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Glenohumeral Dislocation: Class, Complications and Management

Glenohumeral Dislocation: Class, Complications and Management. August 21, 2003 Emergency 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

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Glenohumeral Dislocation: Class, Complications and Management

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  1. Glenohumeral Dislocation: Class, Complications and Management August 21, 2003 Emergency XR Rounds Simon Pulfrey (with much gleaned from Dave Dyck)

  2. 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

  3. Normal

  4. Glenohumeral Joint Dislocation • Anterior • Posterior • Inferior (Luxatio Erecta) • Superior

  5. Anterior • Most common – 94-97% of GH dislocation • 4 Types • Subcoracoid • Subglenoid 99% • Subclavicular • Intrathoracic

  6. 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”

  7. Neuro Median, Ulnar, & Radial Axillary N Shoulder pin prick & deltoid motor activity Injured in 5-54% of cases Usually >50yrs Vascular Axillary Brachial Radial What neurovascular exam will you do?

  8. ? 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?

  9. To classify glenohumeral dislocations • Mechanism – Traumatic vs Non-traumatic • Frequency – Primary vs Recurrent • Anatomic position of humeral head

  10. Diagnostic Strategies • 1- True AP

  11. 2. Axillary

  12. Transcapular or “Y” View

  13. 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

  14. 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

  15. 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…

  16. Post reduction:

  17. Hill-Sachs

  18. Post reduction

  19. Bankhart

  20. 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%.

  21. 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

  22. Infraglenoid Dislocation + Hill-Sachs Fracture

  23. Luxatio Erecta:

  24. 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

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

  26. 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

  27. 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

  28. Rim sign: ant glenoid rim and articular surface of hh increased (usu>6mm)

  29. 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

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