Shoulder Shoulder DislocationsDislocations

fahad zakwanfahad zakwan md5md5

OverviewOverviewCommon shoulder and humerus injuries seen in the EDCommon shoulder and humerus injuries seen in the EDFor each injuryFor each injury

MechanismMechanismPhysical examPhysical examDiagnostic imagingDiagnostic imagingClassificationClassificationManagementManagementWatch out!Watch out!

INJURIES TO BE COVEREDINJURIES TO BE COVERED

Shoulder dislocationShoulder dislocationHumeral FracturesHumeral Fracturesproximalproximalmid shaftmid shaftdistaldistal

SHOULDER SHOULDER DISLOCATIONDISLOCATIONApproximately Approximately 50%50% of all major joint dislocations of all major joint dislocations involve the glenohumeral joint. involve the glenohumeral joint.

Dislocations are commonly classified by Dislocations are commonly classified by directiondirection ( (anterioranterior, inferior, posterior, or , inferior, posterior, or

multidirectional), multidirectional), onsetonset (acute, recurrent, chronic), and by (acute, recurrent, chronic), and by etiologyetiology (traumatic, minimally traumatic, non (traumatic, minimally traumatic, non

traumatic, traumatic, microanterior microanterior instability). instability).

Men 20-30, women 60-80 years.Men 20-30, women 60-80 years.kids more prone to # through growth platekids more prone to # through growth plate

SHOULDER DISLOCATION - SHOULDER DISLOCATION - CLASSIFICATIONCLASSIFICATION

•Anterior (95-97%) Anterior (95-97%) • SubcoracoidSubcoracoid (most common – 70%) (most common – 70%)• subglenoidsubglenoid (30% - 1/3 associated with # greater (30% - 1/3 associated with # greater

tuberosity, or # glenoid rim)tuberosity, or # glenoid rim)• SubclavicularSubclavicular

•PosteriorPosterior• InferiorInferior

1. ANTERIOR DISLOCATION1. ANTERIOR DISLOCATION

subglenoid

subcoracoid

subclavicular

MechanismMechanism•Abduction + extension + posterior Abduction + extension + posterior forceforce• Forced extension along with lateral rotation will Forced extension along with lateral rotation will drive the head of the humerus forward tearing the drive the head of the humerus forward tearing the capsule or avulsing the glenoid labrum.capsule or avulsing the glenoid labrum.• The injury usually results from a traumatic event The injury usually results from a traumatic event in which the position of the arm is in an in which the position of the arm is in an externally rotated and forward-flexed externally rotated and forward-flexed or an or an abducted positionabducted position..• shoulder capsule tornshoulder capsule torn

Signs & symptoms

DeformityDeformity - step - step off (deltoid will look off (deltoid will look flattenedflattened

Arm in Arm in slight abductionslight abduction, , external rotationexternal rotationWill not be able to move shoulder jointWill not be able to move shoulder jointUnable to touch opposite shoulder with Unable to touch opposite shoulder with hand of affected sidehand of affected side

PainPain

ExaminationExamination• Individuals with an acute dislocation Individuals with an acute dislocation hold their arm in an hold their arm in an

adducted position. adducted position. • There is a There is a loss of symmetry of their shoulders loss of symmetry of their shoulders and the and the

humeral head can be palpated anterior and inferior to the humeral head can be palpated anterior and inferior to the coracoid process. coracoid process.

• Any attempt at range of motion of the shoulder is extremely Any attempt at range of motion of the shoulder is extremely painful. painful.

• A A thorough neurovascular check of the upper extremity is thorough neurovascular check of the upper extremity is necessary before any attempt is made to reduce the necessary before any attempt is made to reduce the dislocationdislocation. .

• Attention to checking the sensory function of the Attention to checking the sensory function of the axillary nerve axillary nerve over the lateral aspect of the shoulder is important.over the lateral aspect of the shoulder is important.

