Glenohumeral Dislocation: Class, Complications and Management

1. Glenohumeral Dislocation: Class, Complications and Management August 21, 2003 Emergency XR Rounds Simon Pulfrey (with much gleaned from Dave Dyck)

2. Objectives • Types of dislocations • Review radiographic anatomy • Types of radiographic views • Key issues of physical exam • Reduction strategies • “Common” complications • Pre and Post radiograph discussion • Follow-up/discharge issues

3. Normal

4. Glenohumeral Joint Dislocation • Anterior • Posterior • Inferior (Luxatio Erecta) • Superior

5. Anterior • Most common – 94-97% of GH dislocation • 4 Types • Subcoracoid • Subglenoid 99% • Subclavicular • Intrathoracic

6. Case 1 • 29 y male, fell mountain biking - forced abduction injury to left arm, about 4 hours ago In severe pain. No prior injuries. • Holding arm in slight abduction and external rotation with right hand. • Refuses to adduct or internally rotate L arm. • L shoulder appears “squared-off”

7. Neuro Median, Ulnar, & Radial Axillary N Shoulder pin prick & deltoid motor activity Injured in 5-54% of cases Usually >50yrs Vascular Axillary Brachial Radial What neurovascular exam will you do?

8. ? Need for pre-reduction x-rays • Shuster, Abu-Laban, and Boyd – Banff say NO • BUT – most others say YES! • Maybe NO in patient with recurrent shoulder dislocation and non-traumatic mechanism. • Is there a fracture prior to reduction?

9. To classify glenohumeral dislocations • Mechanism – Traumatic vs Non-traumatic • Frequency – Primary vs Recurrent • Anatomic position of humeral head

10. Diagnostic Strategies • 1- True AP

12. 2. Axillary

14. Transcapular or “Y” View

17. How to manage? • Analgesia? • None, procedural sedation, intraarticular LA injection • Reduction strategy • Incidence of neurovasc complications increase with time • The ideal method is simple, quick & minimally traumatic

18. Reduction methods • Stimson – Hanging weights. Not sedated. • Cooper&Miltch – forward elevation, flexion and abduction. • Traction-counter traction • Liedelmeyer – External rotation and abduction. • All have similar success rates • Hippocratic and Krocher are quite traumatic

19. Post-Reduction Issues • Neurovascular status • Re-radiograph? – 2 small studies –Harvey et al Am J Emerg Med 1992, Hendey et al Am J Emerg Med, 1996 suggest maybe not. Rosen says do. • Need to consider every case – recurrent, trauma, age, difficulty with reduction, comorbidities…

20. Post reduction:

21. Hill-Sachs

22. Post reduction

23. Bankhart

24. Complications of anterior glenohumeral dislocation and reduction • Neurovascular – neuropraxic and recover in days-weeks • Fractures • Hill-Sachs – 11-50% of ant dislocations. May be higher if consider minor compression fractures • Bankart – ant glenoid rim #. 5% of cases. • Avulsion # of greater tuberosity in 10-15%.

25. Complications of anterior glenohumeral dislocation and reduction • Rotator cuff injury – 10-15% will have tear. Higher incidence in those >40yrs. • Capsulolabral avulsions in those of younger years

29. Infraglenoid Dislocation + Hill-Sachs Fracture

31. Luxatio Erecta:

32. Luxatio Erecta • 0.5% • Usually axial load on abducted arm or indirect trauma • Presents with 100-160 deg of abduction • Humeral shafts lies parallel to spine of scapula (infglenoid lies against chest wall) • Usually need ortho help • Wary buttonhole problem

34. Posterior Dislocation: -trough sign. Reverse Hill-Sach# on ante-medial hh. -Lightbulb/drum stick

35. Posterior Dislocation • Rare. 2%. • Commonly missed (50%!) • Seizures, fall on flexed and adducted arm, direct blow • Deceptively normal-appearing AP XR • Increased importance of clinical exam

37. Clinical Findings: • Arm adducted and internally rotated • The anterior shoulder is flat and the posterior aspect full • Prominent coracoid • The patient won’t allow abduction or external rotation

39. Rim sign: ant glenoid rim and articular surface of hh increased (usu>6mm)

40. Summary • Reduce ASAP • Wary neurovascular status, fractures & rotator cuff injuries • Consider necessity of pre & post reduction films on an individual basis • Know well three methods of reduction • Suspect posterior dislocations in appropriate pts