Shoulder dislocation- traumatic and habitual .

Question 1

shoulder dislocation is dislocation of which joint ?

Answer 1

the glenohumeral joint

Question 2

what is the use of the glenoid labrum margining the glenoid fossa ?

Answer 2

The fibrocartiliginous labrum deepens this cavity (the glenoid cavity) and effectively increases the stability of the humeral head

Question 3

which nerve is most commonly associated with glenohumeral joint dislocation ?

Answer 3

axillary nerve

Question 4

the axillary nerve supplied what muscle ?

Answer 4

teres minor (external rotation) and deltoid muscle and skin over the shoulder

Question 5

and injury to the axillary nerve will result in ?

Answer 5

numbness in the shoulder area

deltoid having no muscle tone - loss of shoulder abduction / shoulder flexion /extension
but for axillary nerve injury look for skin sensation patient can still adduct and lift the arm due to supraspinatus muscle

Question 6

types of shoulder dislocation ?

Answer 6

anterior dislocation - comes to rest under the coracoid process

posterior dislocation

inferior shoulder dislocation

Question 7

which is the most common shoulder dislocation ?

Answer 7

anterior shoulder dislocation is the most common

have a high recurrence rate that correlates with age at dislocation

Question 8

what leads to anterior shoulder dislocation ?

Answer 8

anteriorly directed force
shoulder :abduction
external rotation

occurs when the arm is away from the body and often above head rotated backwards
or fall on outreached arm

Question 9

reoccurring anterior dislocation is often found with ?

Answer 9

greater tuberosity fracture

age < 20 (highest risk)
male

contact sports

hyperlaxity

glenoid bone loss >20-25%

Question 10

Associated injuries with traumatic anterior shoulder dislocation ?

Answer 10

labral & cartilage injuries

Bankart lesion
is an avulsion or tear in the anterior inferior labrum and anterior band of the IGHL

Humeral avulsion of the inferior glenohumeral ligament (HAGL)
associated with a higher recurrence rate if not recognized and repaired
an indication for possible open surgical repair
It can be associated with a bony avulsion fracture in which case it is referred to as bony humeral avulsion of the glenohumeral ligament (BHAGL lesion).

Glenoid labral articular defect (GLAD)
sheared off portion of articular cartilage along with the labrum

Anterior labral periosteal sleeve avulsion (ALPSA)
torn anteroinferior labrum heal medially along the anteromedial glenoid neck
associated with higher failure rates following arthroscopic repair

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fractures & bone defects

Bony Bankart lesion
is a fracture of the anterior inferior glenoid
present in up to 49% of patients with recurrent dislocations
higher risk of failure of arthroscopic treatment if not addressed
defect >20-25% is considered “critical bone loss” and is biomechanically highly unstable
stability cannot be restored with soft tissue stabilization alone
require bony procedure to restore bone loss (Latarjet-Bristow, other sources of autograft or allograft)

Hill Sachs defect
posterosuperior humeral head depression fracture (a chondral impaction) secondary to impaction with the anterior glenoid rim.
is not clinically significant

Greater tuberosity fracture
is associated with anterior dislocation in patients > 50 years of age

nerve injuries
Axillary nerve injury
is most often a transient neurapraxia of the axillary nerve

rotator cuff tears
usually > 60 years of age

Question 11

in elderly patients anterior shoulder dislocation is associated with what ?

Answer 11

rotator cuff tear

supraspinatus
infraspinatus - posterioir
teres minor - posterior
subscapularis - anteriorly

Question 12

what are the signs and symptoms of anterior shoulder dislocation?

Answer 12

apprehension test (or fear of subluxation)
patient supine with arm in 90/90 position 
increase in apprehension when more and more external rotation and inferior traction just medially to the elbow joint 
(https://www.youtube.com/watch?v=jZ29dAXKA5M)

decrease in apprehension with inferior force applied on anterioir part of the humeral head with he arm in 90/90

Question 13

treatment of anterior shoulder dislocation ?

