1. ShoulderShoulder
DislocationsDislocations
fahad zakwanfahad zakwan
md5md5

2. OverviewOverview
Common shoulder and humerus injuries seen in theCommon shoulder and humerus injuries seen in the
EDED
For each injuryFor each injury
MechanismMechanism
Physical examPhysical exam
Diagnostic imagingDiagnostic imaging
ClassificationClassification
ManagementManagement
Watch out!Watch out!

3. INJURIES TO BE COVEREDINJURIES TO BE COVERED
Shoulder dislocationShoulder dislocation
Humeral FracturesHumeral Fractures
proximalproximal
mid shaftmid shaft
distaldistal

4. SHOULDERSHOULDER
DISLOCATIONDISLOCATION
ApproximatelyApproximately 50%50% of all major joint dislocationsof all major joint dislocations involveinvolve
the glenohumeral joint.the glenohumeral joint.
Dislocations are commonly classified byDislocations 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,(traumatic, minimally traumatic, non traumatic,
microanterior instability).microanterior 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

5. 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

6. 1. ANTERIOR1. ANTERIOR
DISLOCATIONDISLOCATION
subglenoid
subcoracoid
subclavicular

7. MechanismMechanism
•Abduction + extension + posteriorAbduction + extension + posterior
forceforce
• Forced extension along with lateral rotation willForced extension along with lateral rotation will
drive the head of the humerus forward tearingdrive the head of the humerus forward tearing
the capsule or avulsing the glenoid labrum.the capsule or avulsing the glenoid labrum.
• The injury usually results from a traumatic eventThe injury usually results from a traumatic event
in which the position of the arm is in anin which the position of the arm is in an
externally rotated and forward-flexedexternally rotated and forward-flexed oror
anan abducted positionabducted position..

8. Signs & symptoms
DeformityDeformity - step- step off (deltoid will lookoff (deltoid will look
flattenedflattened
Arm inArm in slight abductionslight abduction,, external rotationexternal rotation
Will not be able to move shoulder jointWill not be able to move shoulder joint
Unable to touch opposite shoulder withUnable to touch opposite shoulder with
hand of affected sidehand of affected side
PainPain

9. ExaminationExamination
• Individuals with an acute dislocationIndividuals with an acute dislocation hold their arm in anhold their arm in an
adducted position.adducted position.
• There is aThere is a loss of symmetry of their shouldersloss of symmetry of their shoulders and theand the
humeral head can be palpated anterior and inferior tohumeral head can be palpated anterior and inferior to
the coracoid process.the coracoid process.
• Any attempt at range of motion of the shoulder is extremelyAny attempt at range of motion of the shoulder is extremely
painful.painful.
• AA thorough neurovascular check of the upper extremity isthorough neurovascular check of the upper extremity is
necessary before any attempt is made to reduce thenecessary before any attempt is made to reduce the
dislocationdislocation..
• Attention to checking the sensory function of theAttention to checking the sensory function of the axillary nerveaxillary nerve
over the lateral aspect of the shoulder is important.over the lateral aspect of the shoulder is important.

10. Shoulder Dislocation - ImagingShoulder Dislocation - Imaging
Do you want films?Do you want films?
Recurrent dislocation vs primary, ?nontraumaticRecurrent dislocation vs primary, ?nontraumatic
Avulsion # of greater tuberosity in 10-15%Avulsion # of greater tuberosity in 10-15%
True APTrue AP
Axillary viewAxillary view
trans-scapular viewtrans-scapular view
Stryker Notch:Stryker Notch:
West point AxillaryWest point Axillary
Apical oblique viewApical oblique view

11. Anterior dislocation

12. ManagementManagement
This is an emergency!!!This is an emergency!!!
Anesthesia - conscious sedation vsAnesthesia - conscious sedation vs
intra-articular lidocaineintra-articular lidocaine
Reduction (“know three methods well”)Reduction (“know three methods well”)
Stimson’sStimson’s
Scapular rotationScapular rotation
External rotationExternal rotation
MilchMilch

13. Stimson maneuverStimson maneuver
• Position the patient prone on elevated stretcherPosition the patient prone on elevated stretcher
• Position the affected shoulder off the edgePosition the affected shoulder off the edge
of the stretcher, hanging downwards in 90ºof the stretcher, hanging downwards in 90º
of forward flexion.of forward flexion.
• Strap the patient slightly with sheet andStrap the patient slightly with sheet and
then securely fasten 2.5-5 kg of weight tothen securely fasten 2.5-5 kg of weight to
the patients wrist to provide continuousthe patients wrist to provide continuous
traction.traction.
• Instruct the patient to maintain thisInstruct the patient to maintain this
position for at least 15-20 minutes or untilposition for at least 15-20 minutes or until
reduction is completed.reduction is completed.
ADVANTAGESADVANTAGES
•no assistance requiredno assistance required
•Shoulder is reduced withShoulder is reduced with
minimal forceminimal force
DISADVANTAGESDISADVANTAGES
•patient may slip off thepatient may slip off the
stretcherstretcher
•Patient must be monitored allPatient must be monitored all
the timesthe times
•Long reduction timeLong reduction time
•Sufficient premedicationSufficient premedication
requiredrequired

