Shouler path disloc/sublax

Question 1

Shoulder Dislocation/subluxation

Answer 1

o Complete/partial dissociation of the articulating surfaces of the glenohumeral joint
o This occurs usually anteriorly (subcoracoid, subglenoid, subclavicular) and less often posteriorly

Question 2

Etiology:

Answer 2

o Anterior dislocation= mechanism of injury is often with excessive abduction and external rotation of the humerus: either direct trauma with shoulder in this position (football) or indirect trauma (FOOSH)
o Posterior dislocation= mechanism of injury is usually flexion, adduction and internal rotation of the humerus – a person breaking their forward fall with an outstretch hand or elbow

Question 3

Signs & Symptoms:

Answer 3

o Joint reduction is usually needed
o Severity of injury depends on the extent of tissue damage (joint and muscle)
o Sulcus sign – visible deformity, loss of deltoid ‘roundedness’
o Acute: pain, severe bruising, protective muscle spasm, joint effusion, possible hemarthrosis/tears/strains, holding pattern to protect joint
o Subacute: unstable joint – muscles provide stability, MTP, decrease in ROM, adhesions develop around the joint, pain and edema slowly diminish
o Chronic: localized joint capsule pain when its stressed, bruising gone, joint is a little more stable except of direction of injury (unless surgically repaired), restricted ROM, matured adhesions, hypertonicity and MTP of muscles crossing the joint and other compensatory structures, muscle weakness, disuse atrophy, loss of proprioception
o Complications= rotator cuff tears, glenoid labrum tear, avulsion fracture (greater tubercle), nerve and blood vessel injury, avascular necrosis, muscle atrophy (true or disuse), adhesive capsulitis

Question 4

OBSERVATION

Answer 4

Protective posturing around affected arm

Sulcus Sign

Question 5

ROM TESTING

Answer 5

Shoulder Apprehension Sign (AROM)

• Instruct Patient to slowly move the arm and joint into the position in which the dislocation took place (e.g. AB + ER+EXT)
• Patient apprehension indicates unstable joint capsule
• *If present, do not perform PROM to avoid further injury to GH joint

Question 6

SPECIAL TESTS

Answer 6

1. Rockwood (Anterior instability)
2. Push-pull (Posterior instability)
3. Feagin ( Inferior instability)

Question 7

Treatment planning:

Answer 7

Acute:
- First 3-4 weeks the guest is usually immobilized
- Position for comfort and stability
- Reduce pain, decrease SNS firing, decrease edema, maintain local circulation, and address compensatory structures with general Swedish, petrissage, and MLD techniques. Ice if needed
Subacute:
- As per acute stage
- Reduce but do not remove protective muscles spasm
- Maintain available ROM (PROM)
- Prevent disuse atrophy (Isometric contractions)
- Late subacute – prevent excess adhesion formation: begin cross-fibre frictions
Chronic:
- As per subacute
- Cross-fibre frictions to areas of fibrosis to prevent adhesions and maintain mobility between structures
- Reduce hypertonicity
- Restore ROM and strength

Question 8

Precautions and Contraindications:

Answer 8

• As per general orthopedic treatment
• Be aware of the type of reduction involved – muscular, screws or pins, etc.
• Joint play should be avoided where the capsule hasn’t been surgically reduced
• Avoid REMEX in the acute stage
• Before restoring ROM in direction of dislocation, ensure the majority of strength is regained in the muscles crossing the joint

Question 9

REMEX & homecare:

Answer 9

• Gradually increase range
• Strengthen muscles to help with stability
• Re-educate proprioception
• Encourage activity to help prevent fibrosis and hypomobility
• Strengthen both anterior and posterior aspects: anterior to increase stability and posterior to reposition the humerus to its anatomical position.