Shoulder dislocation Co Norbert

SHOULDER DISLOCATION
Co NORBERT, UR-CMHS

COLLEGE OF MEDICINE AND HEALTH SCIENCES
CLIN MED α COM HEALTH DEPARTMENT
ACADEMIC YEAR 2016-2017
YEAR THREE
3/31/2017 2CMCH , L3 , G4

INTRODUCTION
Shoulder
Dislocation is when
the head of the
humerus separates
from the scapula at
the glenohumeral
joint. (Anon (a),
2009)
3/31/2017 3CMCH , L3 , G4

Anatomy of Gleno Humeral Joint
• Is a synovial ball-and-socket joint
• between the glenoid cavity of the scapula and the head
of the humerus.
• Both articular surfaces are covered with hyaline
cartilage.
• It is surrounded by the fibrous capsule that is attached
superiorly to the margin of the glenoid cavity and
inferiorly to the anatomic neck of the humerus.
• The capsule is reinforced by the rotator cuff, the
glenohumeral ligaments, and the coracohumeral
ligaments.
3/31/2017 CMCH , L3 , G4 4

Shoulder joint cont’
• it Has a cavity that is deepened by the
fibrocartilaginous glenoid labrum; communicates with
the subscapular bursa; and allows abduction and
adduction, flexion and extension, and circumduction
and rotation.
• It is innervated by the axillary, suprascapular, and
lateral pectoral nerves.
• Receives blood from branches of the suprascapular,
anterior and posterior humeral circumflex, and scapular
circumflex arteries.
3/31/2017 CMCH , L3 , G4 5

Rotator (Musculotendinous)
Cuff
• May be subject to inferior or anterior dislocation
• The later stretches the fibrous capsule, avulses the
glenoid labrum, and may injure the axillary nerves
formed by the tendons of the supraspinatus,
infraspinatus, teres minor, and subscapularis (SITS).
• fuses with the joint capsule and provides mobility.
• Keeps the head of the humerus in the glenoid fossa
during movements and thus stabilizes the shoulder
joint.
3/31/2017 CMCH , L3 , G4 6

Nerves supply
3/31/2017 CMCH , L3 , G4 8

Normal(1) glenohumeral and
ant. Shoulder dislocation (2)
3/31/2017 9CMCH , L3 , G4

REASONS FOR INSTABILITY
• Shallow glenoid
• Extraordinary ROM
• Vulnerability of upper limb to injury
• Underlying conditions : Ligament laxity
3/31/2017 10CMCH , L3 , G4

MECHANISM OF INJURY :
 DIRECT :
less common
Fall on abducted
Extended shoulder
 INDIRECT:
more common
Blow from behind
3/31/2017 CMCH , L3 , G4 11

SUSCEPTIBLE POSITION
 Anterior dislocation :
• abduction
• external rotation
• extension
 Posterior Dislocation :
 Flexion
 adduction
 internal rotation
3/31/2017 12CMCH , L3 , G4

ASS0CIATED INJURIES :
• Humeral head & neck #
• tuberosity #
• glenoid #
• rotator cuff tears( older age)
• neurological ( axillary N.) and vascular injuries
• Any pt. with weakness after shoulder dislocation
must be evaluated for rotator cuff tear
3/31/2017 13CMCH , L3 , G4

MECHANISM OF SHOULDER
AND CLAVICLE INJURY
3/31/2017 14CMCH , L3 , G4

Special case
• In seizures & electrical shock
all the muscles are contracted , external rotators
overpower internal rotators
3/31/2017 CMCH , L3 , G4 15

TYPES OF SHOULDER
DISLOCATION
Shoulder dislocations are usually divided according
to the direction in which the humerus exits the joint:
• Anterior > 95%.
• sub coracoid (majority).
• subglenoid (1/3).
• subclavicular (rare).
• Posterior 2-4%.
• Inferior ( luxation erecta ) < 1%.
3/31/2017 16CMCH , L3 , G4