Shoulder Dislocation - ImagingShoulder Dislocation - Imaging

Do you want films?Do you want films?Recurrent dislocation vs primary, ?nontraumaticRecurrent dislocation vs primary, ?nontraumaticAvulsion # of greater tuberosity in 10-15%Avulsion # of greater tuberosity in 10-15%

True APTrue APAxillary viewAxillary viewtrans-scapular viewtrans-scapular viewStryker Notch: Stryker Notch: West point AxillaryWest point AxillaryApical oblique viewApical oblique view

Anterior dislocation

ManagementManagementThis is an emergency!!!This is an emergency!!!Anesthesia - conscious sedation vs intra-Anesthesia - conscious sedation vs intra-articular lidocainearticular lidocaine

Reduction (“know three methods well”)Reduction (“know three methods well”)Stimson’sStimson’sScapular rotationScapular rotationExternal rotationExternal rotationMilchMilch

Stimson maneuverStimson maneuver• Position the patient prone on elevated stretcherPosition the patient prone on elevated stretcher

• Position the affected shoulder off the Position the affected shoulder off the edge of the stretcher, hanging edge of the stretcher, hanging downwards in 90º of forward flexion.downwards in 90º of forward flexion.

• Strap the patient slightly with sheet and Strap the patient slightly with sheet and then securely fasten 2.5-5 kg of weight then securely fasten 2.5-5 kg of weight to the patients wrist to provide to the patients wrist to provide continuous traction.continuous traction.

• Instruct the patient to maintain this Instruct the patient to maintain this position for at least 15-20 minutes or position for at least 15-20 minutes or until reduction is completed.until reduction is completed.

ADVANTAGESADVANTAGES•no assistance requiredno assistance required•Shoulder is reduced with Shoulder is reduced with minimal forceminimal force

DISADVANTAGESDISADVANTAGES•patient may slip off the patient may slip off the stretcherstretcher•Patient must be monitored all Patient must be monitored all the timesthe times•Long reduction timeLong reduction time•Sufficient premedication Sufficient premedication requiredrequired

Scapular manipulationScapular manipulation• Place the patient in prone or seated Place the patient in prone or seated

position, with back exposed.position, with back exposed.

• Place the affected arm in 90º forward Place the affected arm in 90º forward flexion at the shoulder and apply slight flexion at the shoulder and apply slight traction.traction.• If in prone position, use weight (as in Stimson If in prone position, use weight (as in Stimson

technique)or have assistant apply manual down technique)or have assistant apply manual down traction.traction.

• If in seated position, have the assistant stand If in seated position, have the assistant stand facing the patient and use arm to firmly grasp facing the patient and use arm to firmly grasp the wrist of the dislocated arm. The assistant the wrist of the dislocated arm. The assistant should the apply steady forward traction parallel should the apply steady forward traction parallel to the floor while applying countertraction with to the floor while applying countertraction with the other arm, which is outstretched and resting the other arm, which is outstretched and resting on patients clavicle.on patients clavicle.

Cont…..

• Stand lateral to the affected shoulder and Stand lateral to the affected shoulder and stabilize the scapula by placing the palm of stabilize the scapula by placing the palm of one hand on the lateral aspect of the one hand on the lateral aspect of the shoulder with thumb securely on superior shoulder with thumb securely on superior lateral border. Place other palm over the lateral border. Place other palm over the inferior tip of the scapula and position the inferior tip of the scapula and position the thumb on the inferior lateral border of the thumb on the inferior lateral border of the scapula.scapula.

• Use both hands to rotate the inferior tip of Use both hands to rotate the inferior tip of the scapula medially and the superior aspect the scapula medially and the superior aspect laterally with slight dorsal placement. The laterally with slight dorsal placement. The goal is to move the glenoid fossa back into goal is to move the glenoid fossa back into anatomical position.anatomical position.

• To facilitate reduction, the assistant may To facilitate reduction, the assistant may apply, along with traction, slight external apply, along with traction, slight external rotation of the humerus, elbow flexion in 90º rotation of the humerus, elbow flexion in 90º or both.or both.

