CASE REPORT

ANTERIOR DISLOCATION OF SHOULDER JOINT

Disusun untuk memenuhi sebagian tugas kepaniteraan klinik
bagian Ilmu Bedah di RSUD Soewondo Kendal

Disusun oleh:
Heru Sulistyoaji
01.210.6179
Pembimbing:
dr. WisnuMurti., Sp.OT
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2015

HALAMAN PENGESAHAN

Nama

: Heru Sulistyoaji

NIM

: 012106179

Fakultas

: Kedokteran

Universitas

: Universitas Islam Sultan Agung ( UNISSULA )

Tingkat

: Program Pendidikan Profesi Dokter

Bagian

: Ilmu Bedah

Judul

: ANTERIOR DISLOCATION OF SHOULDER JOINT

Semarang,

Februari 2016

Mengetahui dan Menyetujui

Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Soewondo Kendal

Pembimbing,

dr. Wisnu Murti Sp.OT

CHAPTER I
INTRODUCTION

The shoulder is the most frequently dislocated joint in the body. Anterior
dislocation accounts for 9498% of shoulder dislocations. The incidence of anterior
shoulder dislocation has a bimodal distribution with peaks occurring in the second and
sixth decade. Initial traumatic dislocation is most commonly the result of a posterior
directed force placed on an abducted and externally rotated shoulder. Less commonly,
a dislocation may occur as a result of an anteriorly directed force placed directly on
the posterior aspect of the humeral head.
Many complications to anterior shoulder dislocations are reported in the
literature. A Bankart lesion, an avulsion of the capsulolabral complex from the glenoid
rim, is reported to occur in 8097% of anterior shoulder dislocations. A Bankart lesion
is often referred to as the essential lesion in a dislocation as it pulls the labrum away
from the glenoid and disrupts the attachment of the inferior glenohumeral ligament
(IGHL), greatly reducing anterior stability. A displaced labrum reduces the depth of
the glenoid by half, and a lax IGHL has been shown to double glenohumeral
translation. Hill-Sachs lesions are impression fractures of the articular surface of the
humeral head that occur as the dislocated humeral head is snapped back against the
glenoid rim. They also occur quite frequently, in approximately 80% of anterior
dislocations. While these lesions are usually inconsequential, some authors suggest
that a defect greater than 30% of the articular surface may contribute to instability.
Axillary nerve injury is a potentially serious consequence of dislocation. Damage to
the nerve is cited to occur in 535% of anterior dislocations and is most likely due to
the nerves vulnerability as it travels over the subscapularis tendon and inferior to the
glenohumeral capsule. Avulsion of the IGHL from its insertion on the humerus,
known as humeral avulsion of the glenohumeral ligament (HAGL), is a rare
complication of dislocations. The actual incidence of HAGL lesions associated with

first-time dislocations is unknown, but they are found in 79% of patients with
recurrent instability.
The most common complication of anterior shoulder dislocation is recurrence.
Research implicates age as the single most important prognostic factor in the
development of recurrent anterior dislocations. A patients age at the time of initial
dislocation is inversely related to the development of recurrence. The literature
suggests the recurrence rates of anterior dislocations are quite high in those under
twenty ranging from 6697%, while they are lower in those over forty ranging from
021%. Since age is the major prognostic factor in the development of recurrent
instability, it therefore has a significant role in clinical management. As the literature
suggests the patient in this case was at a reduced risk for recurrent dislocation (based
on age), an informed decision was made to manage this case nonoperatively.
The nonoperative management of anterior shoulder dislocations, as reported in
the literature, generally consists of immobilization of the shoulder in a sling and a
progressive,

individualized

rehabilitation

program

including

strength

and

proprioceptive training. This case discusses an unusual mechanism of injury for firsttime, traumatic anterior shoulder dislocation as well as nonoperative management
using an intensive, individualized program.

CHAPTER II
CONTENTS REVIEW

1.ANATOMI

Shoulder Joint
Movements that occur in the shoulder girdle is made possible by a
number of joints which are closely interconnected, eg joints costovertebral above,
akromioklavikular joints, surface skapulotorakal shift and the glenohumeral joint
or shoulder joint.
Disorders of movement in the shoulder joint often has consequences
for other joints in the shoulder girdle and vice versa. The shoulder joint is formed
by the head of the humerus bone and joint bowl, called the glenoid cavity. This
results in a joint daily functional movements such as combing, scratching his head,
took the wallet, and so on harmonious cooperation and simultaneous with other
joints.