PRESENTATION OF ACUTE
DISLOCATION
• Pain at the injured area
• Loss of normal contour of the shoulder
• Empty glenoid socket
• In ant . Dislocation: limitation of int. rotation &
abduction
• In post. Dislocation: limitation of external
rotation
• In inferior dislocation: in fully abducted position
3/31/2017 CMCH , L3 , G4 17

PHYSICAL EXAMINATION
• Flattening of shoulder
• Fullness in delto-pectoral area
• Axillary fold at lower level
• Able to insinuate finger beneath acromion
• dugas test
• Callaway's test
• Hamilton ruler test
3/31/2017 18CMCH , L3 , G4

Cont,’
• Axillary N. tested for both sensory & motor
components
3/31/2017 CMCH , L3 , G4 19

TESTS OF INSTABILITY
 DRAWER TEST :
 Positive if the translation is excessive in comparison to
other side or if pt develops apprehension or pain
• For both anterior & posterior instability
• LOAD SHIFT TEST – variant of drawer test
3/31/2017 CMCH , L3 , G4 20

SULCUS TEST :
• With arm in 0 and 45 degree abduction
• At 45 degree – inf. Glenohumeral ligament complex
• Significant if noticeable dimple / sulcus at lateral edge of
acromion
• Graded from 0 to 3
• 1+ subluxation < 1 cm
• 2+ 1 to 2 cm
• 3+ > 2 cm
3/31/2017 CMCH , L3 , G4 22

APPREHENSION TEST
• For anterior instability
• Shoulder placed in a position vulnerable to dislocate
• 90 of abduction and external rotation
• FULCRUM TEST & CRANK TEST –
modifications of apprehension test
anteriorly directed force applied to exaggerate
instability
3/31/2017 CMCH , L3 , G4 23

RELOCATION TEST
• Arm placed in abduction & ext rotation
• Posteriorly directed force eliminates apprehension
3/31/2017 CMCH , L3 , G4 25

SURPRISE TEST
• Posteriorly directed force
• Doesn’t experience apprehension even at abduction
& maximal ext rotation
• By abruptly removing force apprehension develops
•
• JERK TEST
• For posterior instability
• After elevating the shoulder to 90 degree in plane of
scapula , axial load placed on the humerus ,
• Gradually adducting the shoulder , head may
subluxate / dislocate posteriorly . Adduction when
removed , head reduces back .
• +ve even if elicits apprehesion
3/31/2017 CMCH , L3 , G4 26

JERK TEST
3/31/2017 CMCH , L3 , G4 27

RADIOGRAPHIC EVALUATION
 ROUTINE AP VIEW
• Glenoid fossa: ellipse
• In normal shoulder: humeral head will overlap glenoid shadow
• Overlap if significantly altered : joint dislocation
• Distance b/w ant. Glenoid rim & humeral head > 6mm
highly s/o post. Dislocation – POSITIVE RIM OR VACANT
GLENOID SIGN
3/31/2017 CMCH , L3 , G4 28

Radiographic findings cont.’
• TRUE AP VIEW – beam perpendicular to scapula ( 35 – 45
degree oblique to sagittal )
• Any overlap in this view is s/o dislocation
3/31/2017 29CMCH , L3 , G4

Inferior Shoulder Dislocation.3/31/2017 CMCH , L3 , G4 37

Normal glenohumeral joint. An anterior shoulder
3/31/2017 CMCH , L3 , G4 38

Computed tomography
• Double-contrast axial
computed tomography
(CT) arthrogram of the
left shoulder shows an
undisplaced
• tear (arrows) of the
anterior glenoid labrum.
The patient had one
episode of an anterior
dislocation.

.
CT
computed tomography (CT)
arthrogram of the right
shoulder shows a deficient
anterior glenoid labrum
(arrows) and medial
stripping of the anterior
capsular attachment
(arrowhead). The patient
had a recurrent anterior
dislocation

CT
arthrogram of the right
shoulder shows a small,
loose body (arrow) in the
axillary recess. The patient
had recurrent anterior
dislocations.

