis of each type of shoulder dislocation based on a combination of anamnesis, clinical, and radiological arguments. The student should be able to establish a positive diagnosis of each type of traumatic shoulder dislocation based on physical examination findings and radiological assessment results. 4) Recognize the specific complications of different types of traumatic shoulder dislocations. The student should be able to identify the immediate, secondary, and late complications of each type of shoulder dislocation. 5) Plan the management of each type of shoulder dislocation. The student should be able to propose a therapeutic approach for a traumatic shoulder dislocation. Orthopedics 2024-2025 Dr BENZARTI. S Learning Activity 1 A 25-year-old patient presents to the emergency department with total functional impairment of the right upper limb following a sports accident. The appearance of the upper limb is shown in photo A. A front-facing X-ray of the right shoulder has been taken; see photo B. 1. Describe the inspection of the right shoulder: - Asymmetry of the shoulders - Shoulder pad sign - Subacromial emptiness 2. Interpret the X-ray of the shoulder: - Complete loss of contact between the humeral head and the glenoid - Humeral head displaced downward and inward 3. What is your diagnosis? - Glenohumeral dislocation 4. Name the most frequent immediate complication: - Axillary nerve (or circumflex) injury 5. What is your management plan? - Reduction - As an emergency - Under general anesthesia  Orthopedics 2024-2025 Dr BENZARTI. S SHOULDER DISLOCATIONS I) Introduction The shoulder is composed of three true joints: Glenohumeral joint Acromioclavicular joint Sternoclavicular joint These three joints can be the site of dislocations, especially the glenohumeral joint, as it is the most mobile joint in the body and its stability is primarily maintained by capsuloligamentous and muscular elements. Acromioclavicular joint Sternoclavicular joint Glenohumeral joint II) Glenohumeral Dislocation This is the loss of normal alignment between the humeral head and the glenoid cavity of the scapula. It mainly affects young individuals and is characterized by a high frequency of recurrences. These are true traumatic emergencies. There are 4 types of glenohumeral dislocation based on the displacement of the humeral head: ✓ Anterointernal dislocation: the most common, 96% ✓ Posterior dislocation: 4% of dislocations ✓ Inferior dislocation: very rare ✓ Superior dislocation: exceptional A) Anterointernal Dislocation 1. Mechanisms It results from either: A direct mechanism such as a fall on the posterior aspect of the shoulder An indirect mechanism, which is the most common, such as: A fall on the upper limb: arm in abduction, retroversion, and external rotation A resisted arm movement Orthopedics 2024-2025 Dr BENZARTI. S Direct mechanism of Indirect mechanism of anterointernal dislocation anterointernal dislocation 2) Clinical Study 2.1) History Taking It should specify: ✓ The patient's medical history ✓ The type of sport practiced ✓ The number of episodes ✓ The mechanism of dislocation ✓ The time of the trauma 2.2) Inspection Inspection from the front and side of the shoulder helps identify signs indicative of anterointernal dislocation. From the front: Shoulder pad sign: flattened shoulder with prominence of the acromion outward External hammer sign: subacromial depression Arm in abduction and external rotation From the side: Filling of the deltopectoral groove with forward bulging of the humeral head The shoulder contour is widened in the anteroposterior direction Shoulder Pad sign Glenoid emptiness Filling of the deltopectoral groove Arm in abduction and external rotation Orthopedics 2024-2025 Dr BENZARTI. S 2.1) Palpation It reveals: ✓ Subacromial emptiness ✓ Humeral head palpated in the axilla or axillary hollow ✓ Berger's sign: elastic resistance during adduction or bringing the arm closer to the body’s axis; irreducible abduction 2.2) Search for Associated Complications Vascular: Check for color, warmth, and