*SHOULDER DISLOCATION · The Shoulder joint also called as Glenohumeral joint from Greek glene, eyeball, + -oid, 'form of', + Latin humerus, shoulder, is structurally classified as a synovial ball and socket joint and functionally as a diarthrosis and multiaxial joint. · It involves articulation between the glenoid cavity of the scapula (shoulder blade) and the head of the humerus (upper arm bone). · It is the most mobile joint of the human body. *DEFINITION OF DISLOCATION A joint dislocation, also called luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet. · A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. · A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. · Dislocations can occur in any joint major (shoulder, knees, etc.) or minor (toes, fingers, etc.). The most common joint dislocation is a shoulder dislocation. DEFINITION OF SHOULDER DISLOCATION · When the head of the humerus is displaced and looses contact with the glenoid cavity, the condition is called the dislocation of Shoulder. · It’s the most common joint dislocation. CLASSIFICATON OF SHOULDER JOINT
1. ACUTE DISLOCATION
a. Anterior dislocation
b. Posterior dislocation
c. Subglenoid dislocation (Luxatio Erecta)
2. RECURRENT DISLOCATION
ACUTE DISLOCATION
a. Anterior dislocation- Head of the humerus will be in front (anterior) of the glenoid cavity.
b. Posterior dislocation- Head of the humerus will be behind (posterior) the glenoid cavity.
c. Subglenoid dislocation- Head of the humerus will be beneath (inferior) the glenoid cavity.
AGE
· Adults- common sufferers, as the shoulder joint capsule is weak because of mobile free joint.
· Children- rare sufferers, as the shoulder joint capsule are strong but because of the weaker epiphysial line, the fractures are common in children.
ANTERIOR DISLOCATION
Aetiology
· Fall on hand with external rotation of shoulder joint over the fixed hand.
Subtypes
· Again in the anterior dislocation, two subtypes can be made as, subcoracoid (below coracoid process) dislocation and subclavicular (below the clavicle) dislocation.
Clinical features
· Extreme pain
· Swelling
· ROM
On examination
· Under the edge of the acromion process, the gap can be felt because of the absence of the humeral head.
· Head of the humerus can be felt below the coracoids process.
· Prominent acromion process.
FOUR TESTS- H,BCD
· Hamilton ruler’s test- the straight ruler can’t touch the acromion process and lateral epicondyle of the humerus normally, but it’s possible in dislocation of shoulder.
· Bryant’s test- misalignment of the levels of anterior and posterior
axillary folds.
· Callaway’s test- the vertical circumference of the shoulder is increased in shoulder dislocation.
· Dugas test- touching of the opposite shoulder with the hand is not possible while the arm is in contact with the chest in shoulder dislocation.
Investigations
X-ray, i.e.,
· AP view,
· axial lateral projection or tangential lateral,
· trans-lateral view
Treatment
· Conventional method
· Position of the pt- Abduction.
Maneuver- Arm traction fixes with the head into the socket.
Result- fixes with clunk.
· Kocher’s method
a. Position of the pt- flexed elbow.
Maneuver- traction with external rotation of arm.
Result- fixes with clunk.
b. Position of the pt- adduction.
Maneuver- adduction of shoulder till the elbow reaches the chest and simultaneously traction with external rotation of arm.
Result- fixes with clunk.
c. Both “a” and “b” simultaneously.
· Hippocratic method
· Position of the pt- the stockinged foot of surgeon is placed over the axilla.
Maneuver- traction of arm with adduction of the arm.
Result- fixes with clunk.
· Gravitational traction
· Position of the pt- prone on the table with the arm hanging on the edge of the table
Maneuver- traction of arm with adduction of the arm.
Result- fixes with clunk.
Note: All the maneuvers should be done under the anaesthesia.
Comlplications
· Injury to the nerves- circumflex nerve.
· Injury to the muscles- tear of supraspinatos tendon.
· Injury to the muscles- fractures may be associated with the greater tuberosity and neck of humerus.
· Complication to the joint- recurrent shoulder dislocation.
POSTERIOR DISLOCATION
Aetiology
· Fall on the outstretched and internally rotataed hand.
· Direct blow on the front of the shoulder.
Clinical features
· Extreme pain
· Swelling
· ROM
Investigations
X-ray, i.e.,
· AP view,
· Axial lateral projection or tangential lateral,
· Trans-lateral view
Treatment
· Position of the pt- Abduction to 900.
Maneuver- Arm traction with external rotation.
Result- fixes with clunk and rested with broad arm sling.
Note: If it’s unstable then the arm should be kept in 600 lateral rotation for 4 weeks in shoulder spica.400 abduction and 600 internal rotation.
Complications
· Recurrent dislocation
· Unreduced dislocation
SUBGLENOID DISLOACTION OR LUXATIO ERECTA
Aetiology
· Fall on the abducted arm levered by acromion process pulls the head of humerus downwards.
Clinical features
· Abducted arm
· ROM
· Pain
· Check for the neurological or vascular involvement
Investigations
X-ray, i.e.,
· AP view,
· Axial lateral projection or tangential lateral,
· Trans-lateral view
Treatment
· Position of the pt- Abduction of arm.
Maneuver- Traction in abduction and swinging the arm into adduction position while the surgeon should fix the head of the humerus in the socket.
Result- fixes with clunk and rested with broad arm sling.
RECURRENT DISLOCATION
Definition
Repeated dislocations with a trivial cause.
Pathology
· The separation of the glenoid labrum completely from the glenoid.
· The separation of the glenoid labrum and the capsule.
· Tear in the anterior wall of the capsule.
Because of the above causes the gap will be created, which causes the head of the humerus to move and dislocate the joint.
Note: Because of the unhealed Bankart lesion which might have resulted because of the improper immobilization in the acute dislocations also the recurrent dislocation might result.
Clinical Features
· Common features with the character of self reduction by the pt himself.
· Apprehension test- Passive movement of the shoulder behind the coronal plane with abduction and lateral rotation will the apprehension (fear or anxiety about the dislocation again), hence the pt resists this manoeuvre.
Investigations
X-ray, i.e.,
· AP view,
· Axial lateral projection or tangential lateral,
· Trans-lateral view
Treatment
· Conservative management is of no use and the ultimate is the operative management.
· Operative management includes two operations i.e., Putti-Platt’s Operation and Bankart’s Operaton.
Putti-Platt’s Operation
· Its dealt as a "double-breasted " approach and a " vest over pants " technique.
· Anterior approach through the deltopectoral groove.
· Coracoid process is reached and divided to expose the subscapularis.
· Scusacpularis is used for double breasting with the capsule.
Bankart’s Operation
· Same as the Putti-Platt’s operation till the exposure of subscapilaris.
· Scapular neck is rawed and 2-4 fin drill holes are made through which the capsule is sutured.
Ref. Book: AConcise Textbook of Surgery by Dr. Somen Das, 4th Ed.