SHOULDER AND HIP

DISLOCATION
Presenters : Anne and Lavinia
Supervisor : Dr Jasreena
SHOULDER DISLOCATION
Important dynamic restraints
Types of shoulder dislocation
1. Anterior dislocation (most
common)
⮚Subcoracoid
⮚Subglenoid
⮚Subclavicular
2. Posterior – abduction and internal rotation of arm
• Subacromial
• Subglenoid
• Subspinous

3. Inferior – arm fully abducted and elbow often flexed on or behind head
Clinical signs
Anterior dislocation
Posterior dislocation
Nerve injuries in shoulder dislocation
• Axillary nerve
o Nerve that originates from middle trunk of brachial plexus that arise
from C5 and C6
o anterior to the subscapularis muscle and posterior to the axillary
artery
o Travels through the quadrangular space
o Divides into anterior and posterior branches
Muscle innervated
• Deltoid (anterior,mid,posterior) and teres minor

Sensory supply
• regimental badge area (lateral aspect of the shoulder and upper arm)

Clinical testing
• examination reveals loss of contour of affected shoulder and
weakness of abduction of the arm
• sensation are lost in the regimental badge area
 Management - Close manipulation and reduction
Step 1 : Prepare patient for CMR
- sedation
- Continuous vitals sign monitoring

Step 2 : Closed manipulation reduction

- Milch maneuver
- Kocher’s maneuver
- Stimson’s maneuver
- Hippocratic maneuver

Step 3 : Post CMR

- armsling
- neurovascular assesement
- check xray
Hippocrates method
 Check xray

Acceptable Not acceptable

Neurovascular deficit
Plan
Yes
No 1. For open reduction
under anesthesia
Discharge plan
1. Continue armsling for 2 weeks
2. TCA 2 weeks to review condition and XOA
3. Analgesics
HIP DISLOCATION
Types of dislocation
Posterior Anterior Central

Most common Rare Very rare

Usually occurs Usually occurs Occurs with fall

when knee in road accident on side/ blow
strikes against with posteriorly on greater
dashboard directed force trochanter
(road accident) on abducted which forced
hip the femoral
head medially
through floor of
acetabulum
Affected joint Limb externally Limb shorter
adducted, rotated,
internally abducted,
rotated and slightly flexed
slightly flexed
and shortened
 Posterior dislocation

• Most common occurence

• Hip joint adducted, internally rotated,
slightly flexed, shortened
 X-ray:
❖ Femoral head appears smaller than
contralateral femoral head
❖ Femoral head superimposes roof of
acetabulum
❖
Thompson and Epstein classification of hip
dislocation
Classification
I Dislocation with no more than minor
chip fractures

II Dislocation with single large fragment

of posterior acetabular wall

II Dislocation with comminuted

I fragments of posterior acetabular wall

I Dislocation with fracture through

V acetabular wall

V Dislocation with fracture through

acetabular floor and femoral head
Pipkin classification of femoral head fractures
Anterior dislocation
• Rare occurrence
• Occurs in road accident with posteriorly
directed force on abducted hip
• Hip joint abducted, externally rotated
• X-ray:
❖ femoral head appears larger than contralateral femoral
head
❖ femoral head is medial or inferior to acetabulum
Central dislocation
• Very rare
• Occurs with fall on side/ blow on greater trochanter which forced the
femoral head medially through floor of acetabulum (side impact
MVA)
Treatments
• Non-operative
• Closed reduction
• Types:
✔ Allis
✔ Captain Morgan
✔ Whistler
✔ Bigelow
✔ Stimpson
* Contraindicated in femoral neck fractures
• Operative
• Open reduction
• Place patient in supine position
• Give sedation
• Assistant stabilize pelvis
• Flex knee to relax hamstring
• Tract in direct line of deformity,
followed by gentle flexion of the
hip to 90 degrees
• Rotate the leg internally and
externally until the femoral head
is rearticulated with the
acetabulum
Captain Morgan Technique
• Place patient on flat surface
• Attach strap over pelvis (stabilize
to board)
• Lift your knee with steady
sustained force
 Bigelow method

● Have an assistant stabilize the

pelvis
● Place forearm behind knee of
affected limb and use another
hand to support the limb at the
ankle
● Use upward traction and while
femur is distracted, externally
rotate and extend limb
 Whistler’s technique
• Patient lies supine on flat surface
• Unaffected leg flexed with an assistant
stabilizing the leg and pelvis
• Another hand grasps the lower leg of the
affected limb, usually around the ankle
• Dislocated hip should be flexed to 90
degrees
• Provider’s forearm is the fulcrum and
affected lower leg is the lever
• When pulling down on the lower leg, it
flexes the knee thus pulling traction along
the femur
Stimpson Technique
• Patient placed in prone position
with lower limbs hanging from end
of table
• Assistant immobilizes the pelvis by
applying pressure on the sacrum
• Hold knee and ankle flexed to 90
degrees and apply downward
pressure to the leg just distal to the
knee
Complications
• Early
• Sciatic nerve injury in posterior dislocation
• Foot drop
• Loss of sensation below knee (except for medial part of leg
and foot as supplied by saphenous nerve)
• Femoral nerve injury in anterior dislocation
• Poor hip flexion, unable to extend knee
• Loss of sensation over anterior and medial aspect of thigh
• Vascular injury
• Associated fractured femoral shaft/ knee injury
• Late
• Avascular necrosis
• Secondary osteoarthritis
• Unreduced dislocation
Post Reduction Care

1. Maintain patient comfort : skin traction adequate analgesia

2. Avoid adduction, internal rotation.
3. No flexion more than 60
4. Early mobilisation within few days with protected weight bearing 4-6weeks.
5. All hip dislocations have to do CT Scan: to rule out femoral head fracture.
Thank you