10. Dislocation of shoulder
Head of humerus loses its articulation from the
glenoid cavity:
1. Anterior dislocation >95%
2. Posterior dislocation <5%
3. True Inferior dislocation (luxatio erecta) <1%
11. Anterior dislocation:
Causes: Frequently seen in younger patients after
trauma (Sports)
Symptoms: Pain, Arm is held abducted and slightly
externally rotated
Examination: Humeral head is prominent, asymmetry,
reduced ROM. Assess Neurovascular status. Commonly
the axillary nerve is affected, check for numbness over
the regimental patch (Skin over proximal arm) / Palpate
pulses (RA).
Posterior dislocation:
Causes: Usually the result of discoordinated rotator cuff
muscle contraction (Electric shock, Seizures, etc)
16. Shoulder Dislocations
Clinical Evaluation
Examine axillary nerve (deltoid function, not
sensation over lateral shoulder)
Examine M/C nerve (biceps function and
anterolateral forearm sensation)
Radiographic Evaluation
True AP shoulder: Head of humerus can be seen
lying beneath coracoid
Axillary view: Head of humerus lying anterior to
glenoid
17.
18.
19.
20.
21.
22.
23. Management of Anterior Shoulder
Dislocation
Is an Emergency
It should be reduced in less than 24 hours or
there may be Avascular Necrosis of head of
humerus
Check AXILLARY NERVE FUNCTION
Because the nerve is so vulnerable, it is
important to test the function of the nerve and
record it before
reduction is attempted.
Following reduction the shoulder should be
immobilised strapped to the trunk for 3-4
24. Methods of Reduction of anterior
shoulder Dislocation
Hippocrates Method(anesthesia required)
Stimpson’s technique (analgesia)
Kocher’s technique is the method used in
hospitals under general anesthesia and
muscle relaxation.
Milch technique is the method in which the
arm is abducted and externally rotated with
thumb pressure applied to the humeral head.
25. Hippocratic method
The doctor holds the patients affected arm by wrist
and applies traction at a 45 angle.
At the same time provides counter traction by
placing foot on the patients chest wall or having an
assistant wrap a sheet around the patient.
26. External rotation method
The patient is kept in
supine position on the
bed.
The affected arm is
adducted and flexed
at 90 at the elbow.
The arm is then slowly
externally rotated.
The shoulder should
be reduced before
reaching the coronal
plane.
27. Stimson's technique
The patient is kept in prone
position on bed.
The affected shoulder is supported
and the arm is left to hang over the
edge of the bed.
A weight is attached to the elbow
or wrist. It is usual to begin with
2kg up to 10 kg may be applied.
Gravity stretches the muscles and
reduction occurs.
Gentle internal humeral rotation
may be applied.
This method takes 15 to 20
minutes.
28. Immediate reduction
If the doctor witnesses an anterior dislocation of
the shoulder and they find no evidence of risk of
fracture then immediate reduction can be done.
This provides quick pain relief and requires less
force.
Local analgesic is injected into the joint.
The maneuver involves initial slight abduction
and internal rotation of the affected arm.
The shoulder is then immobilized using a sling.
An x-ray should be done post reduction to rule
out any fracture.
29. Leverage technique
KOCHER’S METHOD:
The affected arm in bend at 90 at elbow,
adducted against the body, the wrist and the
point of the elbow is grasped by the doctor,
slowly externally rotate between 70 to 85 until
resistance is felt. Lift the externally rotated arm
in the sagital plane as far as possible forwards
now internally rotate the shoulder this brings
the patient hand towards the opposite
shoulder. The humeral head is now slipped
back into the glenoid fossa with pain
eliminated during this process.
This method is not used frequently because of
risk of fracture of humeral neck or shaft.
32. Care after closed reduction
Neurovascular assessment should be
repeated
A post-reduction x-ray should be taken.
After reduction immobilized for 3-4 weeks.
