# Anterior dislocation ## analgesia/anaesthesia - N2O - procedural sedation - intra-articular lignocaine - 20mL of 1% lignocaine ## Reduction techniques | Technique | description | | ------------------------------------ | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Cunningham | - patient upright with vertical back<br>- support arm and adduct as much as possile<br>- flex elbow 90 deg<br>- have them rest hand on shoulder or upper arm<br>- gentle downward traction<br>- massage long head of biceps, trapezious, and deltoid with other hand<br>- have patient shrug shoulders superiorly and backwards <br>- if not working try slight external rotation of humerus<br>- assistant providing scapular manipulation if possible | | Kocher | - external rotation with arm flexed 90 deg. <br>- adduct elbow against body<br>- external rotation until resistance<br>- lift externally rotated arm in sagittal plane<br>- internally rotate slowly<br><br>↑ risk of inferior capsule tears and anterior labrum (bankart)<br>↑ risk humerus fracture | | spaso | - patient supine<br>- arm lifted vertically while traction applied<br>- slight external rotation while maintaining traction<br>- reduction occurs with rotation | | stimson<br>(water bag) | - patient prone<br>- 5-10 kg weight to arm<br>- leave hanging 20 min<br>- may need internal or external rotation<br>- employ scapular manipulation | | scapular <br>rotation / manipulation | - prone or sitting<br>- 90 deg forward flexion and external rotation of shoulder<br>- operator rotates scapula in a clockwise direction from behind, pushing the superior border downwards and laterally with the palm and the lateral border of the tip medially | ## complications - [[Neurovascular assessment|axillary nerve]] damage → deltoid paralysis and loss of sensation over lower half of deltoid - compression of axillary artery → upper limb ischaemia - fractures - surgical neck of humerus fracture - greater tuberosity lesion - bankart tear - avulsion fracture of the capsule and glenoid labrum, can be just cartilage or rim of bone - pre-disposes to recurrent dislocations - Hill-Sachs deformity - "hatchet" shaped deformity in the posterio-lateral aspect of the humeral head. - it is an impaction fracture caused by compression against the anterior bony rim of the glenoid ![[Pasted image 20241223233330.png|Hill-Sachs lesion]] ## post-reduction care - immobilisation 3-4 weeks first dislocation - few days in recurrent dislocations # Posterior dislocation - rare - may be from [[Seizures]] or [[Electric shock and lightning injury|electric shock]], but anterior dislocation is still likely more likely from these events clinical features: - pain - arm fixed *adduction* and *internal rotation* - front of shoulder may appear flat with a prominent coracoid process X-ray: - humeral head "light bulb" appearance due to the arm being locked in internal rotation - head stands somewhat away from glenoid fossa; "empty glenoid" sign - AP may show a gap in the space btwn anterior rim of glenoid fossa and the medial aspect of the humeral head. "positive rim" sign - lateral Y view shows humeral head posterior - can do an "axillary down" view to see if the humeral head will be seen posterior to glenoid - CT if you still are not sure ![[Pasted image 20241223185310.png|posterior shoulder dislocation. Note the position of the head of the humerus on the lateral oblique view, which lies posterior(i.e. away from the side of the clavicle - i.e. well to the left) to the “Mercedes Benz” point]] ![[Pasted image 20241223185424.png|AP showing the "light bulb," "empty glenoid," and "positive rim" signs]] complications: - humeral neck fracture - glenoid rim fracture - lesser tuberosity fracture ## Posterior reduction techniques Traction and reversal of the position in which the arm is being held: - abduct arm while applying traction - externally rotate the arm - humeral head may also need to be pushed forward # ultrasound shoulder dislocation #pocus see: [Musculoskeletal Ultrasonography to Diagnose Dislocated Shoulders: A Prospective Cohort.](bookends://sonnysoftware.com/ref/DL/80218), [AJEM - Point-of-care ultrasonography for the management of shoulder dislocation in ED.](bookends://sonnysoftware.com/ref/DL/139143) [Point-of-care ultrasound for the diagnosis of shoulder dislocation: A systematic review and meta-analysis.](bookends://sonnysoftware.com/ref/DL/220733) | Steps of shoulder dislocation by POCUS | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | | Step 1. View the humeral shaft by placing the transducer to the mid superior part of the humerus at the posterolateral region (1A and 1B) | | Step 2: Slowly slide the transducer to the upward to view the humeral head (2A and 2B) | | Step 3: Slide the transducer to the posterior part of the shoulder to view the glenohumeral joint and posterior glenoid labrum (3A and B). The transducer should be slided toward the right and left if the view could not be achieved. Humeral head is posteriorly located when compared with glenoid in normal shoulder and has a slightly upper view compared with glenoid (3B and 5A). | | Step 4: Evaluate the humeral head, tuberositas major and minor, and intertubercular groove by sliding the transducer to the anterior at the screening area of humerus and glenoid (4A and B). | ![[Pasted image 20241223232545.png]] ![[Pasted image 20241223232617.png| A- postreduction (normal), B - anterior dislocation, C - posterior dislocation, PGL = posterior glenoid labrum]] ![[Pasted image 20241223233113.png]] A- normal humeral head. B- Hill-Sachs deformit, C - fracture tuberculum majus, D- Bankart fracture ![[Pasted image 20241223203656.png|Proper probe placement and the 3-step sequence to examine the shoulder from the posterior approach. images below show probe at level of 1) scapular spine, 2) glenohumeral joint, and 3) humerus]] ![[Pasted image 20241223194156.png]] ![[Pasted image 20241223204934.png]]