ADVANTAGESADVANTAGES•Tolerated well by Tolerated well by patientspatients•Can be performed Can be performed without premedicationwithout premedication•Minimal force requiredMinimal force requiredDISADVANTAGESDISADVANTAGES•It is difficult to locate It is difficult to locate borders of scapulaborders of scapula•Assistance is needed.Assistance is needed.

External rotation methodExternal rotation method

• Place the patient supine position on a stretcher Place the patient supine position on a stretcher

• Using one hand, adduct the affected arm tightly Using one hand, adduct the affected arm tightly to the patients sideto the patients side

• With the other hand gasp the patients wrist, bend With the other hand gasp the patients wrist, bend elbow to 90º of flexion, and then gently rotate the elbow to 90º of flexion, and then gently rotate the upper arm externally, using the fore arm as a upper arm externally, using the fore arm as a lever, without force or traction.lever, without force or traction.

• If the patient experiences pain, pause If the patient experiences pain, pause momentarily to allow the muscles to relax. After momentarily to allow the muscles to relax. After the pain has subsided continue until the coronal the pain has subsided continue until the coronal plane.plane.

• Reduction takes place btw 70-110º of external Reduction takes place btw 70-110º of external rotation and, sometimes, during return of internal rotation and, sometimes, during return of internal rotation.rotation.

ADVANTAGES•Tolerated well by pts.•Sedation not necessary•Can be performed by one person•Minimal force required

DISADVANTAGE•None!!

Milch techniqueMilch techniquePlace the patient supine / prone position on a Place the patient supine / prone position on a

stretcher with shoulder close to the edge of stretcher with shoulder close to the edge of stretcher.stretcher.

Place the affected arm in full abduction Place the affected arm in full abduction overhead or instruct patient to raise affected overhead or instruct patient to raise affected arm laterally and behind the head. Operator arm laterally and behind the head. Operator may assist abduction gently.may assist abduction gently.

With arm in full abduction, gently apply With arm in full abduction, gently apply longitudinal traction and external rotation of one longitudinal traction and external rotation of one arm.arm.

If reduction is not completed, use the thumb or If reduction is not completed, use the thumb or fingers to push the humeral head upward into fingers to push the humeral head upward into the glenoid fossa with gradual adduction of the the glenoid fossa with gradual adduction of the extended arm still held in traction.extended arm still held in traction.

ADVANTAGES•Tolerated well by pts.•Sedation not necessary•Can be performed by one person•Minimal force required

DISADVANTAGE•None!!

Spaso technique

• Place the patient supine on stretcher

• Grasp the affected arm around the wrist or distal forearm and lift vertically to the ceiling and gentle external rotation. If the patient experiences pain, wait until the muscles relax and continue gently. This may take several minutes.

• If an audible/palpable clunk is not heard, use the other hand to apply direct pressure to the humeral head.

Traction and counter Traction and counter tractiontraction

Place the patient supine position on a stretcher with bed Place the patient supine position on a stretcher with bed elevated to the height of operator ischial tuberosities.elevated to the height of operator ischial tuberosities.

Place one sheet over the patient upper chest, under the Place one sheet over the patient upper chest, under the axilla of the affected shoulder and underneath the back, so axilla of the affected shoulder and underneath the back, so that the two ends of the sheet are of equal length and open that the two ends of the sheet are of equal length and open to the unaffected side.to the unaffected side.

Standing on the unaffected side the assistant takes a firm Standing on the unaffected side the assistant takes a firm hold of each end of the sheet with each hand or securely hold of each end of the sheet with each hand or securely ties the sheet around his or her own waist at the level of ties the sheet around his or her own waist at the level of ischial tuberosities. When instructed to start the assistant ischial tuberosities. When instructed to start the assistant leans back to provide countertraction with body weight.leans back to provide countertraction with body weight.

• While maintaining the affected arm in 90º of flexion at the elbow, with While maintaining the affected arm in 90º of flexion at the elbow, with both hands around the forearm, apply traction with fully extended arms. both hands around the forearm, apply traction with fully extended arms. Use body weight not upper arm muscles to provide traction along the axis Use body weight not upper arm muscles to provide traction along the axis of dislocation while the assistant applies countertraction.of dislocation while the assistant applies countertraction.

• Alternatively if fatigued, the clinician can wrap another sheet around Alternatively if fatigued, the clinician can wrap another sheet around his/her proximal fore arm and tie it around his/ her back, letting the his/her proximal fore arm and tie it around his/ her back, letting the continuous loop sitting at the level of ischial tuberosities. While still continuous loop sitting at the level of ischial tuberosities. While still holding the elbow in flexion, step back to make the sheet taut and lean holding the elbow in flexion, step back to make the sheet taut and lean back, using bodyweight to apply traction.back, using bodyweight to apply traction.

• Apply gentle traction for several minutes until reduction is attained. At Apply gentle traction for several minutes until reduction is attained. At reduction the affected arm is usually lengthened and relaxed, with audible reduction the affected arm is usually lengthened and relaxed, with audible clunk.clunk.

Signs of successful reduction includes…

Palpable or audible clunkPalpable or audible clunkReturn of rounded shoulder Return of rounded shoulder contourcontour

Relief of painRelief of painIncrease range of motionIncrease range of motion

Shoulder Dislocation - Shoulder Dislocation - ComplicationsComplications

Bankart lesionBankart lesionprimary lesion in primary lesion in recurrent ant instabilityrecurrent ant instability

Hill Sach lesionHill Sach lesion35-40% of ant dislocations, predisposes to 35-40% of ant dislocations, predisposes to recurrent injuryrecurrent injury

recurrent dislocationrecurrent dislocationyoung adults young adults redislocationredislocation in 55-95% in 55-95%skeletally mature, < 30yo: ? Early arthroscopic skeletally mature, < 30yo: ? Early arthroscopic

reconstruction (Arthroscopy 15(5) 1999: 507-12)reconstruction (Arthroscopy 15(5) 1999: 507-12)

2. POSTERIOR 2. POSTERIOR DISLOCATIONDISLOCATION

• 2-4% of shoulder 2-4% of shoulder dislocationsdislocations• Secondary to seizure, Secondary to seizure, direct blow to direct blow to shouldershoulder•Need to dx early to Need to dx early to prevent long term prevent long term complicationscomplications

Mechanism: Mechanism:

electric shockelectric shockseizuresseizurestrauma ( alchoholics) trauma ( alchoholics) Internal rotation/adduction/flexion Internal rotation/adduction/flexion

clinical features

Arm held across Arm held across chestchest

AdductedAdductedInternally rotatedInternally rotatedFlat and squared offFlat and squared off

Examination

• An obvious clinical deformity is typically not An obvious clinical deformity is typically not present and the patient may be complaining of only present and the patient may be complaining of only minimal symptoms. minimal symptoms.

• Many posterior dislocations are not diagnosed and Many posterior dislocations are not diagnosed and reduced in the emergency department. reduced in the emergency department.

• External rotation of the shoulder is limited and External rotation of the shoulder is limited and painfulpainful, and is the , and is the hallmark of a posterior shoulder hallmark of a posterior shoulder dislocation.dislocation.

ImagingImaging

AP may appear normal!AP may appear normal!Loss of half moon elliptical overlap of humeral Loss of half moon elliptical overlap of humeral head and glenoid fossahead and glenoid fossa

Helpful radiographic signsHelpful radiographic signslight bulb signlight bulb signRim signRim signtrough signtrough sign

Lightbulb sign

Refers to abnormal AP Refers to abnormal AP radiograph appearance of the radiograph appearance of the humeral head in posterior humeral head in posterior shoulder dislocation.shoulder dislocation.

When the humerus dislocates it When the humerus dislocates it also internally rotates such that also internally rotates such that the head contour projects like a the head contour projects like a light bulb when viewed from the light bulb when viewed from the front.front.

Rim signRim sign

Distance between Distance between the medial border the medial border

of the humeral of the humeral head an anterior head an anterior

glenoid rim is glenoid rim is >6mm.>6mm.