Figure 1

Characteristics of the shoulder joint, namely: the ratio between the surface of the
bowl joints with joint heads are not comparable, relatively weak joint capsule. The
muscles wrapping relatively weak joints such as muscles supraspinatus, infraspinatus,
teres minor, and subscapularis, the most widespread movement, but relatively less
stable joint stability. Looking at these joints, the shoulder joint is more susceptible to
interference than the other joint functions.
Glenoid cavity as a slightly concave bowl shape joints were attached to the head
of the humerus bone short glenoid cavity diameter roughly only one-third part and the
head of the bone joints are rather large, this situation does not automatically make the
joint stable, but most widespread movements.

b) The joint capsule

The joint capsule is composed of two layers:

1) The synovial capsule (the inner lining) With the characteristics of the network
has fibrokolagen rather soft and does not have the nerve receptors and blood vessels.
Function of producing the synovial fluid of joints and as a transformer food to the
joint cartilage. If there is a disturbance in the joints that light only, so the first time the
malfunction is a synovial capsule, but because the capsule does not have pain
receptors, so we did not feel the pain if there is interference, for example in joint
arthrosis.
2) fibrous capsule. Its characteristics in the form of hard and fibrous tissue has
receptors nerves and blood vessels. Functions maintain the position and stability of the
joint, and maintaining the regeneration of the joint capsule.

Mechanisms Trauma

1. Anterior Shoulder Dislocation Joints

Is a kind of dislocation is most common in major joints. It usually occurs because
of forced external rotation and extension of the shoulder. The humeral head and then
pushed forward, and often cause a tear in the cartilage of the glenoid labrum and the
capsule of the anterior margin of the pouch glenoid.4 More rarely dislocation can also
occur in patients who dropped by relying on the hand and the shoulder joint in a
position of extension. In this dislocation, the humeral head has shifted towards medial
to the glenoid, just below the processus korakoid.
In recurrent dislocation capsule and labrum often detached from the anterior
glenoid. But in some cases remain intact labrum and capsule and ligament
glenohumerus both apart or stretched to the anterior and inferior. In addition there
may be indents on the posterolateral humeral head (Hill-Sachs lesion) is a
compression fracture of the humeral head due to pressing the anterior glenoid rim
each time experiencing dislokasi.
2. Posterior Shoulder Dislocation Joints
Dislocation type is more rare. Usually due to trauma powerful position falls on
the anterior shoulder or in hand with adduction and internal rotation, due to epileptic
seizures (epilepsy or affected due to electricity), or intoxication alkohol.4,5 may be
accompanied by a fracture dislocation of the proximal humerus, posterior capsule
regardless of bone or stretched, and there may be indented from the anterior aspect of
the caput humerus.

When the shoulder joint that previously suffered a posterior dislocation,

dislocation reset for another injury, a second dislocation and hereinafter referred to as
recurrent dislocation. In cases where the patient can dislocating the shoulder joint and
reduce the suit called habitual dislocation. This usually occurs because of generalized
congenital disorders in the mechanism ligament.
Clinical manifestations
Anterior dislocation of the shoulder joint
Patients usually present with pain. Patients also complained like something out of
place that he could not move his hands. Patients were then used his other hand to help
refute. In the acute event for the first time patients could well explain the mechanism
of trauma; their 'deer on the shoulder in a state of forced abduction, external rotation
and extension.
On physical examination found multiple signs include pain, there is a bump on
the front of the shoulder, arm position-eksorotasi abduction, shoulder looks angled
edge, tenderness, and disruption of motion of the shoulder joint. There are two
distinctive marks on this anterior dislocation of the shoulder joint is the axis humeru
that does not point to the shoulder and the shoulder contour changing as the area under
the acromion empty on palpation. Patients feel the joint out and unable to move her
arms and arm injuries sustained by the hands of the other side and unable to move her
arms and arm injuries sustained by the hands of the other side and he can not touch his
chest. Injured arm appear longer than normal, so it had a fixed shoulder flexion and
forearm rotates toward the internal. The position of the sufferer's body tilted toward
the affected side. Examiner can sometimes make the scapula moves on his chest but
will not be able to move the humerus to the scapula.