Answer 13

dislocation is ruled out or reduced if the person can touch the opposite shoulder

always check for neurovascular injuries -Ensure adequate pulses, finger mobility (brachial plexus), and sensation at the tip of the shoulder (circumflex)

ALWAYS injecting lidocaine to the shoulder joint or sedation

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1) traction counter traction
placing the patient supinely
wrap a sheet around the axilla of dislocated shoulder and over the chest wrap the sheet around the waist of an assistant
and flex the elbow to 90 degrees, wrap another sheet around it and tie to waist and hold the patient wrist with your arms fully
extended hand
gentle external rotation can be provided to reduce the subluxation quicker

2) stimson technique
3) shoulder manipulation
4) modified milch technique

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!!!!
x ray recommended for verification after reduction

Immobilisation: 3 weeks in a sling in order to prevent recurrence.

Question 14

what is the modified milch technique

Answer 14

put the left hand over the trapezium and fixing the scapula with the thumb

the right hand will grab the wrist and putting it in external rotation so the palms are facing forward

and slowly and gently abducting the hand from close to the body to 100 degrees

if relocation has not occurred hold this position call for assistance and to push the bony prominence of the
humeral head anteriorly through the armpit anteriorly rolling it past the glenoid rim

Question 15

what is the shoulder manipulation

Answer 15

patient is asked to rest their unffaceted shoulder against starcher or a wall

the clinician stands behind the patient and feels the inferior border of scapula

and directs a force medially

another assistance stands infront of the patient and provides a downward traction on the humerus with the arm held in a light angle forward

Question 16

what is the Simpson manuever ?

Answer 16

patient is prone on table with the affected limb hanging freely
and weight is suspended of the wrist

Question 17

what are the operative managements of anterioir shoulder dislocations?

Answer 17

arthroscopic bankart repair with or without capsular short

open bankart repair with or without capsular shift

latarjet (coracoid transfer ) and bristow procedures for glenoid bone loss

Autograft (tricortical iliac crest) or allograft (iliac crest or distal tibia) for glenoid bone loss

Remplissage technique for Hill Sachs defects
advancing the infraspinatus tendon into the Hill-Sach’s defect, thereby preventing recurring engagement of the posterior humeral defect and the anterior labrum in the 90/90 position

Bone graft reconstruction for Hill Sachs defects

Question 18

what are the indications for arthroscopic bankart repair with or without capsular shift ?

Answer 18

first-time traumatic shoulder dislocation with Bankart lesion in athlete younger than 25 years of age

reoccurring dislocation/subluxation (> one dislocation) following nonoperative management

< 20-20% glenoid bone loss

Arthroscopic Bankart repair and Remplissage procedure -chronic Bankart tear and an engaging Hill-Sachs lesion causing anterior shoulder instability and engagement of the Hill-Sachs lesion in the 90/90 arm position

Question 19

what are the indications of open bankart repair with or without capsular shift ?

Answer 19

Bankart lesion with glenoid bone loss < 20-25%
stabilization following failed arthroscopic Bankart repair

humeral avulsion of the glenohumeral ligament (HAGL)

Question 20

what are the indications for latarjet (coracoid) / bristow procedures for glenoid bone loss ?

and

Autograft (tricortical iliac crest) or allograft (iliac crest or distal tibia) for glenoid bone loss

Answer 20

chronic bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid)

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bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid)

when failed latarjet

Question 21

indication for Remplissage technique for Hill Sachs defects

Answer 21

engaging (crepitus) large (>25-40%) Hill-Sachs defect (humeral head)
“off-track” Hill-Sachs lesions with <20-25% glenoid bone loss

Question 22

Bone graft reconstruction for Hill Sachs defects

indication

Answer 22

engaging large (>40%) Hill-Sachs lesions

Question 23

what are the techniques for operative anterior shoulder dislocation ?

Answer 23

arthroscopic bankart repair = MORE THAN 3 anchor sutures otherwise failure is high

open bankart repair = open labiaal repair and capsulorraphy

open capsular shift - inferior capsule is shifted superiorly

latarjet procedure
coracoid transfer to anterioir inferior glenoid bone defect with attached conjoined tendon and CA ligament

Remplissage technique for Hill Sachs defects
posterior capsule and infraspinatus tendon sutured into the Hill-Sachs lesion

Question 24

what are the complications for the operative procedures in anterioir shoulder dislocation ?

