Glenohumeral Dislocation: Class, Complications and Management

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Glenohumeral Dislocation Class, Complications
and Management

• August 21, 2003
• Emergency XR Rounds
• Simon Pulfrey (with much gleaned from Dave Dyck)

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Objectives

• Types of dislocations
• Review radiographic anatomy
• Types of radiographic views
• Key issues of physical exam
• Reduction strategies
• Common complications
• Pre and Post radiograph discussion
• Follow-up/discharge issues

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Normal
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Glenohumeral Joint Dislocation

• Anterior
• Posterior
• Inferior (Luxatio Erecta)
• Superior

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Anterior

• Most common 94-97 of GH dislocation
• 4 Types
• Subcoracoid
• Subglenoid 99
• Subclavicular
• Intrathoracic

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Case 1

• 29 y male, fell mountain biking - forced
  abduction injury to left arm, about 4 hours ago
  In severe pain. No prior injuries.
• Holding arm in slight abduction and external
  rotation with right hand.
• Refuses to adduct or internally rotate L arm.
• L shoulder appears squared-off

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What neurovascular exam will you do?

• Neuro
• Median, Ulnar, Radial
• Axillary N
• Shoulder pin prick deltoid motor activity
• Injured in 5-54 of cases
• Usually gt50yrs

• Vascular
• Axillary
• Brachial
• Radial

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? Need for pre-reduction x-rays

• Shuster, Abu-Laban, and Boyd Banff say NO
• BUT most others say YES!
• Maybe NO in patient with recurrent shoulder
  dislocation and non-traumatic mechanism.
• Is there a fracture prior to reduction?

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To classify glenohumeral dislocations

• Mechanism Traumatic vs Non-traumatic
• Frequency Primary vs Recurrent
• Anatomic position of humeral head

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Diagnostic Strategies

• 1- True AP

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2. Axillary
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Transcapular or Y View
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How to manage?

• Analgesia?
• None, procedural sedation, intraarticular LA
  injection
• Reduction strategy
• Incidence of neurovasc complications increase
  with time
• The ideal method is simple, quick minimally
  traumatic

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Reduction methods

• Stimson Hanging weights. Not sedated.
• CooperMiltch forward elevation, flexion and
  abduction.
• Traction-counter traction
• Liedelmeyer External rotation and abduction.
• All have similar success rates
• Hippocratic and Krocher are quite traumatic

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Post-Reduction Issues

• Neurovascular status
• Re-radiograph? 2 small studies Harvey et al Am
  J Emerg Med 1992, Hendey et al Am J Emerg Med,
  1996 suggest maybe not. Rosen says do.
• Need to consider every case recurrent, trauma,
  age, difficulty with reduction, comorbidities

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Post reduction
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Hill-Sachs
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Post reduction
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Bankhart
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Complications of anterior glenohumeral
dislocation and reduction

• Neurovascular neuropraxic and recover in
  days-weeks
• Fractures
• Hill-Sachs 11-50 of ant dislocations. May be
  higher if consider minor compression fractures
• Bankart ant glenoid rim . 5 of cases.
• Avulsion of greater tuberosity in 10-15.

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Complications of anterior glenohumeral
dislocation and reduction

• Rotator cuff injury 10-15 will have tear.
  Higher incidence in those gt40yrs.
• Capsulolabral avulsions in those of younger years

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Infraglenoid Dislocation Hill-Sachs Fracture
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Luxatio Erecta
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Luxatio Erecta

• 0.5
• Usually axial load on abducted arm or indirect
  trauma
• Presents with 100-160 deg of abduction
• Humeral shafts lies parallel to spine of scapula
  (infglenoid lies against chest wall)
• Usually need ortho help
• Wary buttonhole problem

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Posterior Dislocation -trough sign. Reverse
Hill-Sach on ante-medial hh. -Lightbulb/drum
stick
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Posterior Dislocation

• Rare. 2.
• Commonly missed (50!)
• Seizures, fall on flexed and adducted arm, direct
  blow
• Deceptively normal-appearing AP XR
• Increased importance of clinical exam

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Clinical Findings

• Arm adducted and internally rotated
• The anterior shoulder is flat and the posterior
  aspect full
• Prominent coracoid
• The patient wont allow abduction or external
  rotation

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Rim sign ant glenoid rim and articular surface
of hh increased (usugt6mm)
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Summary

• Reduce ASAP
• Wary neurovascular status, fractures rotator
  cuff injuries
• Consider necessity of pre post reduction films
  on an individual basis
• Know well three methods of reduction
• Suspect posterior dislocations in appropriate pts