If the patient is not too much shrugged, then in this case is displaced humeral
head can be touched under korakoideus processes. Sirkumflex nerve function should
be checked because it is vulnerable to injury in this case.
Investigations
1. Plain Photos
Radiological examination should include anteroposterior and lateral angle. On the
anteroposterior angle can be determined when going nterjadi internal and external
rotation. Can be seen on the internal rotation Hill-Sachs lesion in the posterolateral
hemurus caput.
At the corner lateraldapat seen sublukasasi or glenohumeral dislocation, can also
fatherly see if there is a fracture.
In the anterior dislocation of the shoulder joint, caput hemrus be in front or
medial part of the glenoid. In posterior dislocation there is a picture in the form of
light bulb as a result of the internal rotation of the humerus.
2. CT-scan arthrografi once typically used to evaluate patients dengna
glenohumeral instability and dislocation or with a history of previous instability.
However, today Ct scans are used only when there is a contraindication to MRI or if it
is suspected abnormality glenoid.
3. MRI and magnetic Resonanace Arthrografi more sensitive than any other
method for patplogia state of the ligaments, cartilage, biceps injury or abnormality
capsule. MR artrografi more sensitive than MRI, and this is an option on the
examination of the shoulder joint dislocation, especially for cases of recurrent
instability and nicer to diagnose pathological lesions for these things.

Management
1. Management of Anterior Shoulder Dislocation Joints
A wide assortment reduction method performed on a patient with a dislocated
shoulder joint. For patients who have had previous dislocations, simple traction on the
arm is usually successful. Usually the use of sedation or general anesthesia is required.
With Stimson method, patients lie face and arms were sore hanging next to the
bed. Seteleah 15 to 20 minutes shoulders will be reduced.

Gambar. Metode Stimson

With the method of Hippocrates, people laid out on the floor, limbs pulled up and
head hemerus pressed with the feet in order to back into place.
Gambar. Metode Hipocrates

With the method of Kocher, patient lying in bed and the examiner stands beside
the patient. The elbow joint in a flexed position 90 and carried out in accordance
traction humeral line, then do the rotation laterally and diadduksi arm and elbow joint
approach taken towards the midline of the body and then rotated to the medial arm so
that the hand fell in the chest area.

This technique is less recommended because it may result in injury to nerves, blood
vessels and bone.

Gambar. Metode Kocher

Reduction without general anesthesia performed with the arm hanging technique.
Patients given pethidin or diazepam in order to achieve maximum relaxation, then the person
is sleeping on his stomach and let your arms hanging alongside the bed. After some time
reduction can occur spontaneously.
Handling after repositioning
Arm rested with mitella for 3 weeks in patients under the age of 3 years (more
frequent recurrence) and only one week at the age of 30 years (more frequent stiffness). Then
begins the movement of light, but a combination of abduction and lateral rotation should be
avoided for 3 weeks. During this period, elbows and fingers began to be driven every day.
2. Management of posterior shoulder joint dislocation
Reduction is done by pulling the arm forward carefully and external rotation, and
immobilized for 3-6 weeks.

3. Management of shoulder joint dislocation inferior

Closed reduction is done pull the arm forward carefully and rotation
externa. Arm rested until the pain is gone, but avoid doing abduction for 3 weeks after
the healing of soft tissue. If this does not work can be done open reduction surgery.
Rehabilitation Program
Physical Therapy
In the acute phase of a dislocated shoulder, therapy should be limited. The arm should
be immobilized in a sling and swathed for 1-3 weeks. The actual position of the arm in the
sling has been debated and thought to be more beneficial to the torn soft tissues with the arm
in external rotation. Recent literature has shown that having the arm in internal rotation while
in the sling has no impact on the rate of recurrent dislocation when compared with patients
immobilized in external rotation.While the patient is in the sling, elbow, wrist, and hand
range of motion should be encouraged. Working with the parascapular muscles is also
important during this acute phase of rehabilitation since these can be initiated while the
patient is still in the sling. These exercises should be continued when the patient comes out of
the sling.
Active and passive flexion, extension, abduction and internal/external rotation begin
at about the third week, when the patient comes out of the sling. The authors encourage
patients to get about 10 degrees of improvement in their motion per week. One will find that
patients usually progress faster than 10 degrees per week. It is important to educate the
patient and inform him or her that getting all of the motion back "right away" can be
detrimental to the stability of their shoulder. Rehabilitation should be geared to gently
restoring the range of motion over 6-8 weeks.

