Dislocation of shoulder classification, management; Shoulder dislocation, Anterior shoulder dislocation, Posterior shoulder dislocation, Inferior shoulder dislocation, Luxatio erecta

1. Shoulder Dislocation
Dr Saseendar S, MS Ortho, DNB Ortho, MNAMS,
Dip SICOT(Belgium), FISOC(US), FASM (Sing),
Consultant Arthroscopy and Sports Medicine,
Chettinad Super Speciality Hospital,
Chennai

2. Synopsis
Introduction
Definition
Types
Anterior/ Posterior/ Inferior
◦ Mechanism
◦ Subtypes
◦ Evaluation
◦ Clinical findings
◦ Management
◦ Complications
Recurrent

3. Introduction
Most unstable large joint
Mobility at the expense of stability

4. Definition
Glenohumeral instability is the inability
to maintain
the humeral head in
the glenoid fossa

5. Reasons for instability
Shallow glenoid
Extraordinary ROM
Vulnerability of upper limb to injury
Underlying conditions eg. ligament
laxity

6. Directions of instability
Anterior
◦ 97% of recurrent dislocations
subcoracoid - abd, extension and external
rotation
subglenoid
subclavicular
intrathoracic

7. Posterior
◦ 3% of recurrent
◦ Seizures, shock, fall on flexed + adducted
arm
subacromial
subglenoid
subspinous
Inferior
Superior
Bilateral

8. Dislocation of the Shoulder
Mostly Anterior > 95 % of dislocations
Posterior Dislocation occurs < 5 %
True Inferior dislocation (luxatio erecta) occurs <
1%
Habitual - Non traumatic dislocation may
present as Multi directional dislocation due
to generalized ligamentous laxity and is
Painless

9. Mechanism
Usually Indirect fall on Abducted and
extended shoulder
May be Direct when there is a blow
on the shoulder from behind

10. Pathoanatomy of dislocation
Stretching/ tearing of capsule
Avulsion of glenohumeral ligaments
usually off the glenoid
Labral injury
◦ Bankart lesion
Impression fracture
◦ Hill-Sach lesion
Rotator cuff tear

11. Clinical Picture
Pain
Holds injured limb with
other hand close to
trunk
The shoulder is
abducted and the elbow
is kept flexed

12. Clinical Picture
Loss of the normal
contour of the shoulder -
appears as a step
Anterior bulge of head
of humerus may be
visible or palpable
Empty glenoid socket

14. Anterior Shoulder dislocation
Usually also inferior

15. Radiograph

16. Radiograph

17. Anterior Dislocation of Shoulder

18. Management
Emergency
Should be reduced in < 24 hours or
else AVN of head of humerus
Immobilised strapped to the trunk for
3-4 weeks and rested in a collar and
cuff

19. Management
Reduction
◦ Closed
◦ Open

20. Maneouvers
Traction-countertraction method
Hippocrates method
Stimpson’s technique
Kocher’s technique

21. Traction-countertraction

22. Traction-countertraction

23. Hippocrates Method

24. Hippocrates Method

25. Hippocrates Method

26. Stimpson’s technique

27. Kocher’s Technique

28. Complications of anterior Shoulder
Dislocation : Early
Nerve – Axillary
Artery – Axillary
Ligaments
Bone - Associated fracture
◦ Neck of humerus
◦ Greater or lesser tuberosity
◦ Hill Sach
◦ Bankart

29. Axillary nerve injury

30. Bankart lesion – Soft tissue

31. Bankart lesion - Bony

32. Hill-Sachs lesion

33. Hill-Sachs lesion

34. Complications of anterior shoulder
Dislocation : Late
Avascular necrosis of the head of
the Humerus (high risk with delayed
reduction)
Heterotopic calcification ( used to
be called Myositis Ossificans )
Recurrent dislocation

35. Posterior dislocation
5-10% of shoulder dislocations
Shoulder is in adduction flexion and
internal rotation

36. Mechanism
Indirect
◦ Electric shock
◦ Seizure episode
Direct
◦ Force on the anterior shoulder

38. Shoulder AP view

39. Scapular Y-view

40. Closed Reduction
Traction to adduct arm in the line of
deformity
Gentle lifting of humeral head into the
glenoid fossa

41. Operative treatment
Failed closed
Displaced fracture
Recurrence
Large defect
◦ Reverse Hill Sachs

42. Reverse Hill-Sachs

43. Complications
Neurological
◦ Axillary
◦ Nerve to infraspinatus
Vascular
Fractures
Recurrence

44. Inferior Dislocation
Luxatio erecta

45. Mechanism
Hyperabduction force

46. Radiograph

47. Reduction

48. Operative
Buttonholing

49. Complications
High
◦ Vascular
◦ Neurological
◦ Ligaments
◦ Fractures

50. Evaluation of recurrent
atraumatic instability
History
◦ Trauma?
◦ Sports
◦ Throwing or overhead activities
◦ Voluntary subluxation
◦ “Clunk” or knock
◦ Fear
◦ Hx of dislocations and energy associated

51. Physical
◦ Demonstrate dislocation/subluxation ?
◦ Laxity tests
◦ Stability tests

52. Generalised ligament laxity

53. Management
Conservative
◦ Acute episode
◦ Immobilisation
◦ Physiotherapy – Strengthening exercises
Operative reconstruction
◦ Soft-tissue reconstruction
◦ Bony reconstruction

55. Information contained in this presentation
are intended for academic purpose only
for the students of orthopaedic surgery.
The guidelines mentioned cannot be used
absolutely for management of patients.
I am not responsible for any controversies
that arise out of this presentation.
For clarifications/ suggestions please
contact ssaseendar@yahoo.co.in or call
at 91-9500366970.