• Double-contrast, reconstructed, 2-
dimensional coronal computed
tomography (CT) arthrogram
• of the right shoulder shows a large
Hill-Sachs defect (arrow) in the
humeral head. A full-thickness rotator
cuff tear is present, evidenced by a
large amount of air in the
subacromial/subdeltoid
• bursa. The remnant end of the
supraspinatus tendon is seen
(arrowhead).

.
COMPUTED TOMOGRAPHY
arthrogram of the left
shoulder shows a bony
Bankart glenoid fracture
(arrows). The patient had
one episode of an anterior
dislocation

Axial, fat-suppressed, spin-echo T1-weighted magnetic
resonance arthrogram of the right shoulder shows an
undisplaced tear (arrow) of the anterior glenoid labrum.
Part of the middle glenohumeral ligament is shown
(arrowhead). The patient had one episode of anterior
dislocation.
Axial, spin-echo T1-weighted magnetic resonance
arthrogram of the left shoulder shows a deficient
anterior labrum (arrows) and medial stripping of the
anterior capsular attachment (arrowheads). The patient
had recurrent anterior dislocations.
MRI

Coronal, T1WI and fast spin-echo T2-weighted conventional magnetic resonance imaging (MRI) scan of
the left shoulder shows a large Hill-Sachs defect (arrows) in the superolateral humeral head. Surrounding
bone marrow edema is shown. Fluid is present in the subacromial/subdeltoid bursa (arrowheads),
indicative of a full-thickness rotator cuff tear. The patient had one episode of an anterior dislocation.

Coronal, fat-suppressed, spin-echo T1-weighted magnetic resonance arthrogram image
of the right shoulder shows a loose body (arrow) in the axillary recess. The patient had a

arthrogram of the right shoulder shows an
undisplaced tear (arrow) of the anterior glenoid
labrum, which remains attached to the inferior
glenohumeral ligament (arrowhead). The patient had
arthrogram of the right shoulder shows an anterior
labroligamentous periosteal sleeve avulsion lesion
(arrows), seen as a rolled-up mass anterior to the
neck of the scapula. The patient had recurrent
anterior dislocations.

MR images in a 31-year-old male dancer obtained 4 days after acute first-time anterior shoulder
dislocation. A, Oblique coronal fat-suppressed T2-weighted image shows a small Hill-Sachs
fracture (arrow) with prominent bone marrow edema. Effusion is present. B, On more anterior
oblique coronal fat-suppressed T2-weighted image, the inferior labral-ligamentous complex (open
arrow) is detached and displaced from the inferior glenoid rim. The humeral attachment site (solid
arrow) is unremarkable. The cuff is intact. C, On axial gradient-echo image, the anteroinferior
labral-ligamentous complex (open arrow) is displaced from the glenoid rim, and the attached
periosteum (solid arrow) is stripped medially along the glenoid neck. No glenoid rim fracture is

Acute first-time anterior shoulder dislocation: T1-weighted MR images in a 26-year-old man with
shoulder pain after a single anterior dislocation. MR arthrography was performed 2 months after
known dislocation owing to persistent pain and limitation. A, Axial fat-suppressed image
demonstrates an intact anterior labrum (arrow). B, ABER image demonstrates an avulsion of the
anterior labrum with an intact glenoid periosteum and capsule (arrow), highlighting the
mechanical advantage of having the shoulder in this position during imaging.

MR images of acute ALPSA in a 24-year-old man who sustained a first episode of anterior
shoulder dislocation 3 weeks prior to imaging. A, Fat-suppressed T2-weighted and, B,
axial fat-suppressed intermediate-weighted images demonstrate a Hill-Sachs lesion
(white arrow) with marrow edema and associated anteroinferior labral tear with
anteromedially displaced fragment (open arrow). Note stripping and edema of the

