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Dislocation Shoulder Good
Dislocation Shoulder Good
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I. Description
True shoulder dislocation occurs when the head of the humerus becomes dislodged from the glenoid cavity. It is the joint that is most prevalent for dislocation. The shoulder normally dislocates anteriorly but it can also be displaced posteriorly or inferiorly. If the humerus is dislocated once, there is a greater chance that it can later be dislocated again, especially if the person is 30 years or younger. Many times when a shoulder dislocation occurs, ligaments and other tissues are damaged and movement of the humerus is highly limited. Once the shoulder is relocated normal function is usually restored but structures around the glenoid area may still be damaged. The two most common injuries associated with an anteriorly dislocated shoulder are a Bankart lesion and a Hill-Sachs lesion. A Bankart lesion occurs when the anterior labrum is torn. A Hill-Sachs lesion takes place when the humeral head impacts the glenoid fossa causing a fracture of the head of the humerus. These lesions can also occur in the posterior joint with posterior dislocation, and are known as reverse Bankart and Hill-Sachs lesions.1,2,4 All About Shoulder Dislocation
II. Anatomy
The anatomy of the glenohumeral joint consists of the humeral head of the humerus and the glenoid fossa of the scapula. These two structures together create a cavity with a surrounding capsule. Attached to the glenoid cavity is the glenoid labrum which acts as a fibrocartilaginous bumper between the humeral head and the glenoid fossa. The capsule is supported by the rotator cuff muscles which are the supraspinatus, infraspinatus, subscapularis, and teres minor. The deltoid muscle and the biceps tendon also offer some support for the capsule. The superior glenohumeral ligament (SGHL), middle glenohumeral ligament (MGHL), and inferior glenohumeral ligament (IGHL) are three structures that provide support as well.3
V. Diagnostic Tests
With both anterior and posterior shoulder instability, an anteroposterior (AP) view and a Y-view image should be obtained. The AP view can show anterior dislocation and a reverse Hill-Sachs sign for posterior dislocation. The Yview can show a Hill-Sachs lesion for anterior dislocation and a posterior dislocation.6,7 Anterior Dislocation
Hill-Sach's Lesion
Posterior Dislocation
CT scans can also be used to assess the integrity of the labrum. An MRI shows Bankart lesions and any soft tissue injuries.6,7 CT Labrum
Posterior Instability The two most reliable tests for posterior instability are the posterior stress test and the jerk test.5 Posterior Stress Test (Posterior Apprehension Test) Pain or apprehension indicates a positive test. Jerk Test A clunk, or jerk, upon axial load or horizontal adduction indicates a positive test. Another clunk may also occur upon relocation (horizontal abduction).
If immobilization is the sole treatment, the arm is usually immobilized anywhere from 2 to 6 weeks. Combined with exercise, it will usually be immobilized for a lesser time period. For anterior dislocations, the humerus is normally placed in a traditional internally rotated position. However, new studies are being conducted which may show that placing the humerus in an externally rotated position may be more beneficial for healing especially if a Bankart lesion is present. For posterior dislocations the humerus is normally placed in a slightly extended and externally rotated position.4,5,10 Exercise Exercise is normally used in conjunction with immobilization. The shoulder will usually be immobilized for 1-3 weeks. During this time period, wrist and elbow range of motion exercises can be performed so that it is not lost. After immobilization, range of motion of the shoulder can begin followed by strengthening. In the case of anterior
dislocation, strengthening programs should emphasize the internal rotators, adductors, scapular muscles. For posterior dislocation, programs to strengthen the external rotators, posterior deltoid, and scapular muscles are performed. Conservative protocols may take up to 3 months for full recovery.4,5,10 click on the link below to view PT management of shoulder dislocation:
X. References
1. Seade EL, Josey R. Shoulder Dislocation. Medscape Reference Website. Available at:http://emedicine.medscape.com/article/93323-overview. Accessed October 28th, 2011. 2. Mayo Clinic Staff. Dislocated Shoulder. Mayo Foundation for Medical Education and Research. Available at:http://www.mayoclinic.com/health/dislocated-shoulder/DS00597. Accessed November 26th, 2011. 3. Sizer PS, Phelps V, Gilbert K. Diagnosis and management of the painful shoulder. Part 1: clinical anatomy and pathomechanics. Pain Practice, 2003;3(1):40-57. 4. Hayes K, Callanan M, Walton J, Paxinos A, Murrell G. Shoulder instability: management and rehabilitation. Journal of Orthopaedic & Sports Physical Therapy, 2002;32(10):1-13. 5. Millett PJ, Clavert PC, Hatch RGF, Warner JJP. Recurrent posterior shoulder instability. Journal of the American Academy of Orthopaedic Surgeons, 2006;14(8):464-476. 6. Satterwhite YE. Evaluation and management of recurrent anterior shoulder instability. Journal of Athletic Training, 2000;35(3):273-277. 7. Tseng GY, Peh WCG. Shoulder Dislocation Imaging. Medscape Reference Website. Available at:http://emedicine.medscape.com/article/395520-overview. Accessed November 26, 2011. 8. Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT, Cook C. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Journal of Sports Medicine,
2008;42(1):80-92. 9. Farber AJ, Castillo R, Clough M, Bahk M, McFarland EG. Clinical assessment of three common tests for traumatic anterior shoulder instability. Journal of Bone and Joint Surgery, 2006;88(7):1467-1474. 10. Handoll HHG, Al-Maiyah MA. Surgical versus non-surgical treatment for acute anterior shoulder dislocation. The Cochrane Collaboration, 2010;(5):1-34.