SHOULDER DISLOCATION

ORTHOPEDICS DEPARTMENT
DR Kilian K.K
OUTLINE
 Case presentation
 Introduction
 Definition
 Anatomy
 Epidemiology
 Risk factors for shoulder dislocation
 Types of shoulder dislocation
 Mechanism of injury
 Clinical signs and symptoms
 Diagnosis
 Management
 Prognosis
 Complications
A.M 35yo M, Minor in
Mozambique 9/12, Muheza
 Returned to Tanzania, 3 month ago – Mtwara,
Tanga(Kibiboni) BOMBO
C/O – painful Rt shoulder 3/12,
– inability to use the Rt UL 3/12
+ve Hx of falling from height and landing on abducted arm in the
mines where works prior to the onset of the aforementioned Sx.

 At St. elsewhere Traditional Health services (Mtwara) on 21st May,

Dx: ?; Rx. Local Herbal meds for 20days ᶿRelief;
 At Kibiboni in July 2nd Dx: ?? Local traditional meds Reduction
attempt failed. So advised to seek alternative treatment at our
setting.
 Guess the next move!!!!!
…you may guess the next photo!!

…To TRRH….
Admitted ward 08 on Aug 29th (Orthopaedic Male ward)
 O/E: Health looking, in pain , Alert
and oriented to PPT, with Rt arm
immobilized on arm sling, afebrile,
ᶿpale, ᶿ oedema, ᶿ rash, ᶿ petechial

V/S: BP 114/68 mmHg, HR 66 bpm,

RR 18 cpm, T° 36.4°C, SpO2 97%
ORA
SYST EXAM: NAD
L/E: Shoulder abducted on arm sling & supported with other hand,
restricted flexion, adduction about the shoulder with moderate
degree of tenderness to Mobility.
Dugga’s &Hamillton tests +ve
 Investigations

LABs
 Hb 13.7g/dl
 Grouping AB+ve
Diagnosis:
 CHRONIC POSTERIOR DISLOCATION Rt SHOULDER

 DDx
 ANTERIOR SHOULDER DISLOCATION
 NECK OF HUMERUS #
 SOFFT TISSUE INJURY (Rt shoulder) i.e (SPRAIN)
 CHRONIC ACJ DISLOCATION
Rx:
 OPEN REDUCTION done

Post operatively:
 IV Ceftriaxone 2g OD 5/7
 Limb elevation while resting
 Immobilization with arm sling

 Discharged home 6/7 …

 Seen 1/12 at OTC; follow up clinic (ALL IS WELL)

 …..the story continues!.. Complications ..!!!!?
 ..what do we learn?

 Community awareness vs (Traditional medicine’s market vs

modern Medicine)
 Delayed proper diagnosis
 Treatment complexity (emergency closed reduction in acute
cases vs open reduction&/ necessity of specialized center)
 Definition of terms

Dislocation:   
A dislocation is a separation of two bones where they meet at a
joint. A dislocated bone is no longer in its normal position.
 Results
from Stretching or tearing of the joint stabilizing
mechanisms (ligaments and tendons)
A dislocation may also cause ligament or nerve damage.
Dislocations may be associated with a peri-articular fracture
Subluxation:
A subluxation is an incomplete or partial dislocation.
 For example, a nursemaid's elbow is the subluxation of the
head of the radius in the elbow
Introduction to Shoulder dislocation

Definition
 Iswhen the head of the humerus separates from
the scapular at the glenohumeral joint.
ANATOMY
 Bones
 Scapular, Clavicle and humerus
 Joints
 Glenohumerol, acromio-clavicular, sterno-clavicular, scapula-thoracic.
 Muscles
 Stabilizing
 Rotator cuff (S-Supraspinatus,I-Infraspinatus,T-Teres minor,S S-Subscapularis)
 Associated muscles(Deltoid, Biceps, Pectoralis)
 Capsule
 Ligaments
 EPIDEMIOLOGY
 Accounts 50% of all major joint dislocation.
 Bimodal distribution
 Men 20-30yrs (M:F, 9:1)
 Women 61-80yrs (M:f, 1:3)
 Lessin children as their epiphyseal plate is weaker thus tend to
have fracture before dislocation.
 More common in elder as their collagen fibers have fewer cross
link
 >Weaker capsule, tendons and ligaments.
DISLOCATION CAUSES