any potential pulsatile axillary hematoma. Distal pulse palpation (radial pulse) is mandatory in the presence of a glenohumeral dislocation. Nervous: Test the sensation of the shoulder stump and isometric contraction of the deltoid, which depend on the axillary nerve. Bone: Swelling and bruising 3) Radiological Study A front-facing X-ray is sufficient to: Establish the diagnosis Determine the type of dislocation Identify associated bone lesions It is mandatory before any reduction and constitutes a medico-legal requirement. (Photo) 4) Associated Lesions 4.1) Bone Lesions ✓ Glenoid: Fracture or detachment of its anteroinferior rim ✓ Humeral Head: Posterosuperior notch of Malgaigne due to impaction of the head on the anteroinferior rim of the glenoid ✓ Others: Fracture of the humeral neck, fracture of the greater tubercle, and fracture of the coracoid process Orthopedics 2024 Dr BENZARTI. S Detachment of the glenoid Posterosuperior notch of Malgaigne 4.2) Ligamentous lesions Avulsion of the labrum associated with an injury to the inferior glenohumeral ligament: Bankart lesion and a capsular detachment forming the Hartman-Broca dislocation pocket. Dislocation pocket 4.3) Tendon lesions of the rotator cuff: ✓ Rupture of the subscapularis + dislocation of the long biceps ✓ Rupture of the supraspinatus and infraspinatus (partial or complete) ✓ Lesion of the long head of the biceps. 5) Clinical Forms Irreducible dislocation: Muscle incarceration or a bony fragment, or impaction of the head at the level of the glenoid. Chronic dislocation: Persisting beyond 3 weeks. Intractable dislocation: The dislocation reoccurs immediately after reduction. Orthopedics 2024 Dr BENZARTI. S Complicated Forms: Vascular and nerve complications, fracture of the head or glenoid, rotator cuff tear. 6) Evolution 6.1) Favorable evolution without recurrence 6.2) Immediate complications: See clinical forms. 6.3) Late complications: ✓ Chronic dislocations ✓ Scapulohumeral periarthritis: May manifest as a painful or pseudo-paralytic shoulder, or even a blocked shoulder. ✓ Painful and pseudo-paralytic syndrome is known as rotator cuff syndrome, which may involve isolated or associated tendinitis of the long biceps, supraspinatus, infraspinatus, and subscapularis, with or without partial or total tears of these muscles. ✓ Recurrent shoulder dislocations: Characterized by instability with episodes of dislocation, subluxation, or a painful shoulder syndrome. Radiographic assessment (front – Bernageau profile) may show indirect signs such as glenoid detachment or fracture, a notch in the humeral head, or a labral lesion on arthro- CT. 7) Treatment 7.1) Reduction Reduction on-site is to be avoided (issues with medico-legal implications). Reduction under general anesthesia within < 6 hours: « Hippocratic » traction technique: Apply traction along the axis of the limb and push on the humeral head which is in the axillary hollow. The sensation of a "click" indicates the dislocation has been reduced. 7.2) Immobilization Immobilization with a "Mayo Clinic" type bandage. Duration is variable, depending on age, for the first episode: < 20 years: 6 weeks (risk of recurrence) 20 years < age < 30 years: 4 weeks 30 years: 3 weeks (risk of capsulitis) 7.3) Rehabilitation Orthopedics 2024 Dr BENZARTI. S It is a necessary complement to the recovery of joint mobility and adequate muscle strength. 7.4) Treatment of Complications: Nerve: Observe, check with EMG, consider nerve surgery if no recovery is observed. Vascular: To be treated urgently. Fracture: Fixation of humeral neck fractures. Rotator Cuff Syndrome: Rehabilitation ; if there is a complete tear : surgery. Recurrent Shoulder Dislocation: Glenoid bone block, which is the Latarjet procedure. B) Posterior Dislocation 1) Mechanism: Direct: Direct anterior impact on the shoulder. Indirect: Seizures (in the right shoulder), electrocution, fall on the hand with internal rotation. 