A good adage during the first 3 weeks after a shoulder dislocation is to "keep the hand
in view." While looking forward, the patient should never let his or her hand be placed in a
position outside the line of vision. This instruction assures a midrange position that does not
compromise apposition of the torn or stretched anterior capsular structures to the glenoid.
Surgical Intervention
The recurrence rate for shoulder instability is highly dependent on the age of the
patient. Nonoperative care should be performed first before entertaining the thought of
surgery. Most patients are able to rehabilitate their shoulder with rest and physical therapy.
A meta-analysis of 10 studies with 1324 patients analyzed the risk factors which
predispose first-time traumatic anterior shoulder dislocations to events of recurrence. The
study concluded that men, patients younger than 40 years at initial dislocation, shorter time
from initial dislocation, hyperlaxity and lack of greater tuberosity fracture were key risk
factors that increase the risk of recurrent instability after first-time traumatic anterior shoulder
dislocations in adults.
In patients who have recurrent shoulder instability, operative care should be highly
considered. Numerous studies have shown the increased likelihood of traumatic
glenohumeral arthritis in patients with multiple shoulder dislocations. Operative care may
consist of both open or arthroscopic treatment of the cause of instability.
The goal of an operative repair is to reattach the torn tissue back to the place where it
tore off of the bone. The most likely spot where the ligament tears is the glenoid. Recurrent
shoulder dislocations also stretch out the ligaments. It is imperative to also address the tissue
laxity during the operative procedure. The surgery can be done through small incisions
(arthroscopy) or with an open incision.

Complications

A. Early complications of anterior dislocation

Rotator cuff tear. Ordinary accompany anterior dislocation in adults. Patients may
have difficulty mengabduksikan arm after reduction; deltoid muscle contraction
palpable rid of axillary nerve palsy.

Nerve damage. The axillary nerve most frequently injured, the patient can not
contract the deltoid muscle and little loss of feeling in the muscles. The inability of
abduction should be distinguished from rotator cuff tear.

Damage to the blood vessels. Axillary artery can be damaged, especially in older
people with fragile blood vessels. This can happen when the injury or the time of
the reduction. Limbs should always be checked whether there is any signs of

ischemia before and after reduction.

A fracture-dislocation. If there is a relationship of proximal humerus fractures,
may be required open reduction with internal fixation.Biasa accompany anterior
dislocation in adults. Patients may have difficulty mengabduksikan arm after
reduction; deltoid muscle contraction palpable rid of axillary nerve palsy.

 nerve damage. The axillary nerve most frequently injured, the patient can not
contract the deltoid muscle and little loss of feeling in the muscles. The inability of
abduction should be distinguished from rotator cuff tear.

Gambar. Dermatom nervus aksilaris

Too Late
Stiff shoulder. The duration of immobilization can cause stiffness in the shoulder
joint, especially in patients over 40 years.
irreducible dislocation. Dislocation of the shoulder joint is sometimes not
diagnosed. Common in patients who are unconscious or too old. Closed reduction
done until six weeks after the injury; manipulation performed after that can cause
a fracture, torn blood vessels or nerves.
Recurrent dislocation. If tearing an anterior dislocation of the shoulder joint
capsule, followed by reduction of spontaneous repair the dislocation may not
happen, but if the glenoid off the front of the neck or glenoid capsule dated,
recurrence is more common.
Complications of posterior dislocation
irreducible dislocation. At least half of the patients with posterior dislocation is
not reduced when the first time. Weeks to months pass before the diagnosis is
made and more than two-thirds of posterior dislocation was not recognized
initially.
Recurrent dislocation or subluksasio

CHAPTER III
PATIENTS STATUS

I.

IDENTITY
a. Name
: Mr. Zaenudin
b. Age
: 52 years old
c. Sex
: Male
d. Job
: PNS
e. Address
: Damarsari 01/01
f. Room
: Kenanga
g. Register Number : 471518
h. Date of in patient : 22 August 2015
II. ANAMNESA
Chief complaint
Pain in dislocation shoulder anterior and locking movement of the left lower
extremity.
Present status
The man came to the clinic orthopedic that his shounder cant move. Before
accident with for about 3 days ago when doing his job. He just had complained
that he feel decreasing of sensasion of the shoulder and cant move his shoulder
like before.The accident when doing something and then he fell in left side
with the mechanism is exorotation, abduction, extensi of the hand.
Primary Survey
Airway and cervical spine stabilisation : Cleared
Breathing : adequate breathing ( respiration rate : 20x/minutes ) nothing

abnormality
Circulation : adequate circulation
Disability : E4M5V6, pupil refleks +/+ isokor
Exposure : abnormality on upper left extremity

Medical condition history

- History of similar injury
: denied
- History of asthma and allergies : denied
- History of heart disease
: denied

History of hypertension
History of diabetes

: denied
: denied

Family history
-

History of asthma and allergies : denied

History of heart disease
: denied
History of hypertension
: denied
History of diabetes
: denied

Socioeconomic status
The cost of treatment using BPJS

III.

