orthopaedic emergency

1. Acute Shoulder dislocation
Dr. Suraj Upreti
Orthopaedic resident
NAIHS
2076.05.16

2. Outline
• Introduction
• Patho-anatomy of shoulder joint
• Types of shoulder dislocation
• Clinical presentations
• Techniques of shoulder reduction

3. Introduction
• Dislocations are othopaedic emergencies
• Shoulder dislocation comprises of up to half of all joint dislocations
• Most mobile and most commonly dislocated joint of body
• Incidence: Male:21-30yrs Female:61-80yrs

4. Patho-anatomy
Gulf ball on tee

5. Pathoanatomy continued………
Glenoid labrum
Fibrocartilagenous structure
Increases depth of glenoid by
80%
Humeral head coverage by 70%

6. Joint Capsule

7. Ligaments

8. Muscles

9. Function of shoulder
Movement stability
 Ball and socket
joint
 Voluminous glenohumeral
joint
 Ligaments at extremes
of motions
 muscles
Unstable joint

10. Types
Anterior dislocation-90%
Posterior dislocation-10%
Inferior dislocation
Superior dislocation

11. Types of anterior dislocations

12. Types of posterior dislocations
 subacromial
Subspinous
 Subglenoid

13. Types of shoulder joint continued……
Inferior(Luxatio erecta) superior

14. Clinical presentation
Anterior Posterior Inferior
H/o trauma direct trauma, indirect(
seizures, electrocution)
Trauma
Deltoid muslces weakness
MOI Abduction, extension and
external rotation
Adduction and internal
rotation
Forceful hyper-abduction
Attitude of limb Abduction and external
rotation
Adduction and internal
rotation
abduction
signs Swelling
Fattening of deltoid
Posterior fullness
Coracoid prominence
Swelling
Flattening of deltoid
ROM Limited internal rotation
and abduction
Limited external rotation
and abduction
Nerve injury: axillary nerve, musculocutaneous nerve, brachial plexus injury and vascular injury
Laxity of of joints

15. Tests for shoulder dislocation
Hamilton ruler test
Callaway test

16. Investigations
• Plain X ray
• USG
• CT scan
• MRI

17. X ray views
• AP chest
• Garshey view
• Axillary lateral
• Trauma lateral view
• Velpeau view
• Scapular Y views
• Stryker view

18. AP xray

19. Lateral view

20. Velpeau view
Stryker view

21. Anterior dislocation x rays
 Disruption of Maleney line
 Curve line is made when line is
drawn form medial cortex of
humerus and lateral border of
scapula

22. Posterior dislocation x-rays
AP chest
Steeple sign
AP glenoid(empty glenoid
fossa)
scapular Y view
Less contact of humeral head
with glenoid

23. Techniques of shoulder dislocation
Anterior dislocations
Kocher’s method
Hippocratic method
Milch Method
Spaso Method
External rotation
Scapular manipulation
Stimsom method
Inferior dislocations
Axial line traction
Two step reduction
Posterior dislocations:
traction and countertraction

24. Kocher method
Elbow flexion at 900
External rotation(70-900)
Lifting and adduction across chest
Internal rotation

25. Hippocratic method
• Patient is placed supine
• Stockinged heel is placed in the
axilla
• Wrist is grasped in both hand
and gentle traction and external
rotation is given
• Heel acts as fulcrum while
adduction arm

26. Traction-countertraction

27. Stimson method
• Position prone on elevated bed
• Affected arm hang off the bed
edge
• Arm is placed 900 forward
flexion
• 5 lb wt is fastened to the
affected wrist
• Wait for 15-20 min

28. Milch method
• Position: supine
• Surgeon’s one hand place on axilla
over humeral head
• Patient wrist is grasped firmly with
other hand or assistant
• Arm is slowly and gradually
abducted fully
• Gentle external rotation and traction
is applied, simultaneously lateral
pressure is applied to head

29. Spaso Method
• With patient supine on bed,
physician grasps the affected
distal forearm
• Lift arm vertically to ceiling
applying gentle traction and
external rotation
• Audible clunk is heard, if not
give direct pressure to humeral
head

30. Scapular manipulation
• Scaupula is manipulated using
physician’s hand
• Inferior tip is rotated medially and
displaced superiorly

31. External rotation method
• Adduct arm
• Gently apply external
rotation(70-1100)
• Internal rotation

32. Inferior
Axial(inline) traction

33. Posterior dislocation

34. References
• McRae’s Orthopaedic Trauma and Emergency Fracture management
3rd edition
• Rockwood and Greens Fractures in Adults - 2 Volume Set [8th
ed][2014][
• Apley’s system of orthopaedics and fractures, 10th edition
• Campbell’s operative otrhopaedic, 13edition
• Mescape, reduction of shoulder dislocation

35. Thank You