2) Clinical Study 2.1) History Taking It should specify: ✓ The patient's medical history ✓ The type of sport practiced ✓ The number of episodes ✓ The mechanism of the dislocation ✓ The time of the trauma 2.2) Clinical Examination The typical presentation of a posterior shoulder dislocation is an arm held in adduction and internal rotation. Deformation is not obvious. Palpation reveals glenoid emptiness with an anterior hollow and a posterior bulge of the shoulder. The constant and most suggestive sign of posterior dislocation is limited external rotation and anterior elevation of the arm. Neurovascular examination is mandatory. 3) Radiological Study Radiological views should always include a front-facing X-ray of the glenohumeral joint and, importantly, an axillary profile. 3.1) Front-Facing X-ray ✓ Loss of congruence with disappearance of the joint space between the humeral head and the anterior edge of the glenoid. ✓ "Lightbulb sign": Rounded appearance of the humeral head that is in forced internal rotation. ✓ Rupture of the cervicoscapular girdle. Orthopedics 2024 Dr BENZARTI. S Disappearance of the joint space et rupture of the cervicoscapular girdle A. Normal shoulder. B. Dislocated shoulder: "Lightbulb sign" with loss of congruence of the joint space. 3.2) Axillary Profile X-ray The glenohumeral translation is clearly visible and allows visualization of the McLaughlin notch. Axillaire profile X-ray showing a posterior dislocation and the Mclaughlin notch Orthopedics 2024 Dr BENZARTI. S 3.3) Shoulder CT Scan It allows for diagnosis in case of doubt and provides a better study of associated bone lesions. 4) Associated Lesions 4.1) Bone Lesions  Osteochondral impaction: Anteriosuperior notch of the humeral head, known as McLaughlin's notch.  Fracture of the posterior rim of the glenoid.  Fracture of the humeral head. 4.2) Capsuloligamentous Lesions Posterior capsuloligamentous lesions are similar to those in anterior dislocation. 4.3) Vascular and Nerve Lesions  Vascular: Axillary artery  Nerve: Axillary nerve and subscapular nerve 5) Treatment The treatment mainly depends on the size of McLaughlin's notch: Acute dislocation with a notch < 40% of the head size: Reduction under general anesthesia and immobilization with a sling and elbow at the body in external rotation for 4 weeks, followed by rehabilitation. Acute dislocation with a notch > 40% of the head size or humeral head fracture or failure of a closed reduction attempt: Open reduction with additional surgical procedures. 6) Late Complications  Residual instability: The most common  Omarthrosis  Post-traumatic stiffness  Avascular necrosis C) Inferior Dislocation "erecta" Erecta dislocation is a rare form of shoulder dislocations with an incidence estimated at 0.5% of all shoulder dislocations. 1) Mechanism Direct mechanism: Application of violent abduction forces on a limb initially in abduction. Indirect mechanism: Application of heavy load on a limb in full abduction. 2) Clinical Study  Typical shoulder position: Arm raised, in forced abduction with inability to bring the elbow to the body.  Palpation: Humeral head in the axillary hollow.  Glenoid emptiness and changes in muscle and bone contours.  May be mistaken for anterior dislocation. Orthopedics 2024 Dr BENZARTI. S The vascular and nerve examination is of paramount importance, as the humeral head in this case lodges in the axillary hollow. 3) Radiological study Front-facing and axillary profile X-rays of the shoulder are necessary: the humeral head projected below the inferior pole of the glenoid and the humeral diaphysis always above the horizontal. They help to identify associated bone lesions, the most common of which is the fracture of the greater tubercle.. 