Shoulder Dislocation Case File

https://medical-phd.blogspot.com/2021/03/shoulder-dislocation-case-file.html

Author: Eugene C. Toy, MD, Lawrence M. Ross, MD, PhD, Han Zhang, MD, Cristo
Papasakelariou, MD, FACOG

CASE 5
While playing football, a 17-year-old defensive end was attempting to tackle a
fullback with an outstretched left arm. The arm was hit with substantial force, and he
now complains of severe shoulder pain and his left arm is hanging down with some
external rotation. The pain prevents him from moving the limb. A radiograph is
negative for a fracture, but the head of the humerus is superimposed on the neck of the
scapula.

⯈ What is the most likely diagnosis?

⯈ What is the most likely nerve injured?

ANSWERS TO CASE 5:

Shoulder Dislocation
Summary: A 17-year-old football player’s left arm was outstretched and hit with some
force. He has shoulder pain, and his arm hangs limp down his side with external
rotation. There is no fracture, and the humeral head is superimposed on the scapular
neck.
• Most likely diagnosis: Glenohumeral joint dislocation (shoulder dislocation)
• Most likely nerve injured: Axillary nerve

CLINICAL CORRELATION
The shoulder is the most commonly dislocated large joint of the body and is usually
dislocated in an anterior direction. Typically, the dislocation is also inferior such that
the humeral head is located inferior and lateral to the coracoid process. The humeral
head will often have an infraglenoid and infraclavicular position. The diagnosis may
be difficult to make. The typical mechanism consists in a violent force to the humerus
that is abducted and externally rotated, resulting in extension of the joint; this action
displaces the humeral head inferiorly, thus tearing the weak inferior portion of the
shoulder joint capsule. This is facilitated by the fulcrum effect of the acromion. The
strong flexor and adductor muscles pull the humeral head anteriorly and medially to
the usual subcoracoid position. Typically, the patient will not move the arm and will
support the limb flexed at the elbow with the opposite hand. The arm will be slightly
abducted and medially rotated. The usually rounded curve of the shoulder is lost, and
there is a depression evident inferior to the acromion. The humeral head is palpable, if
not visible, in the deltopectoral triangle. First priorities are assessment of the neural
and vascular integrity of the upper limb by testing motor and sensory functions of the
fingers and palpation of the radial pulse. Different methods to reduce the dislocation
exist, including the modified Hippocratic method, in which one operator pulls on a
sheet placed around the thorax of the patient, while a second operator gently applies
traction on the wrist of the affected side. Other injuries that may accompany a
shoulder dislocation include strain on the tendons of the subscapularis and
supraspinatus muscles, tears of the glenoid labrum, fracture of the greater tubercle of
the humerus, trauma to the axillary nerve (as demonstrated by loss of sensation in the
shoulder patch region over the deltoid muscle), and trauma to the axillary artery or its
branches, such as the posterior circumflex humeral or subscapular arteries.

APPROACH TO:
The Shoulder

OBJECTIVES
1. Be able to describe the bones and joints that make up the shoulder girdle
2. Be able to delineate the anatomy of the glenohumeral joint
3. Be able to list the extrinsic muscles of the shoulder, their action at the shoulder, and
their innervation
4. Be able to describe the components of the rotator cuff and their action, innervation,
and functional importance to the shoulder.

DEFINITIONS
SHOULDER: Junction between the arm and the trunk.
SHOULDER GIRDLE: The clavicle, the scapula, and the proximal humerus.