Shoulder dislocation- traumatic and habitual . Flashcards
shoulder dislocation is dislocation of which joint ?
the glenohumeral joint
what is the use of the glenoid labrum margining the glenoid fossa ?
The fibrocartiliginous labrum deepens this cavity (the glenoid cavity) and effectively increases the stability of the humeral head
which nerve is most commonly associated with glenohumeral joint dislocation ?
axillary nerve
the axillary nerve supplied what muscle ?
teres minor (external rotation) and deltoid muscle and skin over the shoulder
and injury to the axillary nerve will result in ?
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
types of shoulder dislocation ?
anterior dislocation - comes to rest under the coracoid process
posterior dislocation
inferior shoulder dislocation
which is the most common shoulder dislocation ?
anterior shoulder dislocation is the most common
have a high recurrence rate that correlates with age at dislocation
what leads to anterior shoulder dislocation ?
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
reoccurring anterior dislocation is often found with ?
greater tuberosity fracture
age < 20 (highest risk)
male
contact sports
hyperlaxity
glenoid bone loss >20-25%
Associated injuries with traumatic anterior shoulder dislocation ?
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
in elderly patients anterior shoulder dislocation is associated with what ?
rotator cuff tear
supraspinatus
infraspinatus - posterioir
teres minor - posterior
subscapularis - anteriorly
what are the signs and symptoms of anterior shoulder dislocation?
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
treatment of anterior shoulder dislocation ?
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.
what is the modified milch technique
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
what is the shoulder manipulation
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
what is the Simpson manuever ?
patient is prone on table with the affected limb hanging freely
and weight is suspended of the wrist
what are the operative managements of anterioir shoulder dislocations?
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
what are the indications for arthroscopic bankart repair with or without capsular shift ?
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
what are the indications of open bankart repair with or without capsular shift ?
Bankart lesion with glenoid bone loss < 20-25%
stabilization following failed arthroscopic Bankart repair
humeral avulsion of the glenohumeral ligament (HAGL)
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
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
indication for Remplissage technique for Hill Sachs defects
engaging (crepitus) large (>25-40%) Hill-Sachs defect (humeral head)
“off-track” Hill-Sachs lesions with <20-25% glenoid bone loss
Bone graft reconstruction for Hill Sachs defects
indication
engaging large (>40%) Hill-Sachs lesions
what are the techniques for operative anterior shoulder dislocation ?
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
what are the complications for the operative procedures in anterioir shoulder dislocation ?
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
===== open bankart "" "" "" 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
which is the best view for obtaining hillsack ‘s defect ?
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
patient will be unable to lift the arm after reduction in anterior shoulder dislocation why ?
young patient - axillary nerve palsy - deltoid muscle helps in abduction / shoulder flexion / shoulder extension
elderly patient rotator cuff - supraspinatus muscle which initiates abduction
posterior dislocation of the shoulder is due to ?
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
50 percent of cases of posterior shoulder dislocation on x ray is ?
missed
posterioir shoulder dislocation is associated with?
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.
clinical presentation of posterior dislocation ?
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
describe the load and shift test ?
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
what is the jerk test
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
describe the kim test ?
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
which radiographing is the best method for posterior shoulder dislocation diagnosing ?
AP - IS UNRELIABLE
axillary lateral
scapular y view
what are the non operative indications for posterior shoulder dislocation ?
initially attempted for all acute traumatic posterior dislocations
what is the non operative method for posterior shoulder dislocation ?
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
what are the operative methods for posterioir shoulder dislocation ?
open or arthroscopic posterior labral repair (Bankart)
open reduction with subscapularis transfer (McLaughlin) or lesser tuberosity transfer to the defect (Modified McLaughlin)
hemiarthroplasty
what are the open or arthroscopic posterior labral repair (Bankart) indications?
recurrent posterior shoulder instability despite appropriate course of physical therapy
continued pain with loading of arm in forward flexed position
open reduction with subscapularis transfer (McLaughlin) or lesser tuberosity transfer to the defect (Modified McLaughlin) indications ?
chronic dislocation < 6 months old
reverse Hill-Sachs defect
hemiarthroplasty indication?
chronic dislocation > 6 months old
humeral head arthritis
collapse of humeral head during reduction
reverse Hill-Sachs defect > 40% of articular surface
complications of Open or arthroscopic posterior labral repair and capsular shift
recurrence
Degenerative joint disease/ capsular necrosis
axillary nerve injury
complication of Open reduction with subscapularis with or without tuberosity transfer to defect ?
stiffness
AVN
osteoarthritis
how is there an inferior dislocation ?
high-energy injury
occurs with force on the hyperabducted arm
inferior dislocation is also called ?
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
what are the signs and symptoms of inferior shoulder dislocation
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
how do we treat inferior dislocation of the shoulder
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
what are the indications for non operative closed reduction and immobilisation in inferior dislocation ?
inactive elderly patients
in the absence of acute traumatic rotator cuff tear
how do you perform traction counter traction in inferior shoulder dislocation ?
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
what are the indications for operative arthroscopic or open repair in inferior shoulder dislocation?
active younger patients
what are the complications of inferior shoulder dislocation ?
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