4) Treatment Emergency reduction under general anesthesia through traction along the arm's axis and then adduction, followed by immobilization with a sling and elbow at the body for 3 to 6 weeks, followed by rehabilitation D) Superior Dislocation ⦿ Exceptional ⦿ Often associated with a fracture of the acromial vault III) Acromioclavicular Dislocations Acromioclavicular dislocations account for about 10% of dislocations occurring at the shoulder girdle. The most common cause is a lateral trauma to the shoulder, often seen in athletes (rugby, judo, and weightlifting). Orthopedics 2024 Dr BENZARTI. S A) Mechanism It is most often a direct trauma from falling on the shoulder. The impact occurs on the acromion, which is pushed downward, inward, and forward, putting tension on the capsuloligamentous structures of this joint. Thus, it is the abrupt lowering of the scapula relative to the clavicle. B) Classification Acromioclavicular stability is maintained by a double system:  The superior acromioclavicular ligament  The coracoclavicular ligaments, including the strong conoid (vertical) and trapezoid (oblique from bottom to top and from front to back) ligaments. These two ligaments ensure anteroposterior and vertical stability. Acromioclavicular Conoid joint Clavicle Acromioclavicular ligament ligament Trapezoid ligament The most commonly used classification is the Rockwood classification, which is currently the most popular and most suitable. It correlates a stage with a level of ligamentous injury. Rockwood Classification Orthopedics 2024 Dr BENZARTI. S Stage 1 Stretching of the acromioclavicular ligament. Stage 2 Tear of the acromioclavicular ligament. Stage 3 Tear of the acromioclavicular ligament and the coracoclavicular ligaments. Stage 4 Stage 3 + posterior dislocation of the clavicle. Stage 5 Stage 3 + detachment of the trapezius and deltoid muscles from the clavicle. Stage 6 Stage 3 + inferior dislocation of the clavicle. C) Clinical study: acromioclavicular dislocation stage 3  Shoulder pain  Acromioclavicular swelling with elevation of the outer end of the clavicle  Anterior-posterior drawer test  "Piano key" sign: increased anteroinferior and superoinferior laxity The "piano key sign" is a clinical term often used to describe a condition where there is instability or abnormal mobility of the distal end of the clavicle, typically seen in cases of acromioclavicular joint dislocation or injury. When pressing down on the lateral end of the clavicle, it behaves like a piano key, bouncing back when pressure is released. This sign indicates injury to the ligaments supporting the acromioclavicular joint Stages 1 and 2 present with pain around the acromioclavicular joint without deformation. D) Radiological study A front-facing X-ray of the shoulder is generally sufficient to make the diagnosis. Front facing X-ray showing acromioclavicular dislocation stage 3 Orthopedics 2024 Dr BENZARTI. S E) Treatment Stages 1 and 2: Analgesic or anti-inflammatory treatment. Stage 3 (non-athletic or inactive): Medical treatment with a sling for 2-3 weeks. Stage 3 (athletic or active), and stages 4, 5, 6: Surgical reduction with fixation using ligamentoplasty. IV) Sternoclavicular dislocations These are rare injuries (3% of shoulder injuries) primarily encountered in young adults, resulting in a loss of contact between the clavicle and the sternum, which represents the only articulation between the upper limb and the trunk. A) Anatomical reminder Sternoclavicular stability is maintained by a powerful ligamentous apparatus:  The superior sternoclavicular ligament, reinforced by the interclavicular ligament.  The sternoclavicular ligaments (anterior and posterior).  The costoclavicular ligament, which is oblique upwards and outwards. These three ligaments limit clavicular elevation as well as its anteroposterior displacement. B) Type and mechanism There are two types: anterior and posterior. The trauma is often severe: traffic accidents, sports injuries. It involves a shock to the shoulder while the other shoulder is fixed. The position of the injured shoulder and the direction of the impact determine the direction of displacement. Anterior dislocation: When the impact is anteroposterior on a lowered shoulder with retro-pulsion. Posterior dislocation: When the impact is from back to front on a shoulder in forward flexion and internal rotation. The clavicle may injure or compress the airways, digestive tract, vessels, or nerves of the same side upper limb. Mechanism of the sternoclavicular dislocation (anterior and posterior) Orthopedics 2024 Dr BENZARTI. S Anatomical Relations Behind the Clavicle (according to F.H. Netter's Atlas of Human Anatomy) C) Clinical study History of trauma to the shoulder followed by sternoclavicular pain. In anterior dislocation, the clavicle is displaced forward on examination. In posterior dislocation, the examination reveals a depression indicating a posterior dislocation. It is important to always look for signs of anterior mediastinal compression, which can range from simple hoarseness to shortness of breath and difficulty swallowing, or sometimes weakness or tingling in the upper limb. In cases of severe trauma, the displacement can be significant, leading to more serious compressions that require urgent treatment. Orthopedics 2024 Dr BENZARTI. S D) Radiological study The radiological examination from the front and ¾ view centered on the sternoclavicular joint is of little interest. However, the lateral view of the sternum centered on the sternoclavicular joint shows the direction of the displacement and assesses its severity. A CT scan is the examination that allows for a proper analysis of the injury. CT scan of a posterior sternoclavicular dislocation V) Conclusion Shoulder dislocations are common and can occur at any of the three joints. The most frequent dislocation is anterior glenohumeral dislocation. These dislocations primarily affect young adults and are often the result of sports accidents. They are both diagnostic (dislocation, complications, associated injuries) and therapeutic emergencies. Orthopedics 2024 Dr BENZARTI. S References 1. Steven Cutts, Mark Prempeh, Steven Drew. Anterior shoulder dislocation. Ann R Coll Surg Engl 2009; 91: 2–7. 2. F.Z. Dahmi, M. Moujtahid, Y. El Andaloussi, Y. Bekkali, T. Zaouari, M. Nechad, M. Ouarab. Luxation erecta de l’épaule à propos de huit cas. Chirurgie de la main 27 (2008) 167–170. 3. Yanaturali S, Aksay E, James Holliman C, Duman O, Ozen YK. Luxatio erecta: clinical presentation and management in the emergency department. J Emerg Med 2005;29:85–9. 4. G. Cunningham, P. Hoffmeyer. Luxation postérieure de l’épaule, défis diagnostiques et thérapeutiques. Rev Med Suisse 2011; 7: 2489-93. 5. Schliemann B, Muder D, Gessmann J, et al. Locked posterior shoulder dislocation: Treatment options and clinical outcomes. Arch Orthop Trauma Surg 2011; 131:1127-34. 6. Rockwood CA. Injuries to the acromioclavicular joint. In: Rockwood CA, Grenn DP, eds. Fractures in Adults, Vol. 1, 2nd ed. Philadelphia: Lippincott, 1984:860. 7. Patte D. Les luxations traumatiques des articulations acromio-claviculaires et sterno-claviculaires. Conférences d’enseignement 1987, Cahier d’enseignement de la SOFCOT, n° 28 1987;133-57. 8. Buckerfield CT, Castle ME. Acute traumatic retrosternal dislocation of the clavicle. J Bone Joint Surg Am 1984;66(3): 379-385. 9. Garretson RB, 3rd, Williams GR, Jr. Clinical evaluation of injuries to the acromioclavicular and sternoclavicular joints. Clin Sports Med 2003;22(2): 239-254. Orthopedics 2024 Dr BENZARTI. S Post-test 1) The factors involved in the recurrence of antero-internal dislocation of the shoulder are: A Ligamentous hyperlaxity B Age less than 20 years C Lesions of the upper gleno-humeral ligament D Failure to comply with immobilization deadlines after reduction of a dislocation E Fracture of the upper edge of the glenoid 2) An anterior dislocation of the glenohumeral joint can be complicated by: A. Subscapular nerve injury B. Fracture of the greater tubercle C. Compression of the axillary artery D. Posterosuperior osteochondral impaction of the humeral head E. Rotator cuff tear 3) What is the most suggestive clinical sign of a posterior shoulder dislocation? A. Emptiness of the glenoid B. Arm in abduction and external rotation C. Limitation of external rotation D. Filling of the deltopectoral groove E. Elastic resistance during adduction or bringing the arm closer to the body's axis Answers : 1- A-B-D 2- B-C-D-E 3- C