14. Scapular manipulationScapular manipulation
• Place the patient in prone or seatedPlace the patient in prone or seated
position, with back exposed.position, with back exposed.
• Place the affected arm in 90º forwardPlace the affected arm in 90º forward
flexion at the shoulder and apply slightflexion at the shoulder and apply slight
traction.traction.
• If in prone position, use weight (as in StimsonIf in prone position, use weight (as in Stimson
technique)or have assistant apply manual downtechnique)or have assistant apply manual down
traction.traction.
• If in seated position, have the assistant standIf in seated position, have the assistant stand
facing the patient and use arm to firmly grasp thefacing the patient and use arm to firmly grasp the
wrist of the dislocated arm. The assistant shouldwrist of the dislocated arm. The assistant should
the apply steady forward traction parallel to thethe apply steady forward traction parallel to the
floor while applying countertraction with the otherfloor while applying countertraction with the other
arm, which is outstretched and resting on patientsarm, which is outstretched and resting on patients
clavicle.clavicle.

15. Cont…..
• Stand lateral to the affected shoulder andStand lateral to the affected shoulder and
stabilize the scapula by placing the palm ofstabilize the scapula by placing the palm of
one hand on the lateral aspect of the shoulderone hand on the lateral aspect of the shoulder
with thumb securely on superior lateralwith thumb securely on superior lateral
border. Place other palm over the inferior tipborder. Place other palm over the inferior tip
of the scapula and position the thumb on theof the scapula and position the thumb on the
inferior lateral border of the scapula.inferior lateral border of the scapula.
• Use both hands to rotate the inferior tip of theUse both hands to rotate the inferior tip of the
scapula medially and the superior aspectscapula medially and the superior aspect
laterally with slight dorsal placement. The goallaterally with slight dorsal placement. The goal
is to move the glenoid fossa back intois to move the glenoid fossa back into
anatomical position.anatomical position.
• To facilitate reduction, the assistant mayTo facilitate reduction, the assistant may
apply, along with traction, slight externalapply, along with traction, slight external
rotation of the humerus, elbow flexion in 90ºrotation of the humerus, elbow flexion in 90º
or both.or both.
ADVANTAGESADVANTAGES
•Tolerated well byTolerated well by
patientspatients
•Can be performedCan be performed
without premedicationwithout premedication
•Minimal force requiredMinimal force required
DISADVANTAGESDISADVANTAGES
•It is difficult to locateIt is difficult to locate
borders of scapulaborders of scapula
•Assistance is needed.Assistance is needed.

16. External rotation methodExternal rotation method
• Place the patient supine position on a stretcherPlace the patient supine position on a stretcher
• Using one hand, adduct the affected arm tightly toUsing one hand, adduct the affected arm tightly to
the patients sidethe patients side
• With the other hand gasp the patients wrist, bendWith the other hand gasp the patients wrist, bend
elbow to 90º of flexion, and then gently rotate theelbow to 90º of flexion, and then gently rotate the
upper arm externally, using the fore arm as a lever,upper arm externally, using the fore arm as a lever,
without force or traction.without force or traction.
• If the patient experiences pain, pause momentarilyIf the patient experiences pain, pause momentarily
to allow the muscles to relax. After the pain hasto allow the muscles to relax. After the pain has
subsided continue until the coronal plane.subsided continue until the coronal plane.
• Reduction takes place btw 70-110º of externalReduction takes place btw 70-110º of external
rotation and, sometimes, during return of internalrotation 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!!

17. Milch techniqueMilch technique
Place the patient supine / prone position on aPlace the patient supine / prone position on a
stretcher with shoulder close to the edge ofstretcher with shoulder close to the edge of
stretcher.stretcher.
Place the affected arm in full abduction overheadPlace the affected arm in full abduction overhead
or instruct patient to raise affected arm laterallyor instruct patient to raise affected arm laterally
and behind the head. Operator may assistand behind the head. Operator may assist
abduction gently.abduction gently.
With arm in full abduction, gently applyWith arm in full abduction, gently apply
longitudinal traction and external rotation of onelongitudinal traction and external rotation of one
arm.arm.
If reduction is not completed, use the thumb orIf reduction is not completed, use the thumb or
fingers to push the humeral head upward into thefingers to push the humeral head upward into the
glenoid fossa with gradual adduction of theglenoid 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!!