MR images of acute recurrent anterior shoulder dislocation with Bankart fracture in a 64-year-old man. A, Sagittal and, B, C,
coronal fat-suppressed T2-weighted images demonstrate extensive periarticular posttraumatic swelling (☆) with high-grade
partial thickness tears of the subscapularis myotendinous junction (white arrow) and humeral muscular insertion (open
arrow) as well as strains of the supraspinatus (SST), infraspinatus (IST), teres minor (Tmi), latissimus dorsi (LD), triceps (T),
and teres major (Tma) muscles. Glenohumeral and subacromial subdeltoid effusions (★), as well as humeral avulsion of the
inferior glenohumeral ligament (HAGL ▲) and a detached and mildly displaced Bankart fracture (black arrow). D, Sagittal T1-
weighted image demonstrates a displaced Bankart fracture fragment. The defect in the anteroinferior glenoid rim is
somewhat ill defined. E, Three-dimensional MR reconstruction demonstrates the amount of glenoid bone loss, glenoid
fracture margin (white arrow), and adjacent fracture fragment (open arrow) to a better extent than the conventional MR
images. F, Three-dimensional MR reconstruction of the humeral head demonstrates a mildly displaced avulsion fracture of
the greater tuberosity at the insertion of the supraspinatus tendon (black arrow), as well as an impacted Hill-Sachs lesion

Chronic multidirectional instability in a 41-year-old woman with apprehension, disability, and
provocative testing positive for instability and without previous dislocation or major
traumatic event. At conventional MR imaging of the shoulder 5 weeks earlier at an outside
institution, findings were interpreted as negative for labral-ligamentous injury. On this
oblique coronal fat-suppressed T1-weighted arthrographic MR image, contrast material
outlines the anterior band of the inferior glenohumeral ligament (black arrow), which is
ruptured and retracted from its humeral attachment site. Contrast material leaks from the

Chronic ALPSA in a young baseball player with clinical findings of anteroinferior instability and
no history of prior dislocation. A, B, Axial and, C, sagittal fat-suppressed T1-weighted MR
arthrograms demonstrate a medially displaced anteroinferior labral tear (black arrows) and
stripped off scapular periosteum with scar tissue annealing the fragment and periosteum to the

MR images in a 24-year-old extreme athlete who denied previous dislocation or major shoulder trauma. A, Axial, fat-suppressed
T1-weighted MR arthrogram shows increased signal intensity at the labral chondral junction (black arrow), as well as a
nondisplaced posteroinferior labral tear and a contrast agent–filled chondral defect with a GLAD lesion (white arrow). A small
subchondral cyst is found adjacent to the posterior tear (open arrow). B, On ABER fat-suppressed T1-weighted MR arthrogram,
tear of the anteroinferior labral chondral is made conspicuous (arrow). At the time of initial MR imaging, the patient elected to
continue competition, forgoing surgical intervention. Repeat MR imaging 2.5 years later was performed due to disability
preventing further competition. C, Axial fat-suppressed T1-weighted MR arthrogram shows a Bankart lesion and marked
displacement of the anteroinferior labral-ligamentous complex (arrow) from the glenoid rim. D, ABER fat-suppressed T1-weighted
MR arthrogram demonstrates progression to a GLAD injury in the anteroinferior labrum with detachment and displacement of a
large labral chondral fragment (arrow). Arthroscopic stabilization procedure was performed. The posteroinferior labral chondral

(A-C): Bony Bankart lesion in a 28-year-old male with recurrent anterior
shoulder dislocation. Axial TSE T1W fat-saturated MRA image (A) shows an
absent anteroinferior labrum with bony injury (arrow). Sagittal TSE T1W fat-
saturated MRA (B) and sagittal MRA image (C) 5 mm medial to B, show the full
extent of the bony Bankart lesion (arrow).

(A-C): Perthes lesion. A 16-year-old male presented with post-traumatic recurrent anterior
shoulder dislocation. TSE T1W fat-saturated axial MRA image (A) and TSE T1W fat-saturated
oblique axial MRA image with arm in ABER position (B) show intercalation of intra-articular
contrast beneath the anterior labrum (small arrow) with an intact scapular periosteum (long
arrow); this suggests a diagnosis of Perthes lesion. TSE T1W fat-saturated oblique sagittal
MRA image (C) shows the extent of the lesion (arrows).

