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Shoulderdislo kan

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AntSoulderDislocation

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Shoulderdislo kan

  1. 1. EXTERN CONFERENCE By Kan Panyapinitnugoon
  2. 2. Patient profile ชายอายุ 24 ปี อาชีพรับจ้าง ภูมิลาเนา อาเภอเมือง จังหวัดนครราชสีมา CC : ปวดไหล่ซ้ายมา 1 ชม PTA
  3. 3. Present illness •1hr PTA ขณะเล่นฟุตบอล ล้มไหล่ซ้ายกระแทกพื้น ปวดมาก ขยับแขนไม่ได้ ไม่มีชา ไม่มีบาดแผล ศีรษะไม่กระแทก ไม่มีรอย ช้า ขยับข้อมือ นิ้วมือได้ปกติ
  4. 4. Past history •2 yr PTA ระหว่างขายของ หกล้มเอาไหล่ซ้ายลงไหล่หลุดไป รพ. ดึงไหล่เข้า ใช้งานไหล่ได้ปกติ •1 wk PTA ขณะอาบน้าลื่นหกล้มไหล่ซ้ายกระแทกพื้นหลุด ไป รพ. ดึงไหล่เข้า ใช้งานได้ปกติ •No underlying disease
  5. 5. Physical examination • A – Can speak, no posterior cervical tenderness • B – Equal breath sound both lung • C – BP 144/93 mmHg, PR 118/min • D – E4V5M6 , Pupil 3 mm RTLBE • E – As in picture
  6. 6. Physical examination • V/S – BP 144/93 mmHg, PR 118 /min , T 36.8 c, RR 18 /min • GA – Alert, good conscious • CVS – Normal S1,S2 , no murmur • Lung – Clear both lung • Abd – Soft not tender
  7. 7. Physical examination • Lt shoulder • Dropping of left shoulder • Present of bony prominence distal to clavicle • Limit ROM • No loss of sensation • Brachial pulse 2+ , Capillary refill < 2s • Full ROM at elbow, wrist, finger • Duga’s test Positive
  8. 8. Film Lt. shoulder AP Lt. Shoulder transcapular view
  9. 9. Diagnosis Anterior left shoulder dislocation
  10. 10. Glenohumeral joint dislocation • Type • Anterior (>95%) • Subcoracoid • Subglenoid • Subclavicular • intrathoracic • Posterior • Inferior
  11. 11. Mechanism Anterior type • Posteriorly directed force on the shoulder when the shoulder is abducted , extension , and external rotation
  12. 12. Presentation • Shoulder pain • Feeling instability • Shoulder abduction and external rotation • Prominent humeral head • Hamilton ruler test • Duga’s test • Axillary nerve injury (33%) – numbness at deltoid
  13. 13. Duga’s test Ruler test Positive is inability to do
  14. 14. Deltoid sensation
  15. 15. Film • AP view • Lateral view • Transcapular (Y-view)
  16. 16. Management • Pain control • Neurovascular examination • Reduction • Hippocrates • Stimson • Kocher • Traction-counter traction • Milch
  17. 17. Hippocrates
  18. 18. Stimson 2 kg , 5-10 mins
  19. 19. Kocher
  20. 20. Milch
  21. 21. Traction-Counter traction
  22. 22. Traction-Counter traction
  23. 23. Postreduction • Recheck neurovascular and Film • Immobilized with sling and swath (or interlocking sling) for 1-3 wks • <40 yrs : 3 wks • >40 yrs : 1wk due to stiffness • Begins passive, active ROM after 3 wks (ex Pendulum exercise, overhead pulley system) • Strengthening exercise after 3 months (rotator cuff exercise)
  24. 24. Complication • Recurrent dislocation (Usually in first 2 yrs) <20 yrs rate 90% >40 yrs rate10-15% • Fracture • Hill-Sachs lesion • Proximal humerus • Greater tuberosity • Coracoid • Acromion • Rotator cuff tear • Neurovascular injury
  25. 25. Instability Severity Score Variable Parameter SCORE AGE < 20 years 2 > 20 years 0 DEGREE OF SPORTS PARTICIPATION Competitive 2 Recreational/none 0 TYPE OF SPORT PARTICIPATION Contact/forced overhead 1 Other 0 SHOULDER HYPERLAXITY Hyperlaxity (anterior/inferior) 1 Normal 0 HILL SACHS ON AP XRAY Visible on external rotation 2 Not visible on external rotation 0 GLENOID CONTOUR LOSS ON AP XRAY Loss of contour 2 No lesion 0 Clinical Implications Total Possible = 10 An acceptable recurrence risk of 10% with arthroscopic stabilization. < 6 points A score of > 6 points has an unacceptable recurrence risk of 70% and should be advised to undergo open surgery (i.e. Laterjet procedure). > 6 points
  26. 26. Hill Sachs lesion
  27. 27. In this patient • Pain control by • Morphine 4 mg IV • Valium 10 mg IV • Traction-Countertraction • Immobilize by arm sling • Follow up in 2 wks
  28. 28. Film post reduction
  29. 29. Thank you for your attention
  • nattakul

    Jul. 28, 2017

AntSoulderDislocation

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