GLENOHUMERAL DISLOCATION

Anterior = most common

Posterior <2%
Inferior (luxatio erecta) = rare
Superior = very rare

Always do neurovasc exam before & after.

ANTERIOR DISLOCATION
4 types:
Subcoracoid – ant to glenoid, inf to coracoid
Subglenoid – inf and ant to glenoid fossa
Subclavicular – displaced medially below clavicle
Intrathoracic – between ribs

ABDUCTED & SLIGHT EXT ROTATION

Resist abduction & INTERNAL rotation

Remember to test axillary nerve – shoulder tip sensation

Commonest associated injury = BANKART (90%)

COMMONEST COMPLICATION = RECURRENT DISLOCATION

Age < 20yo = >90% recurrence (usually due to Bankart)
Age > 40yo = 10-15% recurrence

ASSOCIATED INJURIES
1) BONE
HUMERUS
i) Hill-Sachs:
Posterolateral humeral head indentation fracture
Soft base of humeral head impacts against relatively hard anterior glenoid
- seen in 35-60% of anterior dislocations
- up to 80 % of recurrent dislocations
May destabilizes glenohumeral joint & may predispose to further dislocation
Best seen with “Stryker-notch view” (hand behind head) xray

ii) Greater Tuberosity #:

Magnitude of fracture defect may be overestimated due to concurrent, unrecognised
Hill-Sachs
Associated with longitudinal tears in rotator cuff (which attach to greater tuberosity)
Often displaced
Closed reduction of shoulder may reduce fracture
(NB if this # occurs in isolation often requires open reduction)

iii) Head of humerus #

iv) Neck of humerus #

SCAPULA
i) Anterior Glenoid
Compression or avulsion seen in up to 30% of 1st dislocations

ii) Coracoid

iii) Acromion

2) CARTILAGE/CAPSULE/MUSCLE
i) Bankart:
Up to 90% of 1st dislocations
Avulsion of the anteroinferior glenoid labrum at its attachment to IGHL complex

In up to 30% of patients the IGHL will heal in a redundant position

ii) SLAP tear:

5-7% of 1st dislocations
“Superior Labrum Anterior & Posterior”
- tear from sup aspect labrum  anteriorly
- May involve long head biceps (ie can detach)
Also seen in throwing athletes, FOOSH & blunt trauma
“detachment lesion of the superior aspect of glenoid labrum, which serves as the
insertion of long head of biceps”
Classification: 4 types…
Syx: pain, greater with overhead activity, and painful "catching" or "popping" in the
shoulder
Mx: Many can be fixed arthroscopically

iii) Rotator cuff tear

More common in older Pt (as many as 86% >40yrs)
Pain/weakness 2-4 weeks post reduction  get MRI

3) NEUROVASCULAR
i) Nerve – usually traction neuropraxia
Seen in 10-25%
Usually resolve spontaneously
Axillary nerve = most common
Posterior cord brachial plexus
Musculocutaneous nerve
Radial/ulnar/median

NB Testing sensation over deltoid may not be reliable (EMG better)

ii) Vessels
Axillary artery – more common in elderly
Axillary haematoma, chest wall bruising, axillary bruit, absent distal pulses.

REDUCTION
HIPPOCRATIC (MODIFIED)
Traction-countertraction

STIMSON:
Prone, weight tied to hand (“10lb”)
Takes 20-30 min
“Complete muscle relaxation is required” = difficult to achieve

MILCH
Supine, Arm straight, slowly abducted & ext rotated till reaching above head, then
traction
Can use other hand to push head of humerus over glenoid lip

SCAPULAR MANIPULATION
Prone & weights as per Stimson
Inferior tip of scapula pushed medially while sup aspect stabilised
Up to 96% success

EXTERNAL ROTATION
Supine, Arm adducted (to side)
Slow external rotation, no traction
Enlocation usually not felt

SPASO
Upward traction

…..and many others

POSTERIOR DISLOCATIONS
Subacromial = most common (postero-inferior to glenoid)
Subglenoid ) rare
Subspinous ) rare

Most commonly the anterior aspect of the humeral head becomes impacted against the
posterior glenoid rim

Mechanism:
Forceful internal rotation & adduction
Fall
Violent contraction eg Seizure, ECT, Electric shock (internal rotators more powerful)
Direct force to ant shoulder

COMMONLY MISSED
CLINCAL:
1) Arm ADDUCTED & INTERNALLY ROTATED
2) Ant shoulder flat, posterior fullness
3) Prominent coracoid
4) Abduction/external rotation limited by pain

Xray Signs:
1) Half moon sign
Loss of normal overlap bet med humerus & glenoid (that normally produces a “half
moon”)
2) Rim Sign:
>6mm between ant glenoid rim and medial aspect of humeral head
Seen because humerus impacted on post rim, and glenoid faces anteriorly
Also seen in haemarthrosis & lymphoedema
3) Lightbulb sign
4) Reverse Hill Sachs )
ie compression # of humeral head ) ie opposite of Ant dislocation
5) # Lesser Tuberosity )
6) # Posterior rim glenoid )

If in doubt – get AXILLARY VIEW

REDUCTION:
Supine
Traction to adducted arm (in long axis of humerus)
Assistant can gently push humeral head (anteriorly)

Complications:
As per Xrays
Fractures; glenoid (post), reverse hill-sachs, humeral shaft, lesser tuberosity
Neurovascular/Rotator Cuff injuries = less common

INFERIOR DISLOCATIONS: “Luxatio Erecta”

Rare
Always severe
Associated with significant soft tissue trauma/#
Mechanism = Hyper-Abduction

Clinical:
Arm full abducted, elbow flexed (ie hand behind head)
Humeral head palpable on lat chest wall

Reduction:
Traction/countertraction:
Traction superiorly (along line of humerus)
Countertraction: sheet over ipsilateral clavicle, pulled inferolaterally

COMPLCIATIONS = THE NORM

ROTATOR CUFF = ALWAYS DETACHED
Neurovascular compression – usually resolve after reduction
Fracture of humerus
Head of humerus may “buttonhole” through inferior capsule = irreducible = surgery