ALPSA lesion in three different patients with anterior shoulder instability. TSE T1W
fat-saturated coronal MRA images (A,B) and axial MRA image (C) show the
anteroinferior labrum and antero-inferior glenohumeral ligament rolled back
medially along the scapular neck (arrow)

GLAD lesion in an 18-year-old male student. TSE T2W fat-saturated axial
conventional MRI image (A) and coronal TSE T1W fat-saturated MRA images
(B,C) show anterior-inferior labral injury (long arrow) with an articular cartilage

(A-B): Coronal TSE T1W MRI (A) and axial TSE T1W fat-saturated MRA (B) images show a
comminuted greater tuberosity fracture (arrow) in this 38-year-old male presenting with
traumatic shoulder instability

(A-B): Reverse Hill-Sachs and reverse Bankart lesion in a 34-year-old male who had
multidirectional instability with a posterior dislocation at presentation. Axial TSE T1W fat-saturated
MRA images (A,B) show a reverse Hill-Sachs lesion (long arrow) as a bony defect in the anterior
humeral head. A posterior labral tear is indicated with a thick arrow. The patient also had an
anterior labral tear (small arrow in B) and a Hill-Sachs lesion from previous anterior dislocations. A
Bennett lesion is seen as ossification, posteriorly along the scapular neck (long arrow in B)

Morphologic abnormality of the posteroinferior glenoid in a patient with
posterior instability. Axial GRE MEDIC T2W MRI image (A) and axial CT
arthrogram image (B) reveal the "lazy J" deformity; better appreciated
on CT scan

MRI of shoulder after dislocation with
Hill-Sachs lesion and labral Bankart's

Dual post-traumatic findings - Note the presence of both a Hill-Sachs
deformity of the posterolateral humeral head and a partial thickness

Combined tendinous injuries from a single, devastating shoulder injury. Displaced
tendon of long head of biceps muscle (Fig A), Subscapularis tendinous avulsion and
Teres minor tendon partial tear (Fig B), Posterior capsular disruption (Fig C) and
Supraspinatus tendinous disruption (Fig D).

Bankart and Hill-Sachs lesions in anterior shoulder dislocation. (A) T1-weighted oblique
coronal and (B) STIR axial MR images of the shoulder show a bony Bankart lesion with
detachment of the anteroinferior labrum from the underlying glenoid, involving the bony
margin (impaction fracture) (arrows). STIR axial (C) and oblique sagittal (D) MR images
show a Hill-Sachs lesion with posterolateral humeral head compression fracture with
bone edema as the humeral head comes to rest against the anteroinferior part of the
glenoid. These types of lesions frequently occur in collision-sports

Management
• Emergency
• Should be reduced in ˂ 24 hours
• Immobilized strapped to the trunk for 3-4 weeks and rested in a
collar and cuff
 REDUCTION
 Closed reduction
 Open reduction / surgery
3/31/2017 66CMCH , L3 , G4

Maneuvers
• traction- counter traction method
• Hippocrates method
• Stimpson’ s technique
• Kocher’ s technique
3/31/2017 67CMCH , L3 , G4

Hippocrates method
3/31/2017 68CMCH , L3 , G4

Stimpson’ s technique
3/31/2017 69CMCH , L3 , G4

Kocher’ technique
• Step I : flex elbow traction
• Step II : external rotation
• Step III : adduction
• Step IV : internal rotation
3/31/2017 70CMCH , L3 , G4

MILCH TECHNIQUE
• Pt in supine / prone position
• With moderate traction
• arm abducted & externally rotated
• humeral head is manually manipulated back into joint
3/31/2017 71CMCH , L3 , G4

DEFINITIVE NONOPERATIVE
TREATMENT
 reduction confirmed by radiographs
 exact protocol for immobilization : controversial
 simple sling : preferred
 immobilization , protection and rehabilitation
 strengthening of rotator cuff M. , deltoid & scapular stabilizers
3/31/2017 72CMCH , L3 , G4

OPERATIVE TREATMENT
 SURGICAL STABILISATION FOR ANT . INSTABILITY
 in failed appropriate non operative treatment
 recurrent dislocation at young age
 irreducible dislocation
 open dislocation
 unstable joint reduction
 1st dislocation in young pt with high demand activity
3/31/2017 73CMCH , L3 , G4