PHYSICAL EXAMINATION
GCS
: 15
Vital sign
HR : 88 x/m
RR : 22 x/m
to
: 36,5o
BP : 120/80
Status Generalis
1.
2.
3.
4.
5.
6.
7.
8.

Skin
Head
Eyes
Ear
Nose
Mouth
Neck
Thorax

: Turgor (N)
: Mesocephal, Wound (-)
: Anemis -/-, Icteric -/: Discharge -/: Deviation septum -/-, discharge -/: Bleeding (-)
: Simetris, Trachea deviation (-)
: Normochest, simetris

COR
Inspeksi
Palpasi

: Ictus cordis (-)

: Ictus cordis palpable at SIC V, 2 cm medial to the

linea mid clavicularis sinistra, pulsus the sternal (-), pulsus

epigastrium (-)
Percussion : heart border
Bottom left: SIC V, 2 cm medial linea mid clavicularis sinistra
Top left : SIC II linea sternalis sinistra
Top right : SIC II linea sternalis dextra
Waist heart: SIC III linea parasternalis sinistra
Impression: configuration of the heart normal
Auscultation : heart sound I-II regular, gallop (-), murmur (-)
Pulmo :
Anterior
Posterior
I: Statis: normochest(+/+), simetris (+/ I: Statis: normochest(+/+), simetris (+/
+), retraction (-/-). Dinamis: simetris

+), retraction (-/-).Dinamis: simetris

Pa:

Pa:

statis:

simetris

(+),

nothing

statis:

simetris

(+),

nothing

widening between the ribs, retraction

widening between the ribs, retraction

(-/-), sterm fremitus dx=sin

(-/-), sterm fremitus dx=sin

Pe: Sonor (+/+)

Pe: Sonor (+/+)

Aus: vesicular (+/+), ronchi (-/-),

Aus: vesicular (+/+), ronchi (-/-),

wheezing (-/-)

wheezing (-/-)

9. Abdomen
Inspection : normal, massa (-)
Palpation
: Supel, pain (-), hepar and lien are not papble
Percussion : tympani (+)
Auscultation : bowel (+) Normal
10. Back : kifosis and lordosis (-)
11. Extremity:
Akral

Superior
-/-

Inferior
-/-

Oedem

-/-

-/-

IV.

Capillary refill

<2

<2

Lession

-/-

-/-

Hematom

-/-

-/-

LOCALIS STATUS
Left shoulder and caput humeral
Look
: flexed (+), endorotated (+), adducted (+)
Feel
: pain (+) and caput humeral palpable on left shoulder sinistra

Move
:
o Active movement:
- Limitation (+) and pain (+) in the abduction, adduction, flexion, extension,
endorotasi, eksorotasi upper extremities.
- Clear (+) and pain (-) in supination, pronation of the wrist joint.
- Clear (+) and pain (-) in flexion, extension, abduction, extension of the
fingers.
o Passive Movement:
- Limitation (+) and pain (+) in the abduction, adduction, flexion, extension,
endorotasi, eksorotasi upper extremities.
- Clear (+) and pain (-) in supination, pronation of the wrist joint.
- Clear (+) and pain (-) in flexion, extension, abduction, extension of the
fingers.
V. LABORATORY RESULT
26 Januari 2016
Hematologi
Hemoglobin
Leukosit
Trombosit
Hematokrit
Protombin Time (PT)
APTT

Hasil
14,8 gr/dL
11,5 10^3/uL
314 10^3/uL
45 %
11,8 s
33,4 s

Reference value
13-18
4,0-10,0
150-500
39,0-54,0
11,3-14,7
27,4-39,3

VI.

RADIOLOGY
Before:
X foto rontgen shoulder sinistra AP (26-01-2016)

After Close Reduction:

X foto rontgen shoulder sinistra AP

VII.

