By: David Gan

` ` ` ` ` ` ` ` ` `

Definition Causes and Mechanism X-ray Classification Clinical Features Special Test Complications Treatments References Other Useful Links

Subluxation
` `

Dislocation
`

Lesser degree of displacement. Articular surface still partly apposed.

Joint surface completely displace. No longer in contact.

Adapted: Solomon, Warwick and Nayagam, 2005, pp. 280

` `

Anterior Dislocation: Arm Abducted, Extended & Externally Rotated. Posterior Dislocation: Arm abducted, Flexed & Internally Rotated. Weak muscles in supporting the GH joint Neurological Conditions ie. Ligaments & joint Stroke. margins are damaged. Recurrent Repeated Dislocation. Knack of dislocating the joint Habitual (voluntary)
by voluntary muscle contraction.

Adapted: Shankman, 2004, pp.397

Major Associated Injuries

Bankart lesion

Hill-Sachs lesion.

Adapted: Solomon, Warwick and Nayagam, 2005, pp. 280

Causes and Mechanism

Definition :

An avulsion of the capsule & glenoid labrum off the anterior rim of the glenoid.

Resulting from :

Traumatic anterior dislocation of the shoulder.

Causes and Mechanism

Definition :

Compression or impaction fracture of posterior aspect of humeral head. Anterior shoulder instability. Forceful impact of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly.

Resulting from :

Anterior Dislocation Overlapping shadows of humeral head and glenoid fossa, humeral head usually lying below medial socket.

Posterior Dislocation In AP projection, humeral head looks somewhat globular because it is medially rotated. Lateral film is essential which I cant find on internet.

Large lucencies in the humeral head and glenoid (arrow), subluxation of the glenohumeral joint and small calcifications in the soft tissues (thin arrow).

Rockwood divided shoulder subluxation and dislocation into 4 categories:

Category I II III a. III b. IV Description No history of traumatic dislocation of subluxation A history of traumatic dislocation subluxation Non-traumatic voluntary subluxation, accompanied by psychological barriers Non-traumatic voluntary subluxation is not associated with mental disorders Non-voluntary subluxation

For further details please refer to: http://www.eorif.com/Shoulderarm/ShoulderDislocation.html

Adapted: Knowledge of disease, 2010

Clinical Features

Pain is severe. ` Supports arm with opposite hand. ` Loath to permit any kind of examination ` Lateral outline of shoulder is flattened ` Small bulge may be seen and felt just below clavicle.
`

 Arm must always be examined for nerve and vessel injury.

Clinical Features

Clinical Features

Diagnosis frequently missed *in AP X-ray, humeral head seems to be in contact with glenoid. ` Arm held on medial rotation and is locked in that position.
`

Clinical Features

Anterior dislocation in vast majority of cases but occasionally it is posterior dislocation. Often by time patient is examined, the head is back in the socket. Recurrent Anterior Dislocation: C/o shoulder slips out when the arm is lifted into abduction and lateral rotation. *Apprehension test +ve if shoulder is passively manipulated into abduction, extension and lateral rotation. tense up and resist further movement.

` ` ` `

Anterior Apprehension Test Posterior Apprehension Test Jerk Test Clunk Test

Rotator cuff tear

Often torn, particularly in older people.

Nerve injury
Axillary nerve Unable to contract deltoid, small patch of anaesthesia over muscle, lesion usually neurapraxia. Posterior cord of brachial plexus, median nerve or musculocutaneous nerve may be injured.

Vascular injury
Axillary artery may be damaged Signs of ischemia.

Fracture-dislocation
Associated fractures of proximal humerus.

Recurrent dislocation
If glenoid labrum damaged or detached.

Treatment

` `

Dislocation must be reduce asap; usually with general anaesthetic and sometimes muscle relaxant. Joint is rest/immobilized until soft-tissue healing occurs (3-4 weeks). All positions that may reproduce mechanism of dislocation are avoided. Follow by a course of physiotherapy. If ligaments torn Repair (surgery).

Treatment

` `

` ` `

Pain & Swelling : Ice packs, eletrical stimulation and other physical agent. General conditioning program of strength, flexibility and endurance activities. *Avoid certain movement that aggravates dislocation. Strengthening Isometric exercise. Scapular motion and stabilization exercise (avoid pain and harmful glenohumeral joint position). Life-style modification voluntary dislocation.

Treatment

ROM exercises

after immobilization

 Codmans pendulum exercise, active assisted stretching for flexion and cable pulleys.
`

Strengthening of rotator cuff, anterior shoulder muscles and scapular stabilizers.

 2:1ratio of motion between scapular and glenohumeral joint must be address (2 glenohumeral flexion after 30 shoulder motion rotate scapular upward 1 )

Combination of abduction and external rotation are avoided (3 month after remove sling) anterior dislocation.

Treatment

Criteria established by Wilk:

Full, non painful ROM No palpable tenderness Continued progression of shoulder strength

Close Kinematic Chain activities Enchance proprioception & promote dynamic joint stability. Initiate isotonic resistance exercise
Accommodate limitations of motion, pain, provocative position

Local muscle endurance activities Upper body ergometer, stepper or walking on treatmill.

Treatment

Codmans pendulum exercise

Active assisted stretching for flexion

Cable pulleys

Treatment

Strengthening of Rotator cuff muscles

Strengthening of anterior shoulder muscles

Strengthening of Scapular Stabilizers

Treatment

Plyoball Close-chain proprioceptive exercises

Treatment

Treatment

Endurance Exercise using Body Ergometer

Knowledge of Disease (2010) Shoulder dislocation classification. Available at: http://www.sicheng.net/diseased-reprinted-shoulderdislocation-classification-2919.html (Accessed: 8 January 2011). Shankman, G.A. (2004) Fundamental orthopedic management for physical therapist assistant. 2nd edn. Missouri: Mosby. Solomon, L., Warwick, D.J. and Nayagam, S. (2005) Apleys concise system of orthopaedics and fractures. 3rd edn. London: Hodder Arnold.

Shoulder Dislocation
http://www.eorif.com/Shoulderarm/ShoulderDislocation.ht ml

Scapular Exercises
http://www.exercisebiology.com/index.php/site/articles/the _best_scapular_muscle_exercises_to_prevent_treat_sho ulder_pain/