Analgesics for pain
Physiotherapy should be done.
33. Shoulder Dislocations
Postreduction
Post reduction films are a must to confirm the
position of the humeral head
Pain control
Immobilization for 7-10 days then begin
progressive ROM
Operative Indications
Irreducible shoulder (soft tissue interposition)
Displaced greater tuberosity fractures
Glenoid rim fractures bigger than 5 mm
Elective repair for younger patients
34. Complications of anterior Shoulder
Dislocation : Early
Neuro vascular injury ( rare )
Axillary nerve injury
Associated Fracture of neck of humerus or
greater or lesser tuberosities
35. Axillary Nerve Injury
Also called circumflex nerve
It is a branch from posterior
cord of Brachial plexus
It hooks close round neck of
humerus from posterior to
anterior
It pierces the deep surface
of deltoid and supply it and
the part of skin over it
36. Complications of anterior shoulder
Dislocation : Late
Avascular necrosis of the head of the
Humerus (high risk with delayed reduction)
Heterotopic calcification ( used to be called
Myositis Ossificans )
Recurrent dislocation
37. Fractures of The Humerus
Remember the anatomy, to understand pain, nerves, vasculature/ Nerve palsies
39. Proximal Humerus Fractures
Epidemiology
Most common fracture of the humerus
Higher incidence in the elderly, thought to be
related to osteoporosis
Females 2:1 greater incidence than males
Mechanism of Injury
Most commonly a fall onto an outstretched arm
from standing height
Younger patient typically present after high energy
trauma such as MVA
40. Proximal Humerus Fractures
Clinical Evaluation
Patients typically present with arm held close to
chest by contralateral hand.Pain and crepitus
detected on palpation.
Careful NV exam is essential, particularly with
regards to the axillary nerve. Test sensation
over the deltoid. Deltoid atony does not
necessarily confirm an axillary nerve injury.
41.
42. Proximal Humerus Fractures
Neer Classification
Four parts
Greater and lesser
tuberosities,
Humeral shaft
Humeral head
A part is displaced if >1
cm displacement or
>45 degrees of
angulation is seen
43. Proximal Humerus Fractures
Treatment
Minimally displaced fractures- Sling immobilization, early
motion
Two-part fractures-
Anatomic neck fractures likely require ORIF. High incidence of
osteonecrosis
Surgical neck fractures that are minimally displaced can be
treated conservatively. Displacement usually requires ORIF
Three-part fractures
Due to disruption of opposing muscle forces, these are unstable
so closed treatment is difficult. Displacement requires ORIF.
Four-part fractures
In general for displacement or unstable injuries ORIF in the
young and hemiarthroplasty in the elderly and those with severe
comminution. High rate of AVN (13-34%)
Generally recovery takes atleast one year but union is expected
at 6 to 8 weeks.
47. Mid- Shaft Fracture
Fracture of diaphysis of the humerus
Causes: Usual cause is direct trauma/ Fall on an
outstretched hand/ Fracture pattern depends on the
stress applied)
Symptoms: Pain, swelling, decreased ROM
Examination: Assess Neurovascular status. Most
commonly the radial nerve is affected (Supplies
motor innervation to the wrist extensors and sensory
innervation to lateral dorsal hand)
48.
49.
50. Humeral Shaft Fractures
Holstein-Lewis Fractures
Distal 1/3 fractures
May entrap or lacerate radial nerve as the fracture
passes through the intermuscular septum
51. Humeral Shaft Fractures
Clinical evaluation
Thorough history and
physical
Patients typically present
with pain, swelling, and
deformity of the upper arm
Careful NV exam
important as the radial
nerve is in close proximity
to the humerus and can be
injured
52. Humeral Shaft Fractures
Conservative Treatment
Goal of treatment is to establish
union with acceptable alignment
>90% of humeral shaft fractures
heal with nonsurgical
management
53. Humeral Shaft Fractures
Treatment
Operative Treatment
Indications for operative treatment
include inadequate reduction,
nonunion, associated injuries, open
fractures, segmental fractures,
associated vascular or nerve injuries
Most commonly treated with plates
and screws but also Intermedullary
nails.