>6mm

Trough signTrough sign• In posterior dislocation, the anterior aspect of In posterior dislocation, the anterior aspect of

the humeral head becomes impacted against the humeral head becomes impacted against the posterior glenoid rim.the posterior glenoid rim.

• With sufficient force, this causes compression With sufficient force, this causes compression fracture on the anterior aspect of the fracture on the anterior aspect of the humeral head.humeral head.

• This compression fracture is analogous to the This compression fracture is analogous to the Hill-Sachs compression fracture seen with Hill-Sachs compression fracture seen with anterior shoulder dislocation of the anterior shoulder dislocation of the Glenohumeral joint.Glenohumeral joint.

• Frontal radiographs reveal 2 nearly parallel Frontal radiographs reveal 2 nearly parallel lines in the superomedial aspect of the lines in the superomedial aspect of the humeral head.humeral head.

Shoulder DislocationPosterior: Imaging

ManagementManagement

Conscious sedation and closed reductionConscious sedation and closed reductionAxial traction, pressure on humeral head, external rotationAxial traction, pressure on humeral head, external rotationMuscle relaxation via IV sedation is Muscle relaxation via IV sedation is

recommended. Reductions can usually be recommended. Reductions can usually be obtained by gentle traction on the arm with obtained by gentle traction on the arm with an additional anterior and laterally directed an additional anterior and laterally directed force applied to the posterior aspect of the force applied to the posterior aspect of the humeral head. humeral head.

3. INFERIOR DISLOCATION 3. INFERIOR DISLOCATION (Luxatio Erecta)(Luxatio Erecta)

Rare 5%Rare 5%Arm locked overhead 110-160 deg Arm locked overhead 110-160 deg

abduction, hand resting on headabduction, hand resting on headAP radiograph: spine parallel to humerusAP radiograph: spine parallel to humerusReduce with tractionReduce with tractionMechanism axial loading foreceful Mechanism axial loading foreceful

hyperabduction.hyperabduction.Pt falls grasping object above their headPt falls grasping object above their headArm locked in abduction often fore arm Arm locked in abduction often fore arm

resting on headresting on head60% of pts have some neurologic 60% of pts have some neurologic

dysfunctiondysfunction

Shoulder DislocationInferior (Luxatio Erecta)

POSTREDUCTION POSTREDUCTION TREATMENTTREATMENT

• The shoulder should be immobilized for a brief period as needed for The shoulder should be immobilized for a brief period as needed for pain control after a dislocation or subluxation episode. pain control after a dislocation or subluxation episode.

• A range-of-motion and rotator cuff strengthening program is initiated A range-of-motion and rotator cuff strengthening program is initiated early, but the extremes of range of motion for forward flexion or early, but the extremes of range of motion for forward flexion or external rotation are avoided. external rotation are avoided.

• Patients are allowed to return to sports and other activities when the Patients are allowed to return to sports and other activities when the shoulder has good strength and minimal apprehension in an shoulder has good strength and minimal apprehension in an abducted, externally rotated position. abducted, externally rotated position.

• A general rule is the younger the patient, the higher the possibility of A general rule is the younger the patient, the higher the possibility of recurrent instability .recurrent instability .

COMPLICATIONS OF DISLOCATIONSCOMPLICATIONS OF DISLOCATIONS

1.1. Damage to the nerves originating with the brachial Damage to the nerves originating with the brachial plexus plexus The The axillary nerve axillary nerve and and musculocutaneous nerve musculocutaneous nerve are most are most commonly injured. commonly injured. Most injuries are a neuropraxia, and a full recovery is typical. Most injuries are a neuropraxia, and a full recovery is typical.

2.2. Rotator cuff tearsRotator cuff tears are common in patients older than 40 years are common in patients older than 40 years with an anterior dislocation. with an anterior dislocation. If good range of motion and strength have not returned within 3 If good range of motion and strength have not returned within 3 to 4 weeks after the injury, visualization of the rotator cuff with to 4 weeks after the injury, visualization of the rotator cuff with magnetic resonance imaging (MRI) or ultrasound is indicated.magnetic resonance imaging (MRI) or ultrasound is indicated.

Wrist drop