Answer 24

Arthroscopic Bankart repair +/- capsular plication

=recurrence, most often due to unrecognized glenoid bone loss or lack of concomitantly addressing “off-track” HS lesion
increased risk in age < 20, male sex, contact/collision sport, ligamentous laxity

stiffness, especially in external rotation,

axillary nerve injury

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open bankart 
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subscapularis injury or failed repair 

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Open Capsular shift

subscapularis injury or failed repair - positive lift off and excessive er IS THE PRESENTATION

overtightening of capsule- loss of external rotation

Axillary nerve injury
iatrogenic injury with surgery (avoid by abduction and ER of arm during procedure)
LATE ARTHRITIS

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latarjet

nonunion

graft lysis

stiffness, particularly in external rotation

nerve injury
majority are traction or contusion neuropraxias and resolve spontaneously
musculocutaneous nerve is most common

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Remplissage technique for Hill Sachs defects

external rotation defect

Question 25

which is the best view for obtaining hillsack ‘s defect ?

Answer 25

Stryker notch view

patient supine with the arm flexed toward the ceiling, flexed at the elbow, and the patient’s hand placed on top of the head and the xray beam is directed anteroposteriorly, with 10° of cephalic angulation

Question 26

patient will be unable to lift the arm after reduction in anterior shoulder dislocation why ?

Answer 26

young patient - axillary nerve palsy - deltoid muscle helps in abduction / shoulder flexion / shoulder extension

elderly patient rotator cuff - supraspinatus muscle which initiates abduction

Question 27

posterior dislocation of the shoulder is due to ?

Answer 27

acute -
seizures

chronic -
microtrauma from repetition. may lead to a labral tear, incomplete labral avulsion, or erosion of the posterior labrum
common in lineman, weight lifters, overhead athletes
ligamentous laxity

fixed , adducted and internally rotated - high risk position

Question 28

50 percent of cases of posterior shoulder dislocation on x ray is ?

Answer 28

missed

Question 29

posterioir shoulder dislocation is associated with?

Answer 29

avulsion of the posterior BAND OF IGHL

posterior inferior capsulolabral bankart lesion

Reverse Hill-Sachs lesions - locked and difficult to reduce dislocations

Posterior glenoid rim fracture - chronic reverse Bankart lesion

lesser tuberosity fractures -acute posterior dislocation

Kim lesions are superficial tears between the posterior glenoid labrum and glenoid articular cartilage without labral detachment.

Question 30

clinical presentation of posterior dislocation ?

Answer 30

History
trauma or microtrauma with the arm in a flexed, adducted, and internally rotated position

if chronic -usually pain and not instability as opposed to anterior instabilit

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pain with flexion, adduction, and internal rotation of the arm

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inspection
prominent posterior shoulder and coracoid for acute posterior dislocation

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motion
limited external rotation
shoulder locked in an internally rotated position
pain on flexion, adduction and internal rotation

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load and shift test

jerk test

kim test

Question 31

describe the load and shift test ?

Answer 31

used in both anterior and posterior shoulder dislocation

patients sits upright , one hand over the shoulder to stablise the scapula
grab the humeral head with the other hand
load - trying to position the humeral head centrally as possible in glenoid fossa
shift position - testing the anterior capsule when translating the humeral head forward vice versa

positive if head translates more to one side and if symptoms can be recreated
25 percent translation anteriorly normal
and 50 percent posteriorly

1 - translation but not to rim
2 - to glenolabral rim
3 - over glenoid rim
4 - complete dislocation

Question 32

what is the jerk test

Answer 32

diagnose posteroinferior labral tear

pain when performing the test after conservative treatment is a sign of failure

patient in sitting position , standing behind stablasie the scapula with one hand
bring the arm to 90 degrees abduction and internal rotation
apply axial force along axis of humerus
and move the arm so the hand come to one shoulder

SUDDEN CLUNK positive test for posterior subluxation
or pain

97% sensitive for posterior labral tear when combined with a Kim test

Question 33

describe the kim test ?

Answer 33

for Posteroinferior Labrum Lesions

patient sitting with support on back
abduct the arm to 90 degrees , forearm pronated , and elbow 90 degree flexion
support underneath the arm

apply axial force along the humerus with your body

using the other arm wrap it over the bicep and create a inferior posterior force on the bicep

while moving the arm upward and diagonally across with the other arm and body

Question 34

which radiographing is the best method for posterior shoulder dislocation diagnosing ?