DIAGNOSE
Anterior dislocation shoulder sinistra
VIII. INITIAL PLAN
a. Ip Terapeutik
Medical treatment
- Infus RL 20 tpm
- Inj. Cefazolin 2x1 g
- Inj. Dexketoprofen 2x50mg
- Inj. Ranitidine 3x1
b. Ip. Operatif
Close Reduction
c. Ip. Monitoring
General situation, Vital sign, the result of supporting examination
IX.

PROGNOSIS
Quo ad vitam
: ad bonam
Quo ad sanam
: ad bonam
Quo ad fungsionam : ad bonam

CHAPTER IV
DISCUSSION

Anamnesis :
The man came to the clinic orthopedic that his shounder sinistra cant
move. Before accident with for about 3 days ago when doing his job. He just
had complained that he feel decreasing of sensasion of the shoulder and cant
move his shoulder like before.The accident when doing something and then he
fell in left side with the mechanism is exorotation, abduction, extensi of the
hand.
LOCALIS STATUS
Left shoulder and caput humeral
Look
: flexed (+), endorotated (+), adducted (+)
Feel
: pain (+) and caput humeral palpable on left shoulder sinistra
Move
:
o Active movement:
- Limitation (+) and pain (+) in the abduction, adduction, flexion, extension,
endorotasi, eksorotasi upper extremities.
- Clear (+) and pain (-) in supination, pronation of the wrist joint.
- Clear (+) and pain (-) in flexion, extension, abduction, extension of the
fingers.
o Passive Movement:
- Limitation (+) and pain (+) in the abduction, adduction, flexion, extension,
endorotasi, eksorotasi upper extremities.
- Clear (+) and pain (-) in supination, pronation of the wrist joint.
- Clear (+) and pain (-) in flexion, extension, abduction, extension of the
fingers.
Therapy

Infus RL 20 tpm
Inj. Cefazolin 2x1 g
Inj. Dexketoprofen 2x50mg
Inj. Ranitidine 3x1
Patient in this case 52 years old complained of pain in shoulder sinistra

and cant move. Before accident with for about 3 days ago when doing his job.
He just had complained that he feel decreasing of sensasion of the shoulder and
cant move his shoulder like before.The accident when doing something and then
he fell in left side with the mechanism is exorotation, abduction, extensi of the
hand.
The patient with anterior dislocation holds the arm at the side of body in
external rotation.The shoulder loses its usual roundness. An anterior bulge may be
seen in thinner patients. The humeral head is palpable anteriorly. Abduction and
internal rotation are resisted. Check the radial pulse to assess for vascular injury.
Check sensation in the regimental badge area on the lateral aspect of the shoulder
over the deltoid muscle. This tests for axillary nerve damage. Contraction of the
deltoid during attempted abduction can also be palpated. Assess radial nerve
function: test for thumb, wrist and elbow weakness on extension as well as
reduced sensation on the dorsum of the hand. The rotator cuff is frequently
damaged and should be examined after reduction
The dislocation must be reduced as soon as possible under general anaesthesia. In
the vast majority of cases this is performed closed, but if this is not achieved after
two or three attempts an open reduction is required. The methodes are External
rotation method, Stimson's technique, Kocher's method.

External rotation method: The patient is in a supine position on the bed. The
affected arm is adducted and flexed to 90 at the elbow. The arm is then slowly
externally rotated.

BAB V
CONCLUSSION
The shoulder is the most frequently dislocated joint in the body. Anterior
dislocation accounts for 9498% of shoulder dislocations. The incidence of
anterior shoulder dislocation has a bimodal distribution with peaks occurring in
the second and sixth decade.2 Initial traumatic dislocation is most commonly the
result of a posterior directed force placed on an abducted and externally rotated
shoulder. Less commonly, a dislocation may occur as a result of an anteriorly
directed force placed directly on the posterior aspect of the humeral head.
Patients usually present with pain. Patients also complained like something
out of place that he could not move his hands. Patients were then used his other

hand to help refute. In the acute event for the first time patients could well explain
the mechanism of trauma; their 'deer on the shoulder in a state of forced
abduction, external rotation and extension.
Hip dislocations are classified according to the direction of the femoral
head displacement: posterior by far the commonest variety, anterior and central, a
comminuted or displaced fracture of the acetabulum.
The dislocation must be reduced as soon as possible under general
anaesthesia. In the vast majority of cases this is performed closed, but if this is not
achieved after two or three attempts an open reduction is required