RECURRENT SHOULDER DISLOCATION Dr khalid PG-4

1. RECURRENT SHOULDER DISLOCATION Dr khalid PG-4

2. ANATOMY The shoulder joint as such is not a single joint but a combination of many different joints. It includes the following joints 1. Scapulo-thoracic joint 2. Acromio-clavicular joint 3. Sterno-clavicular joint 4. Gleno-humeral joint 

3. ANATOMY

4. Stability Inherently unstable joint 1. Coracoacromial arch 2. Rotator cuff 3. Glenoid labrum GHL 4. Muscles such as the long head of biceps

5. definition Recurrent shoulder dislocation is a condition characterized by repeated partial or total separation of the head of humerus from the glenoid cavity. This separation can occur during normal day to day activity, even during sleep, causing the patient to wake up.

6. Shoulder dislocations account for almost 50% of all joint dislocations Anterior dislocation (96%) Posterior dislocation (2-4%) Inferior dislocation/luxatio erecta (1-2%) Superior dislocation (<1%)

7. ANT DISLCOATION Most commonly(96%) subcoracoid Subglenoid subclavicular, intrathoracic or retroperitoneal

8. CAUSES congenitally lax shoulders injury to the shoulder direct by a blow to the shoulder indirect by a injury causing abduction, extension and external rotation epileptic fit electric shock

9. PATIENT PRESENTATION The patient presents with the arms held to the side.

10. On examination

11. On examination The acromion is prominent loss of the normal rounded contour of the shoulder absence of the humeral head in its usual location. Fullness in the anterior shoulder may be palpated The patient permits some abduction and external rotation of the arm, but resists any attempts at internal rotation and adduction

12. On examination cont� Axillary nerve injury is the most common occurring in approximately 12% of cases. In addition, the radial, ulnar, and brachial pulses should be evaluated as well as the integrity of the median, ulnar, and radial nerves.

13. CLINICAL TESTS THE APPREHENSION TEST Abduct shoulder to 90 Slowly ext rotate Push humeral head Apprehension , fear or refusal

14. CLINICAL TESTS cont�. RELOCATION TEST Apprehension test with pt in recumbent position Press down on the upper arm When pain or apprehension appear press down on the upper arm this will stabilize the head in the gleniod and should releive pain or apprehension When pain or apprehension appear press down on the upper arm this will stabilize the head in the gleniod and should releive pain or apprehension

15. CLINICAL TESTS cont� DRAWER test of gerber &ganz Pt lying supine.abduct shoulder at 90,slightlly flex and ext rotate..steady the scapula with one hand while try to move the humeral head ant, note click or pt apprehensionPt lying supine.abduct shoulder at 90,slightlly flex and ext rotate..steady the scapula with one hand while try to move the humeral head ant, note click or pt apprehension

16. IMAGING Standard radiographic views of the shoulder (AP internal and external rotation

17. A true AP (Grashey) view in which the beam is directed at a 45� angle in a medial to lateral direction may be helpful to assess subtle joint incongruity

18. scapular Y view

20. The Velpeau axillary view can be used to diagnose shoulder dislocations in patients who are unable to abduct the arm

21. Other investigations Radiography cannot demonstrate labral, ligamentous, or capsular lesions MR arthrography�(more sensitive and specific ) Conventional MRI CT arthrography Limitations of arthrography include discomfort to patients, risk of septic arthritis

22. LESIONS SEEN IN ANT DISLOCATION Bankart lesion the labrum with a piece of bone�this is known as a bony Bankart lesion anterior glenoid rim fractures (44%), fracture of the greater tuberosity Ligamentous lesions - Anterior band of the IGHL Capsular abnormalities - Separation of the capsule from the anterior glenoid rim (85%)

23. Lesions seen in ant dislocation cont� Hill-Sachs lesions, posterolateral humeral head indentation fracture (77%)

24. Lesions seen in ant dislocation cont� Intra-articular loose body Rotator cuff lesions - Supraspinatus or subscapularis tears A Perthes lesion is similar to a Bankart lesion, except the medial scapular periosteum remains intact; thus, the labrum may appear normal on MRI and arthroscopy unless the arm is abducted and externally rotated away from the neutral position.

