Saturday, February 4, 2017

Shoulder Dislocation - A Brief DIscussion

Anterior shoulder dislocations are the most common and frequently caused by falling with the arm externally rotated and abducted.

Clinical Presentation: Patients present with the affected extremity held in adduction and internal rotation. Often, they complain of shoulder pain, refuse to move the affected arm, and may support the dislocated shoulder with the other arm. The acromion becomes prominent with loss of the rounded contour of the deltoid. A neurovascular examination of the upper extremity should be
performed to rule out associated injury, most commonly of the axillary nerve (sensation over the deltoid) and of the musculocutaneous nerve (sensation on the anterolateral forearm). Vascular injuries have rarely been reported to occur.

Diagnosis: Standard radiographic examination to evaluate for associated fracture should include AP and either axillary lateral or scapular views.

Anterior Shoulder Dislocation. Radiographic evaluation demonstrates that the humeral head is not in the glenoid fossa but is located anterior and inferior to it.

Posterior shoulder dislocations are commonly missed because of subtle radiographic findings.

Clinical Presentation: The arm is held internally rotated and slightly abducted. Patients are unable to externally rotate their shoulder. On examination, a posterior prominence exists. Posterior dislocations can occur with a posterior-directed force as seen during grand mal seizures or electric shock.

Posterior Shoulder Dislocation. AP radiograph of this rare type of shoulder dislocation. Because of internal rotation of the greater tuberosity, the humeral head appears like a dip of ice cream on a cone, thus called the “ice cream cone sign.”

Management: Closed reduction is the treatment for all types of shoulder dislocations and should be completed as soon as possible to avoid avascular necrosis to the humeral head. Due to shoulder girdle spasm, conscious sedation is often required. There are many methods to reduce anterior shoulder dislocations, including Stimson, Rockwood traction and counter traction, and Milch. The basic premise is to apply axial traction, externally rotate, and abduct. Scapular manipulation and the Stimson method are successful techniques, especially in the thin patient.

Neurovascular and radiographic examination should occur before and after reduction.

The patient should be placed in a sling after reduction and follow-up with a musculoskeletal specialist should be recommended.

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