 Dislocations are usually caused by a sudden impact to the

joint.
 This usually occurs following a blow, fall, or other trauma
RISK FACTORS

 Age
 Trauma
 Previous dislocation
 Repetitive strain
TYPES OF SHOULDER DISLOCATION
 Anterior dislocation (95%)
In this injury the head of the humerus comes out of the glenoid joint and
lies anteriorly.
Occurswhen there is a fall on an outstretched hand with the shoulder
abducted and externally rotated.
 Posterior dislocation (4%)
In this injury the head of the humerus comes out of the glenoid joint and
lies posteriorly.
Itresults from a direct blow on the front of the shoulder when the arm
adducted and internally rotated.
 Inferior dislocation (1%)
It’s a rare type where the head comes to lie in the sub-glenoid position
Occurs when the arm is fully abducted and elbow often flexed on or behind
 CLINICAL PRESENTATION
 Includes;
 Severe shoulder pain
 Loss of normal contour of the shoulder joint
 Palpable/displaced humeral head
 ROM decreased
 Numbness/paraesthesia to the fingers (ulnar/radial distribution)
 Mostly pt’s enters causality with shoulder abducted and elbow supported with the opposite
hand.
 N:b
 Check radial pulse to asses for vascular injury
 Check sensation on the lateral aspect of the shoulder over the deltoid muscle.
 Assessfor radial nerve function (Test for thumb, wrist and elbow weakness on extension +
reduced sensation in dosurm of the hand)
 CLINICAL TESTS
DIAGNOSIS
 DUGAS’ TEST
Inability to touch the opposite shoulder.
 HAMILTON RULER TEST
Because of the flattening of the shoulder, it is possible to place a ruler on
the lateral side of the arm, This touches the acromion and lateral condyle
of the humerus simultaneously.
 CALLWAY’S TEST
In dislocation of the shoulder, vertical circumference of axilla is increased
compared to the normal side.
 INVESTIGATION
 Mostly Shoulder X-ray. Two planes at 90 degrees to each other, Good quality,Standard views &
See the entire joint
ANTERIOR DISLOCATION
POSTERIOR DISLOCATION INFERIOR DISLOCATION
 MANAGEMENT
 Can either be non-operative or operative
 Non-Operative management consist of;
 Reduction under anesthesia.
 Immobilization of the shoulder in a chest arm bandage for three weeks.
 Physiotherapy

 >>Management of pain.
 Indications for operative management
 Failure of closed reduction
 Recurrent

 Neurovascular injury
 Fracture-dislocation.
TECHNIQUES OF REDUCTION.
 Kocher’s maneuver
 T-Traction
 E-External rotation
 A-Adduction
 M-Medial rotation
 Hippocrates maneuver.
 Stimson maneuver
 Milch Maneuver
HIPPOCRATIC METHOD
CONTRAINDICATIONS OF CLOSED
REDUCTION OF SHOULDER DISLOCATION

Includes;
Subclavicular/Intrathorasic dislocation
Suspicion of major vessel damage 6P’s
(Pale,Pulseless, Unreasonable pain, Paralyzed,
Paraesthetic, Perishing with cold.
Fracture
 PROGNOSIS

 Good follow up care leads to best prognosis for preventing

dislocation again and healing damaged tissues.
 Even with the best care however, dislocation can reoccur.
 Most people who experience shoulder dislocations when
younger than 20years of age go on to experience a second
dislocation.
 After age 40, a significant percentage have a second
dislocation.
 COMPLICATIONS OF SHOULDER JOINT
DISLOCATION.
 Early complications
 Injury to the axillary nerve
 Brachial plexus, radial and other nerve damage
 Axillary artery damage.
 Rotator cuff injury
 Late complications
 Recurrent dislocation.
 Bankart’s lesion
 Hill-sachs lesion.