18. 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.

19. Traction and counterTraction and counter
tractiontraction
Place the patient supine position on a stretcher with bedPlace 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 axillaPlace one sheet over the patient upper chest, under the axilla
of the affected shoulder and underneath the back, so that theof the affected shoulder and underneath the back, so that the
two ends of the sheet are of equal length and open to thetwo ends of the sheet are of equal length and open to the
unaffected side.unaffected side.
Standing on the unaffected side the assistant takes a firmStanding on the unaffected side the assistant takes a firm
hold of each end of the sheet with each hand or securely tieshold of each end of the sheet with each hand or securely ties
the sheet around his or her own waist at the level of ischialthe sheet around his or her own waist at the level of ischial
tuberosities. When instructed to start the assistant leans backtuberosities. When instructed to start the assistant leans back
to provide countertraction with body weight.to provide countertraction with body weight.

20. • While maintaining the affected arm in 90º of flexion at the elbow, withWhile maintaining the affected arm in 90º of flexion at the elbow, with
both hands around the forearm, apply traction with fully extendedboth hands around the forearm, apply traction with fully extended
arms. Use body weight not upper arm muscles to provide tractionarms. Use body weight not upper arm muscles to provide traction
along the axis of dislocation while the assistant appliesalong the axis of dislocation while the assistant applies
countertraction.countertraction.
• Alternatively if fatigued, the clinician can wrap another sheet aroundAlternatively if fatigued, the clinician can wrap another sheet around
his/her proximal fore arm and tie it around his/ her back, letting thehis/her proximal fore arm and tie it around his/ her back, letting the
continuous loop sitting at the level of ischial tuberosities. While stillcontinuous loop sitting at the level of ischial tuberosities. While still
holding the elbow in flexion, step back to make the sheet taut and leanholding 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. AtApply gentle traction for several minutes until reduction is attained. At
reduction the affected arm is usually lengthened and relaxed, withreduction the affected arm is usually lengthened and relaxed, with
audible clunk.audible clunk.

21. Signs of successful reduction
includes…
Palpable or audible clunkPalpable or audible clunk
Return of rounded shoulder contourReturn of rounded shoulder contour
Relief of painRelief of pain
Increase range of motionIncrease range of motion

22. Shoulder Dislocation -Shoulder Dislocation -
ComplicationsComplications
Bankart lesionBankart lesion
primary lesion inprimary lesion in recurrent ant instabilityrecurrent ant instability
Hill Sach lesionHill Sach lesion
35-40% of ant dislocations, predisposes to35-40% of ant dislocations, predisposes to
recurrent injuryrecurrent injury
recurrent dislocationrecurrent dislocation
young adultsyoung adults redislocationredislocation in 55-95%in 55-95%
skeletally mature, < 30yo: ? Early arthroscopicskeletally mature, < 30yo: ? Early arthroscopic
reconstruction (Arthroscopy 15(5) 1999: 507-12)reconstruction (Arthroscopy 15(5) 1999: 507-12)

23. 2. POSTERIOR2. POSTERIOR
DISLOCATIONDISLOCATION
• 2-4% of shoulder2-4% of shoulder
dislocationsdislocations
• Secondary to seizure,Secondary to seizure,
direct blow to shoulderdirect blow to shoulder
• Need to dx early toNeed to dx early to
prevent long termprevent long term
complicationscomplications

24. Mechanism:Mechanism:
electric shockelectric shock
seizuresseizures
trauma ( alchoholics)trauma ( alchoholics)
Internal rotation/adduction/flexionInternal rotation/adduction/flexion

25. clinical features
Arm held across chestArm held across chest
AdductedAdducted
Internally rotatedInternally rotated
Flat and squared offFlat and squared off

26. Examination
• An obvious clinical deformity is typically not presentAn obvious clinical deformity is typically not present
and the patient may be complaining of only minimaland the patient may be complaining of only minimal
symptoms.symptoms.
• Many posterior dislocations are not diagnosed andMany posterior dislocations are not diagnosed and
reduced in the emergency department.reduced in the emergency department.
• External rotation of the shoulder is limited andExternal rotation of the shoulder is limited and
painfulpainful, and is the, and is the hallmark of a posterior shoulderhallmark of a posterior shoulder
dislocation.dislocation.

27. ImagingImaging
AP may appear normal!AP may appear normal!
Loss of half moon elliptical overlap ofLoss of half moon elliptical overlap of
humeral head and glenoid fossahumeral head and glenoid fossa
Helpful radiographic signsHelpful radiographic signs
light bulb signlight bulb sign
Rim signRim sign
trough signtrough sign

28. Lightbulb sign
Refers to abnormal APRefers to abnormal AP
radiograph appearance of theradiograph appearance of the
humeral head in posteriorhumeral head in posterior
shoulder dislocation.shoulder dislocation.
When the humerus dislocates itWhen the humerus dislocates it
also internally rotates such thatalso internally rotates such that
the head contour projects like athe head contour projects like a
light bulb when viewed from thelight bulb when viewed from the
front.front.

