Glenohumeral Dislocation: Class, Complications and Management
August 21, 2003Emergency XR Rounds
Simon Pulfrey (with much gleaned from Dave Dyck)
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
Normal
Glenohumeral Joint Dislocation
• Anterior• Posterior• Inferior (Luxatio Erecta)• Superior
Anterior
• Most common – 94-97% of GH dislocation• 4 Types
– Subcoracoid– Subglenoid 99%– Subclavicular– Intrathoracic
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”
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 >50yrs
• Vascular• Axillary• Brachial • Radial
? 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?
To classify glenohumeral dislocations
• Mechanism – Traumatic vs Non-traumatic• Frequency – Primary vs Recurrent• Anatomic position of humeral head
Diagnostic Strategies
• 1- True AP
2. Axillary
Transcapular or “Y” View
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
Reduction methods
• Stimson – Hanging weights. Not sedated.• Cooper&Miltch – forward elevation,
flexion and abduction.• Traction-counter traction• Liedelmeyer – External rotation and
abduction.• All have similar success rates• Hippocratic and Krocher are quite traumatic
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…
Post reduction:
Hill-Sachs
Post reduction
Bankhart
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%.
Complications of anterior glenohumeral dislocation and
reduction• Rotator cuff injury – 10-15% will have tear.
Higher incidence in those >40yrs.• Capsulolabral avulsions in those of younger
years
Infraglenoid Dislocation + Hill-Sachs Fracture
Luxatio Erecta:
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
Posterior Dislocation: -trough sign. Reverse Hill-Sach# on ante-medial hh. -Lightbulb/drum stick
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
Clinical Findings:
• Arm adducted and internally rotated• The anterior shoulder is flat and the
posterior aspect full• Prominent coracoid• The patient won’t allow abduction or
external rotation
Rim sign: ant glenoid rim and articular surface of hh increased (usu>6mm)
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