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Shoulderdislo kan
- 1. EXTERN CONFERENCE By Kan Panyapinitnugoon
- 2. Patient profile ชายอายุ 24 ปี อาชีพรับจ้าง ภูมิลาเนา อาเภอเมือง จังหวัดนครราชสีมา CC : ปวดไหล่ซ้ายมา 1 ชม PTA
- 3. Present illness •1hr PTA ขณะเล่นฟุตบอล ล้มไหล่ซ้ายกระแทกพื้น ปวดมาก ขยับแขนไม่ได้ ไม่มีชา ไม่มีบาดแผล ศีรษะไม่กระแทก ไม่มีรอย ช้า ขยับข้อมือ นิ้วมือได้ปกติ
- 4. Past history •2 yr PTA ระหว่างขายของ หกล้มเอาไหล่ซ้ายลงไหล่หลุดไป รพ. ดึงไหล่เข้า ใช้งานไหล่ได้ปกติ •1 wk PTA ขณะอาบน้าลื่นหกล้มไหล่ซ้ายกระแทกพื้นหลุด ไป รพ. ดึงไหล่เข้า ใช้งานได้ปกติ •No underlying disease
- 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. 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
- 9. 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
- 10. Film Lt. shoulder AP Lt. Shoulder transcapular view
- 12. Diagnosis Anterior left shoulder dislocation
- 13. Glenohumeral joint dislocation • Type • Anterior (>95%) • Subcoracoid • Subglenoid • Subclavicular • intrathoracic • Posterior • Inferior
- 14. Mechanism Anterior type • Posteriorly directed force on the shoulder when the shoulder is abducted , extension , and external rotation
- 15. 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
- 16. Duga’s test Ruler test Positive is inability to do
- 19. Film • AP view • Lateral view • Transcapular (Y-view)
- 20. Management • Pain control • Neurovascular examination • Reduction • Hippocrates • Stimson • Kocher • Traction-counter traction • Milch
- 21. Hippocrates
- 22. Stimson 2 kg , 5-10 mins
- 23. Kocher
- 24. Milch
- 27. 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)
- 28. 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
- 29. 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
- 31. 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
- 34. Thank you for your attention