SURGICAL OPTIONS
 arthroscopic surgery
 open tech. with soft tissue repair
 open tech. with bony augmentation
3/31/2017 74CMCH , L3 , G4

Surgery cont.’
• Open preferred over arthroscopy in
• Procedures involving isolation & fixation of
bony fragment
• Large hill- sachs lesion
• Substantial glenoid defect
• HAGL lesion : humeral avulsion of gleno -
humeral ligament
3/31/2017 75CMCH , L3 , G4

ARTHROSCOPIC PROCEDURES
3/31/2017 76CMCH , L3 , G4

PROCEDURE
 Begins with complete examination of joint
 Glenoid bony defect > 25 % convert to open
 Two anterior portals : one immediately superior to subscapularis
, other superior edge of rotator interval
 Accessory inferior portal also can be used
 Capsulolabral complex identified , advanced to anatomical
position , suture anchor inserted into rim .
 no instrument should enter the joint inferior to subscapularis –
nearby axillary nerve
 Pre op exam – consistent with rotator interval laxity ( + ve sulcus
sign ) – rotator interval closure
 Capsular redundancy addressed simultaneously
3/31/2017 77CMCH , L3 , G4

Open procedures
 BANKART OPERATION
 MC performed surgery
 Ant. Labral defect identified , mobilized & reattached
to original anatomic site with suture anchor .
 Capsular reconstruction also recommended
 Subscapularis tendon is split at junction of upper 2/3rd
& lower 2/3rd
3/31/2017 78CMCH , L3 , G4

Bankart procedure
3/31/2017 CMCH , L3 , G4 79

LATERJET PROCEDURE
 For anterior stabilization with ass. Glenoid def.
 with engaging hill-sachs lesion
 The graft lengthens the articular arc to prevent hill-
sachs lesion from engaging
 Coracoid process is transferred to the glenoid rim ,
extraarticularly & fixed with two screws
3/31/2017 CMCH , L3 , G4 80

LATERJET PROCEDURE
3/31/2017 CMCH , L3 , G4 81

LATERJET PROCEDURE
3/31/2017 CMCH , L3 , G4 82

LATERJET PROCEDURE
3/31/2017 CMCH , L3 , G4 83

BRISTOW OPERATION
•
• Suturing of coracoid process with the conjoint tendon
to the ant. Portion of scapular neck through a
transversely sectioned subscapularis M.
• The transferred short head of biceps &
corachobrachialis – strong buttress across the anterior
& inferior aspects of joint
• Tendon also holds the lower half of subscapularis M.
thus prevents slipping over the humeral head when
abducted
3/31/2017 CMCH , L3 , G4 84

BRISTOW OPERATION
 coracoid process must be near ( < 5mm from glenoid
rim ) but not over the rim
 Used when previous procedures resulted in
dysfunctional subscapularis & backup procedure
when secure capsulolabral reconstruction is not
obtained
3/31/2017 CMCH , L3 , G4 85

BRISTOW OPERATION
3/31/2017 CMCH , L3 , G4 86

BRISTOW OPERATION
3/31/2017 CMCH , L3 , G4 87

PUTTI-PLAT OPERATION
 Subscapularis and capsule incised vertically
 Lateral leaf sutured to the labrum & medial leaf
imbricated
 Subscapularis is advanced laterally
 Gross limitation of ext. rotation
 Rarely indicated
3/31/2017 CMCH , L3 , G4 88

3/31/2017 CMCH , L3 , G4 89

3/31/2017 CMCH , L3 , G4 90

MAGNUSON & STACK OPERATION
 Ant. Capsulomuscular wall tightened by advancing
the capsule & tendon of subscapularis M laterally on
the humerus
 Adv : simple & good success rate
 Disadv : cant correct labral or capsular defect
3/31/2017 CMCH , L3 , G4 91

