Shoulder Dislocation

Question 1

ESSENCE

Answer 1

Head of humerus comes entirely out of the glenoiod cavity of scapula

Question 2

Most common direction

Answer 2

• Anterior displocations (90%)
  
  • Head of humerus moves anteriorly in relaiton to glenoid cavity

Question 3

AETIOLOGY

Differences between anterior and posterior

Answer 3

Anterior - arm forced backwards whilst abducted and extended (falling on outstretched arm)

Posterior - electric shocks and seizures

Question 4

What is some associated damage

Answer 4

• Bankart lesions
  
  • Tears to anterior portion of labrum
• Hill-Sachs lesions
  
  • Compression fractures to posterolateral part of head of humerus
• Axillary nerve damage
• Fractures
• Rotator cuff tears

Question 5

Signs of axillary nerve damage

Answer 5

• Loss of sensation over regimental badge area
• Weakness in deltoid and teres minor muscles

Question 6

Fractures associated with shoulder dislocation

Answer 6

• Humeral head
• Greater tuberosity of humerus
• Acromion of scapula
• Clavicle

Question 7

CLINICAL FEATURES

Presentation

Answer 7

• Acute injury
• Usually hol darm against side of body, deltoid appears flattended and head of humerus will cause a bulge and be palpable from front

Question 8

INVESTIGATIONS

First choice

Answer 8

• Apprehension test
• X-ray - confirm dislocation and exclude fracture
• MRI with contrast - assess for damage such as Bankart and Hill-Sachs lesions and to plan for surgery
• Arthroscopy - camera into shoulder to visualise structures

Question 9

What is apprehension test

Answer 9

• Special test for shoulder instability, specifically in anterior direction
• Likely to be positive after previous anterior dislocation or subluxation
• Patient lies supin, shoulder is abducted to 90 degrees and elbows flexed to 90, shoulder slowly externally rotated and watch patient, as arm approaches 90 degrees of external roation patients with shoulder instability become anxious, worried that should will dislocate

Question 10

MANAGEMENT

Acute management gerneral principles

Answer 10

• Shoulder relocated as soon as possible
• Analgesia
• Gas and air
• Broad arm sling to support arm
• Closed reduction of shoulder (after excluding fractures)
• Dislocations associated with fracture may need surgery
• Post-reduction x-rays
• Immobilisation for period

Question 11

What gas and air may be used in acute management

Answer 11

• Entonox
  
  • 50% nitrous oxide and 50% oxygen

Question 12

MANAGEMENT

Ongoing management general principles

Answer 12

• Physiotherapy
• Shoulder stabilisation surgery might be needed to correct underlying structural problems
  
  • Bankart lesions
  • Tightended shoulder capsule
  • Hill-Sachs lesions
  • Bony injury to glenoid rim

Question 13

What procedure fixes bony injury to glenoid rim

Answer 13

• Latarjet procedure
  
  • Bone graft using bone from coracoid process

Question 14

What procedure corrects Hill-Sachs lesions

Answer 14

Remplissage procedure