25. Complications of anterior dislocation Axillary nerve damage Axillary artery damage (more likely if brachial plexus injury is present, look for axillary haematoma, a cool limb and absent or reduced pulses) Associated fracture (30% of cases) e.g. humeral head, greater tuberosity, clavicle, acromion

26. Posterior Shoulder Dislocation Posterior dislocations are far less common Often missed are less common, less pain than anterior dislocations. Diagnosis requires a thorough history and examination,

27. Post dislocation cont� three types subacromial, subglenoid, subspinous. Ninety-eight percent of all posterior dislocations are of the subacromial type.

28. Post dislocation cont� There are several mechanisms by which this injury occurs, among them being a violent internal rotational force such as would occur during a fall on the forward flexed internally rotated arm. This type of dislocation may be seen after a seizure or an electric shock.

29. Patient presentation the arm is held in adduction and internal rotation. Abduction is severely limited and external rotation of the shoulder is block

30. On examination

31. On examination the examiner will note a prominence in the posterior aspect of the shoulder accompanied by an anterior flattening of the normal shoulder contour. The coracoid process is usually more obvious than its counterpart on the normal side. Blocking of external rotation and limitation of abduction occur in all cases of posterior dislocations.

32. Associated Injuries fractures of the humerus posterior aspect of the glenoid rim. An isolated fracture of the lesser tuberosity should lead one to suspect a posterior dislocation until proven otherwise. Neurovascular complications with this injury are uncommon.

33. CLINICAL TESTS DRAWER TEST Pt supine, elbow flexed , shoulder in 200 flexion and 900 abduction. place the thumb lat to coracoid. Int rotate and flex , pressing the humeral head backwards with thumb. Detect post displacement with thumbDetect post displacement with thumb

34. CLINICAL TESTS cont� JERK TEST. pt,s shoulder over the edge of the table,flex both the shoulder and elbow to 900 .with one hand on elbow push downward and attempt to sublux the humeral head post.if this occur a jerk or jump will be felt.

35. IMAGING

36. Lesions seen in post dislocation Posterior labral tear or detachment (reverse Bankart lesion) Ligamentous � Tear of the posterior band of the IGHL Capsule - Capsule tear or laxity Intra-articular loose bodies

37. Lesions seen in post dislocation reverse Hill-Sachs lesion (impacted fracture of the anterior aspect of the humeral head) Abnormal glenoid Teres minor lesions, including partial tear and edema in the tendon or muscle

38. INFERIOR DISLOCATION uncommon but can be quite serious The mechanism by which this injury occurs is forceful hyperabduction This dislocation is always accompanied by both disruption of the rotator cuff and tear through the inferior capsule.

39. EXAMINATION This injury is unlikely to be missed because the patient holds the arm elevated 180� and cannot adduct it, patients usually present in significant pain. On palpation, the humeral head is felt along the lateral chest wall

42. Associated Injuries neurovascular compression recover following reduction Fractures of the acromion, inferior glenoid rim, greater tuberosity of the humerus

43. EXAMINATION SULCUS SIGN. Pt standing,grasp the arm and pull it downward. depression b/w humeral head and acromion

44. CLOSE REDUCTION Various manoeuvres described include Hippocratic method in which the surgeon puts his foot in the arm pit of the patient and applies traction with his hands. Kocher's method in which the surgeon first applies traction to the limb followed by external rotation then adduction and lastly internal rotation. The dislocation should reduce at the point of adduction and then only should the limb be internally rotated. If this is not followed then fracture of the humerus can occur. Stimson's method in which the patient is made to lie on his belly and the dislocated limb is allowed to hand down by the edge of the table by a weight. Traction and counter traction method is similar to Hippocratic method except for the surgeon using his foot, an assistant provides counter traction by a sheet of folded cloth across the arm pit and chest wall.

45. Thomas and Matsen Classification In 1989 Thomas and Matsen introduced a classification system, which used the acronyms: TUBS� Traumatic Unidirectional Bankart Lesion Treated with Surgery. AMBRI� Atraumatic Multidirectional Bilateral Treated with rehabilitation and if surgery is required an Inferior capsular shift. A second I was later added to denote closure of the rotator Interval.

46. Flow Chart

47. TREATMENT OPTIONS CONSERVATIVE ARTHROSCOPIC OPEN SURGERY

48. INDICATIONS FOR SURGERY IN ANT DISLOCATION soft-tissue interposition (rotator cuff, capsule, biceps tendon) subglenoid or subclavicular. In the young athlete, fracture of the greater tuberosity that is displaced >1 cm post-reduction. Glenoid rim fractures that are displaced >5 mm

49. TREATMENT OPTIONS cont� ARTHROSCOPIC SURGERY The same structures are repaired, but via key-hole surgery, using three small incisions. The only advantages are less pain, and smaller incisions. Lower infection rate Less scarring Earlier mobilization

50. Arthroscopic Repairs Arthroscopic bankart Electro thermal capsular shift Capsular plication

51. Surgery for ant dislocation Bankart operation. Indicated when the labrum and cap r separated from gleniod rim or if the cap is thin The scapularis and joint capsule are opened vertically.The lateral leaf is stitch to ant gleniod rim while the med leaf is imbricated Jobe modificatoin; capsulotomy via horizantal incision,divide capsule into sup and inf leaf

52. Surgery for ant dislocation Later jet procedure Bristow procedure trasfer the coracoid process via the subcapsularis tendon

53. Surgery for ant dislocation Weber subcapital osteotomy of the prox hemurus. The objective is to rotate the hill sachs lesion more post lat. Staple sapsulorrhaphy Putti plate operation. Same as that of banket operation but in this procedure the subscapularis is advanced laterally

54. Treatment options for post dislocation Conservative management. Avoid porv0cative activities Educate the pt to avoid specific voluntory manevers that would cause dislocation Strenghthening exercise prog.

55. Surgical options Neer inf capsular shift procedure via post approach. The post capsule is split longitudinally and the cap attachment along the hemural neck is released as far inf and ant. The sup cap is advance inf and inf cap is advance sup.the inraspinatous is cut,overlaped and shortened adding further buttress to the post cap.

56. Surgical options Tibone and bradley; same as that of neer and foster procedure but damage to the post rotator cuff is reduced. Post capsular tendon re-tensioning Capsular shift reconstruction with post gleniod osteotomy

57. Surgical options Mc langhlin procedure; indicated in post dislocation with large hill sachs lesion In this procedure the subscapularis tendon is transfer into the defect Neer modification,lesser tuberosity with attached subscapularis is transferred into the defect and fixed with bone screw

58. THANKS

59. Labral lesions (ie, Bankart lesions) When they tear it is called a Bankart Lesion. In this case the inferior (i.e. lower) glenohumeral ligament pulls the inferior labrum away from the glenoid. Less commonly the ligament will pull the labrum with a piece of bone�this is known as a bony Bankart lesion Bony glenoid lesions - Osseous anterior glenoid rim fractures (44%), bony Bankart lesions, fracture of the greater tuberosity Ligamentous lesions - Anterior band of the IGHL Capsular abnormalities - Separation of the capsule from the anterior glenoid rim (85%) Hill-Sachs lesions (77%) Intra-articular loose body Rotator cuff lesions - Supraspinatus or subscapularis tears A Perthes lesion is similar to a Bankart lesion, except the medial scapular periosteum remains intact; thus, the labrum may appear normal on MRI and arthroscopy unless the arm is abducted and externally rotated away from the neutral position.