MAGNUSON & STACK OPERATION
3/31/2017 CMCH , L3 , G4 92

EDEN – HYBBINETTE PROCEDURE
•
• Places tricortical iliac graft
• Intraarticularly or extraarticularly
3/31/2017 CMCH , L3 , G4 93

WEBER SUBCAPITAL OSTEOTOMY
-
- For large posterior defects in humeral head
- To rotate the hill sachs lesion more posterolaterally
-by increasing humeral retroversion - it doesn’t
encounter the glenoid during normal rotation
3/31/2017 CMCH , L3 , G4 94

PECTORALIS MAJOR transfer for
subscapularis deficiency
3/31/2017 CMCH , L3 , G4 95

For severe capsular deficiency
 Reconstruction with :
 Semitendinosus autograft
 Hamstring tendon
 Iliotibial band fascia
 Achilles tendon
3/31/2017 CMCH , L3 , G4 96

Grafting
3/31/2017 CMCH , L3 , G4 97

Cont.’
 Large engaging hill-sachs lesion involving
 20 – 30 % of humeral head
 acute – disimapction & bone grafting
 chronic – transfer of infraspinatous tendon
 - 30 – 40 % - fresh frozen allograft / humeral
rotational osteotomy + imbrication of ant. Capsule
and subscapularis tendon
 - > 45 % prosthetic replacement
3/31/2017 CMCH , L3 , G4 98

TREATMENT FOR
MULTIDIRECTIONAL INSTABILITY
In most cases generalized ligamentous laxity
- Primary treatment : non operative strengthening of
dynamic stabilizers
- Surgical only if failed conservative treatment disability
frequent & significant not a voluntary dislocator
Primary abnormality : loose redundant inferior pouch
- Detach the capsule from the humeral neck & shift to
opposite side
- Approach : ant / posterior depends on direction of greatest
instability
3/31/2017 CMCH , L3 , G4 99

NEER TECH OF CAPSULAR SHIFT
3/31/2017 CMCH , L3 , G4 100

O’BRIEN TECH OF CAPSULAR SHIFT
3/31/2017 CMCH , L3 , G4 101

MANAGEMENT OF POSTERIOR
INSTABILITY
- initial management : conservative
- surgery in failed conservative , habitual dislocation ruled out
& emotionally stable
1. posterior capsulorrhaphy
2. neer inferior capsular shift through posterior approach -
3. posterior capsular tendon retensioning
4. posterior glenoid osteotomy – if glenoid retroversion > 20
degree
5. mclaughlin procedure - if reverse hill-sachs lesion –
subscapularis tendon into the defect
( modified – along with tuberosity )
3/31/2017 CMCH , L3 , G4 102

POSTERIOR CAPSULAR
RETENSIONING
3/31/2017 CMCH , L3 , G4 103

Mclaughlin operation
3/31/2017 CMCH , L3 , G4 104

MODIFIED Mc LAUGHLIN
PROCEDURE
3/31/2017 CMCH , L3 , G4 105

NEER INFERIOR CAPSULAR
SHIFT – POSTERIOR APPROACH
3/31/2017 CMCH , L3 , G4 106

GLENOID OSTEOTOMY
3/31/2017 CMCH , L3 , G4 108

Supportive management
• Wound care
• analgesics
• Antibiotics
• Enough rest
• Avoid movement of affected joint
• Nutritional support with balanced diet
• Avoid lifting heavy objects
3/31/2017 109CMCH , L3 , G4

Oxygenate and Resuscitate Before You Operate

“Failure to promptly recognize and treat simple life-threatening injuries is the
tragedy of trauma, not the inability to handle the catastrophic or complicated
injury.”
(F.William Blaisdell)
GOOD JUDGMENT COMES FROM EXPERIENCE
EXPERIENCE COMES FROM BAD JUDGMENT

• THIS IS THE END OF
OUR
PRESENTATION
• HAVE A NICE DAY :
LADIES AND
GENTLEMEN

Shoulder dislocation Co Norbert

More Related Content

What's hot

Viewers also liked

Similar to Shoulder dislocation Co Norbert

Recently uploaded

Shoulder dislocation Co Norbert