59. Reduction of supra-condylar
Fracture
Absolute Emergency
Should de done under G A by experienced
doctor as soon as possible
In the past the arm was held in flexed elbow
position in back-slab POP after reduction
At present time Percutaneous K wire
fixation is ALWAYS carried out after
reduction
64. Radial Head Fracture
Result from fall on
outstretched hand
May occur in elbow
dislocation
Swelling lat aspect
Limited ROM
Maximal tenderness
over radial head
65. Radial Head Fracture
Radiographic:
AP and lat
Fat pad may be only
clue
(occurs as a result of
distension of the
capsule by an intra-
articular
hemarthrosis)
Large sail shape
abnormal
Posterior abnormal
66. Radial Head Fracture
Most common complication
10º to 15º limit to ROM
Does not limit function
Immediate ortho referral criteria:
fracture dislocation
brachial artery or nerve injury
2mm displacement
1/3 of articulating surface
Angulated > 30º
Depressed > 3mm
Severely comminuted
67. Radial Head Fracture
Treatment non-
displaced fracture:
Immob in long-arm
posterior splint with
elbow flexed 90º.
Ice and elevation for
48 hours
Analgesia
Forearm rotation out
of splint 3-5 days
1 week – sling for
comfort only
Active ROM
68. Colles’ Fracture
Most common fracture
of the distal radius
Results from a fall on
an outstretched hand
(FOOSH)
Dorsal swelling
Eccymosis
“Silver fork” deformity of
the hand and wrist
70. Colles’ Fracture
Radiographs
(AP, lat, & oblique)
Apex volar fracture
with dorsal
comminution and
shortening of the
radius
Typically occurs
within 2cm of distal
radius articular
surface
71. Colles’ Fracture
Definitive care may
be provided by
primary care
provider
Reduction of fracture
Splinting
Ortho referral
Inter-articular
fracture needs ortho
follow up
72. Smith’s Fracture
Less common fracture
of distal radius
Unstable fracture
Distal fragment is
displaced volarly and
proximally (apex dorsal)
Direct blow to dorsum
of the wrist
Splint and immediate
ortho referral
73.
74. Galeazzi’s Fracture
Radial shaft fracture at
junction of middle and
distal thirds with
disruption of distal
radioulnar joint
Fall on extended
pronated wrist
Suspect if tenderness at
distal radius and distal
radial ulnar joint (DRUJ)
disruption
75. Galeazzi’s Fracture
Radiographic:
Transverse or oblique
fracture at junction of
middle and distal thirds
seen on AP view
Widening of DRUJ on AP
view
Fracture of base of the
ulnar styloid
Radial shortening > 5mm
Dislocation of radius
relative to ulna on lat
view
77. Monteggia’s Fracture
Fracture of ulnar shaft
with dislocation of radial
head
Fall on outstretched,
extended, and pronated
elbow is usual
mechanism
Radial head may be
palpated in antecubital
fossa
Radial nerve
neuropraxia
81. Both slip after an initial good result, both are
mistaken for other fractures, and both may need
internal fixation.
Complication: MALUNION Because the distal
fragment has no longitudinal stability, the fracture is
unstable and is notorious for slipping in plaster after
an initial good position.
The fracture is best treated by internal fixation of the radius
Editor's Notes
Deepened by Genu labrum for insertion of head of humerus
The shoulder joint has the greatest range of motion of any joint in the body and as a result is particularly susceptible to subluxation and dislocation
Dislocation of head of the humerus from the glenoid cavity
Bankart: Damage to glenoid labrum and detachment of anteroinferior segment
Hill Sachs lesion: Damage to back of humeral head