Professional Documents
Culture Documents
Shoulder Dislocation
An overview
Heather Campion
Sports Medicine Conference
1/22/08
Incidence
Shoulder is the most commonly dislocated joint
Traumatic Dislocations
Anterior 96%
Posterior 2-4%
Diverse group of patients experience dislocations;
M and F
young and old
active and inactive
Anatomic Consideration
Glenohumeral stabilization mechanisms
Passive: joint conformity, vacuum effect, ligamentous and
capsular restraints, labrum
Active: long head of Biceps and Rotator Cuff
Pathoanatomy of shoulder dislocations
Bankart Lesion: avulsion of anteroinferior labrum
Hill-Sachs Lesion: posterolateral humeral head defect
Assoc. RCT: more common in older patients
Clinical Evaluation
PE:
Prominent acromion, sulcus
sign, palpable humeral head
anteriorly
Neuro integrity of axillary
and musculcutaneous nerves
Apprehension Test:
reproduces sense of
instability and pain in
shoulder reduced prior to
exam
Radiographic Evaluation
AP vs true AP
Axillary vs Valpeau
Axillary
Special Views:
West Point axillary: for
visualization of glenoid rim
Hill-Sach view: internal
rotation view
Stryker Notch: view 90% of
posterolateral humeral head
Management
Pre-Medication
Reduction Maneuvers
Post-Reduction
Immobilization
Pre-Medication
Methods of Premedication
prior to Reduction
None
Intraarticular Lidocaine
IV Sedation
Supraclavicular Block
Suprascapular Block
IV Sedation vs Intraarticular
Lidocaine Injection
Level 1 RCT: Miller et al JBJS 2002
Prospective Randomized study put isolated shoulder
dislocation patients (#30) into 2 groups
Variety of Outcome Measures:
Reduction Success
Complications
Pain
Cost
IV Sedation vs Intraarticular
Lidocaine Injection
No significant difference between:
Reduction Success
Reduction Time
Pain Score
Statistical Significance:
Pts tx with intraarticular Lidocaine
left the ER earlier
Fewer Complications
Lower Cost with Lidocaine
IV Sedation vs Intraarticular
Lidocaine Injection
Intra-articular Lidocaine
Injection is Preferred over
IV Sedation
Reduction Maneuvers
Is there an Ideal Method for Reduction?
Over 24 Techniques Described
Most Common Techniques
Kocher (71-100%)
External Rotation (78-90%)
Milch (70-89%)
Stimson (91-96%)
Traction/Countertraction
Scapular Manipulation (79-96%)
Kocher Maneuver
Arm is adducted and
flexed at the elbow
Externally rotate arm
until resistance is felt
The ER arm is flexed
forward as far as
possible
The arm is internally
rotated
External Rotation
Arm aducted to body
Forearm flexed to 90
degrees
Traction on forearm
Gentle and gradual
external rotation until
reduction
Milcher Technique
Patient is supine
One hand on shoulder,
with thumb on
dislocated humeral head
Other arm slowly
abducts shoulder to
overhead position
Head is gently pushed
over glenoid rim to
reduce dislocated
shoulder
Stimson Technique
Patient is supine
Affected arm hanging
down over the edge
10 lbs weight applied to
wrist
Wait for relaxation and
auto-reduction
Traction/Countertraction
Arm in some abduction
No premedication
What Method
is Best?
Does immobilization
reduce recurrence?
Level I RCT: Hovelius JBJS 2008
Prospective multi-center study
257 primary anterior shoulder dislocations
25 year follow up
Results: