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Posterior Dislocation of Shoulder – Presentation and Treatment

September 28, 2008 By 2 Comments

Anteroposterior view of shoulder revealing posterior dislocation

Anteroposterior view of shoulder revealing posterior dislocation

Posterior dislocation is rarer as compared to anterior dislocation. When it occurs damage to the structures is much more owing to the force required for disruption of the joint.

These patients present with pain and deformity. The patients have much more pain than those with acute traumatic anterior dislocations.

After the clinical examination and xrays the diagnosis can be reached at with certainty. A greater damage to the glenoid and humeral head may be evident on xrays.

Careful note is made of associated fractures, including the extent of the impression fracture of the anteromedial humeral head.

Closed reduction should be caried out as soon as possible.

Because of associated muscle spasms, the reduction may not be achievable with sedation and muscle relaxants. [Read more...]

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Acute Anterior Dislocation of Shoulder – Treatment

September 20, 2008 By Leave a Comment

Like any other dislocation acute dislocations of the glenohumeral  or shoulder joint should be reduced as quickly and gently as possible. There are many advantages of early reduction of shoulder dislocation.

  • Eliminates the stretch and compression of neurovascular structures
  • Reduces amount of muscle spasm that must be overcome to effect reduction
  • Prevents further insult to  humeral head  and glenoid labrum

If patient reports within short time, some dislocations can be reduced without medication especially in thinly built patients. Reduction is difficult without medications if patient is very muscular , dislocation is of a long standing duration, the dislocation is locked in soft tissue. [Read more...]

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Acute Dislocation of Shoulder – Clinical Presentation

September 19, 2008 By Leave a Comment

There would be history of trauma to shoulder and patient would present with severe pain in the shoulder.
The shoulder would be held in position of typical attitude depending on direction of dislocation.

Anterior Dislocation

The physical examination is almost diagnostic.

Muscles are in spasm because there is an attempt to  stabilize the joint. The head of humerus may be palpable anteriorly especially in case of thin patients. The glenoid area appears  hollow. The attitude of uper limb is abduction and external rotation at the shoulder.

Patient is unable to perform adduction and internal rotation (Duga’s Test).

A detailed examinaton to look for neural and vascular injury should be done. Axillary nerve is a commonly injured nerve in anterior dislocaion of shoulder, therefore should be always looked for.

Posterior Dislocation

The shoulder is held in the traditional sling position of adduction and internal rotation. The classic features of a posterior dislocation include:

  • Limited external rotation of the shoulder
  • Limited elevation of the arm – often to less than 90 degrees
  • Posterior prominence and rounding of the shoulde
  • Flattening of the anterior aspect of the shoulder
  • Prominence of the coracoid process

In both kind of injuries treatment is reduction of the dislocation preferably closed

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Radiographic Studies In Shoulder Dislocation

September 16, 2008 By Leave a Comment

Radiography is a very important aid in making and confirming diagnosis of shoulder dislocation. It also helps to find if any associated injuries.

To make a wholesome diagnosis of the injury, the physician needs to know the following

  • Direction of the dislocation
  • Existence of associated fractures
  • Difficulty if any in the reduction

Following views are used around the shoulder [Read more...]

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Acute Dislocation of Shoulder – Mechanism of Injury

September 15, 2008 By Leave a Comment

The shoulder joint is formed by four articulations

  • Sternoclavicular joint
  • Acromioclavicular Joint
  • Glenohumeral joint
  • Scapulothoracic joint

All of these joints work together  for smooth functioning of the shoulder.

Acute traumatic dislocation of shoulder is quite a common injury. The normal shoulder can become unstable as a result of trauma. Although the shoulder can be dislocated by direct trauma such as a blow directed at the proximal humerus, indirect force is the most common cause of shoulder sprain, subluxation, or dislocation. [Read more...]

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Posterior Sternoclavicular Dislocations – Operative Treatment

September 12, 2008 By Leave a Comment

Operative treatment of posterior strernoclavicular dislocation should be undertaken when the dislocation is not reducible because most adult patients cannot tolerate posterior displacement of the clavicle into the mediastinum.

Unreduced posterior dislcatiion can lead to complications like respiratory compromise, dyspnea (breathlessness) and thoraccic outlet syndrome. Vascular problems also have been reported.

Several procedures have been described  to maintain the medial end of the clavicle in its normal articulation with the sternum. These include use of loop of fascia lata, suture, internal fixation across the joint, subclavius tendon, osteotomy of the medial clavicle, and resection of the medial end of the clavicle.

Postoperative Care
Tthe shoulders are held back with a figure-of-eight bandage for 4 to 6 weeks.

The patient should avoid vigorous activities until the pins are removed. The pins should be carefully monitored with radiographs until they are removed.

Range of motion exercises are begun after that and conyinued till  maximum possible functional recovery is achieved.

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Nonoperative Treatment of Posterior Sternoclavicular Injuries

September 7, 2008 By Leave a Comment

Posterior  sternoclavicular injuries are more dangerous than anterior sternoclavicular injuries. They should be carefully evaluated for severity before deciding in favor of nonoperative treatment.

Mild to Moderate Injury (sprain, Subluxation)

The ligaments remain intact and there is moderate discomfort to the patient. There may be swelling and tenderness. Careful examination and evaluation must be done to rule out posterior dislocation. It is best to protect the sternoclavicular joint with a figure-of-eight banÍdage for 2 to 6 weeks. [Read more...]

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Non Operative Treatment of Anterior Sternoclavicular Injuries

September 5, 2008 By Leave a Comment

Most of sternoclavicular injuries can be treated non operatively. The treatment depends on the severity of injury.

Mild Injury

In mild injury the  sternoclavicular joint is stable but painful.  Apply ice for the first 12 to 24 hours. Then immobilize the  upper limb. The immobilization should continue for 4 days to one week. Following that the limb should be gradually used in day to day activities. [Read more...]

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Radiographic Imaging In Sternoclavicular Dislocations

August 30, 2008 By 3 Comments

Radiological imaging is very important part of diagnosis making of sternoclavicular injuries. In addition to routine xray views,special views have been developed to confirm the injury. Sometimes imaging additional to Xrays might be necessary.

Anteroposterior and Lateral Views
Anteroposterior x-rays of the chest or sternoclavicular joint may show sternoclavicular joint displaced as compared with the normal side. Lteral x-rays are difficult to interpret due to overlapping of structures.

Heinig View
Patient is in supine position, the x-ray tube is placed approximately 30 inches from the involved sternoclavicular joint and the central ray is directed tangential to the joint and parallel to the opposite clavicle. The cassette is placed against the opposite shoulder and centered on the manubrium.

Hobbs View
The patient is seated at the x-ray table,leaning forward in a way that the nape of his flexed neck is almost parallel to the table and lower anterior rib cage against the cassette  on the table. The x-ray source is above the nape of the neck.

Serendipity View
The patient is positioned on his back and the tube is tilted at a 40-degree angle off the vertical centering over sternum with cassette under patient’s upper shoulders and neck.

In children, the distance from the tube to the cassette is 45 inches and  in adults 60 inches.

If the  sternoclavicular joint is dislocated anteriorly, the affected clavicle will appear to be displaced and riding higher. If it is dislocated posteriorly, it will appear to be lower.

CT Scan

CT scan is the best modality  to study  the sternoclavicular joint injury. It clearly distinguishes injuries of the joint from fractures of the medial clavicle and defines minor subluxations of the joint. Opposite joint should also be included in the study for a comparitive analysis.

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Sternoclavicular Injuries-Clinical Presentation

August 20, 2008 By 1 Comment

Sternoclavicular injuries are rare. The literature quotes incidence to be 3%. Anterior dislocations of the sternoclavicular joint are much more common than are posterior ones. The ratio of anterior dislocations to posterior dislocations of the sternoclavicular joint of approximately 20 to 1.

Sternoclavicular joint can be mild, moderate, and severe

Mild Injury-Sprain

Mild injury is equivalent to sprain.

The ligaments of the joint are intact. There is mild to moderate amount of pain, particularly with movement of the upper extremity. The joint may be slightly swollen and tender to palpation, but instability is not noted. [Read more...]

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