29. Rim signRim sign
Distance betweenDistance between
the medial borderthe medial border
of the humeralof the humeral
head an anteriorhead an anterior
glenoid rim isglenoid rim is
>6mm.>6mm.
>6mm

30. Trough signTrough sign
• In posterior dislocation, the anterior aspect ofIn posterior dislocation, the anterior aspect of
the humeral head becomes impacted againstthe humeral head becomes impacted against
the posterior glenoid rim.the posterior glenoid rim.
• With sufficient force, this causes compressionWith sufficient force, this causes compression
fracture on the anterior aspect of the humeralfracture on the anterior aspect of the humeral
head.head.
• This compression fracture is analogous to theThis compression fracture is analogous to the
Hill-Sachs compression fracture seen withHill-Sachs compression fracture seen with
anterior shoulder dislocation of theanterior shoulder dislocation of the
Glenohumeral joint.Glenohumeral joint.
• Frontal radiographs reveal 2 nearly parallelFrontal radiographs reveal 2 nearly parallel
lines in the superomedial aspect of the humerallines in the superomedial aspect of the humeral
head.head.

31. Shoulder Dislocation
Posterior: Imaging

32. ManagementManagement
Conscious sedation and closed reductionConscious sedation and closed reduction
Axial traction, pressure on humeral head, external rotationAxial traction, pressure on humeral head, external rotation
Muscle relaxation via IV sedation isMuscle relaxation via IV sedation is
recommended. Reductions can usually berecommended. Reductions can usually be
obtained by gentle traction on the arm with anobtained by gentle traction on the arm with an
additional anterior and laterally directed forceadditional anterior and laterally directed force
applied to the posterior aspect of the humeralapplied to the posterior aspect of the humeral
head.head.

33. 3. INFERIOR DISLOCATION3. INFERIOR DISLOCATION
(Luxatio Erecta)(Luxatio Erecta)
Rare 5%Rare 5%
Arm locked overhead 110-160 degArm locked overhead 110-160 deg
abduction, hand resting on headabduction, hand resting on head
AP radiograph: spine parallel to humerusAP radiograph: spine parallel to humerus
Reduce with tractionReduce with traction
Mechanism axial loading forecefulMechanism axial loading foreceful
hyperabduction.hyperabduction.
Pt falls grasping object above their headPt falls grasping object above their head
Arm locked in abduction often fore armArm locked in abduction often fore arm
resting on headresting on head
60% of pts have some neurologic60% of pts have some neurologic
dysfunctiondysfunction

34. Shoulder Dislocation
Inferior (Luxatio Erecta)

35. POSTREDUCTION TREATMENTPOSTREDUCTION TREATMENT
• The shoulder should be immobilized for a brief period as needed for painThe shoulder should be immobilized for a brief period as needed for pain
control after a dislocation or subluxation episode.control after a dislocation or subluxation episode.
• A range-of-motion and rotator cuff strengthening program is initiated early,A range-of-motion and rotator cuff strengthening program is initiated early,
but the extremes of range of motion for forward flexion or external rotationbut the extremes of range of motion for forward flexion or external rotation
are avoided.are avoided.
• Patients are allowed to return to sports and other activities when thePatients are allowed to return to sports and other activities when the
shoulder has good strength and minimal apprehension in an abducted,shoulder has good strength and minimal apprehension in an abducted,
externally rotated position.externally rotated position.
• A general rule is the younger the patient, the higher the possibility ofA general rule is the younger the patient, the higher the possibility of
recurrent instability .recurrent instability .

36. COMPLICATIONS OF DISLOCATIONSCOMPLICATIONS OF DISLOCATIONS
1.1. Damage to the nerves originating with the brachialDamage to the nerves originating with the brachial
plexusplexus
TheThe axillary nerveaxillary nerve andand musculocutaneous nervemusculocutaneous nerve areare
most commonly injured.most commonly injured.
Most injuries are a neuropraxia, and a full recovery isMost injuries are a neuropraxia, and a full recovery is
typical.typical.
2.2. Rotator cuff tearsRotator cuff tears are common in patients older than 40are common in patients older than 40
years with an anterior dislocation.years with an anterior dislocation.
If good range of motion and strength have not returnedIf good range of motion and strength have not returned
within 3 to 4 weeks after the injury, visualization of thewithin 3 to 4 weeks after the injury, visualization of the
rotator cuff with magnetic resonance imaging (MRI) orrotator cuff with magnetic resonance imaging (MRI) or

37. Wrist drop