Answer 34

AP - IS UNRELIABLE

axillary lateral

scapular y view

Question 35

what are the non operative indications for posterior shoulder dislocation ?

Answer 35

initially attempted for all acute traumatic posterior dislocations

Question 36

what is the non operative method for posterior shoulder dislocation ?

Answer 36

acute reduction and immobilization in external rotation immobilize in 10-20 degrees of external rotation with elbow at side for 4 to 6 weeks
after 6 weeks advance to physical therapy (rotator cuff strengthening and periscapular stabilization)

reduction - traction , counter traction - palpable clunk and return to mobility

Question 37

what are the operative methods for posterioir shoulder dislocation ?

Answer 37

open or arthroscopic posterior labral repair (Bankart)

open reduction with subscapularis transfer (McLaughlin) or lesser tuberosity transfer to the defect (Modified McLaughlin)

hemiarthroplasty

Question 38

what are the open or arthroscopic posterior labral repair (Bankart) indications?

Answer 38

recurrent posterior shoulder instability despite appropriate course of physical therapy
continued pain with loading of arm in forward flexed position

Question 39

open reduction with subscapularis transfer (McLaughlin) or lesser tuberosity transfer to the defect (Modified McLaughlin) indications ?

Answer 39

chronic dislocation < 6 months old

reverse Hill-Sachs defect

Question 40

hemiarthroplasty indication?

Answer 40

chronic dislocation > 6 months old

humeral head arthritis

collapse of humeral head during reduction

reverse Hill-Sachs defect > 40% of articular surface

Question 41

complications of Open or arthroscopic posterior labral repair and capsular shift

Answer 41

recurrence
Degenerative joint disease/ capsular necrosis
axillary nerve injury

Question 42

complication of Open reduction with subscapularis with or without tuberosity transfer to defect ?

Answer 42

stiffness
AVN
osteoarthritis

Question 43

how is there an inferior dislocation ?

Answer 43

high-energy injury

occurs with force on the hyperabducted arm

Question 44

inferior dislocation is also called ?

Answer 44

luxatio erecta - the humeral head is trapped underneath the glenoid and coracoid

the position of the arm is over the head (abducted shoulder 140 degrees ) with shoulder in full abduction an the elbow is usually flexed for it to lie transversely over the head

Question 45

what are the signs and symptoms of inferior shoulder dislocation

Answer 45

arm is in fixed, abducted, overhead position

usually neurological and vascular injury is checked ESP for inferior dislocation

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sulcus sign - standing with relaxed shoulder muscle
grab the patient arm just distal to the elbow joint and pull the arm inferiority

place the thumb of the other hand inferior to the acromion

sulcus sign is he little dip under the acromion between the humeral head and acromion or the feeling of subluxation

gagey test / hyperabduction
sitting upright and arm over patient
slowly lifting the elbow up
shoulder abduction exceeding 105 degrees

Question 46

how do we treat inferior dislocation of the shoulder

Answer 46

analgesia - lidocaine given to the joint

always check for neuromuscular problems

non operative :
traction counter traction 
or two step technique
post reduction immobilise the
followed by ROM
focus on periscapular and rotator cuff strengthening

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operative arthroscopic open repair

Question 47

what are the indications for non operative closed reduction and immobilisation in inferior dislocation ?

Answer 47

inactive elderly patients

in the absence of acute traumatic rotator cuff tear

Question 48

how do you perform traction counter traction in inferior shoulder dislocation ?

Answer 48

always provide analgesia

apply axial traction in the direction of the arm
an assistant applies counter traction towards the patinets feet with a sheet wrapped over the injured the shoulder

x recommended after reduction to verify

Question 49

what are the indications for operative arthroscopic or open repair in inferior shoulder dislocation?

Answer 49

active younger patients

Question 50

what are the complications of inferior shoulder dislocation ?

Answer 50

greatest incidence of neurovascular injury than all others dislocations :
axillary nerve palsy
injury to the brachial plexus
axillary artery thrombosis

proximal humerus fractures
especially greater tuberosity

rotator cuff tears esp old patients