Shoulder Dislocation

SHOULDER DISLOCATION
SHOULDER JOINT
• Has the greatest ROM of any joint in the body

• Reliant on soft tissues restrains of capsule, ligaments and muscles
• Shoulder is held reduced by static and dynamic stabilizers
• Static stabilizers maintain congruity of shoulder joint through
buttressing support & stability at end of ROM
• Dynamic stabilizers actively stabilizes the moving joint at mid ranges
of ROM
Shoulder Joint :
- Bones
- Joint cavity
- Ligaments
- Muscles
- Bursae
Shoulder Joint :
- Bones
- Joint cavity
- Ligaments
- Muscles
- Bursae
Shoulder Joint :
- Bones
- Joint cavity
- Ligaments
- Muscles
- Bursae
Shoulder Joint :
- Bones
- Joint cavity
- Ligaments
- Muscles
- Bursae
Shoulder Joint :
- Bones
- Joint cavity
- Ligaments
- Muscles
- Bursae
American Academy of Orthopaedic Surgeons (2014). Review Article : Acute Management of Shoulder Dislocation.
CLINICAL DEFINITION
Complete displacement of the humeral head out of the glenoid

CLASSIFICATION
Anterior
dislocation
Traumatic
Inferior
Shoulder dislocation
dislocation
Posterior
Atraumatic
dislocation
ANTERIOR SHOULDER DISLOCATION
Anterior dislocation : most common, 97%

• Mechanism of injury : a blow to an abducted, externally
rotated and extended extremity or posterior humerus force of
FOOSH
• O/e : arm abducted, externally rotated and acromion appears
prominent. Loss of rounded appearance of shoulder
• Associated injuries occur in 40% of cases
HILL SACHS LESION
• With anterior dislocation, the posterosuperior head contacts the anteroinferior

glenoid rim which may result in wedge shaped posterosuperior humeral head
impression fracture known as Hill-Sachs lesion
• This lesion is best depicted on AP view of shoulder with internal rotation and
appears as flattening/concavity of posterolateral aspect of humeral head
• Hill Sachs lesion larger than 40% of the articular surface are likely to
contribute to recurrent dislocation
BANKART LESION
• First time dislocation in a young person usually results in a tear or avulsion of

anterior labroligamentous complex from the inferior glenoid, known as Bankart
lesion
• An injury that included anterior labral injury and fracture of anteroinferior
glenoid
• Osseous Bankart lesion involving inferior glenoid rim are subtle and best
depicted with AP or axillary view of shoulder
BANKART LESION
POSTERIOR SHOULDER DISLOCATION
• Account for 2% to 4% of shoulder dislocations.

• Usually, the injury is caused by a hit to the anterior shoulder and axial
loading of the flexed, adducted internally rotated arm.
• It may also be a result of violent muscle contractions (seizures,
electrocution).
• Chronic instability presents with insidious onset and vague symptoms.
• O/e the arm is usually held in adduction, and internal rotation and patient is
unable to rotate externally. Prominent
POSTERIOR SHOULDER DISLOCATION
- Higher risk of associated injuries such as fractures of surgical neck or tuberosity, reverse Hill-
Sachs lesions (also called a McLaughlin lesion which is an impaction fracture of anteromedial
aspect of humeral head), and injuries of the labrum or rotator cuff.
- Often the humeral head is subluxed rather than completely dislocated.
- Anterior humeral head can impact against posterior glenoid rim which can result in anterior
humeral head impression fracture (reverse Hill Sachs lesion/trough sign) or posterior glenoid
rim fracture (reverse Bankart lesion)
INFERIOR SHOULDER DISLOCATION
• the most uncommon type (less than 1%).

• Usually caused by hyperabduction or with axial loading on the
abducted arm.
• O/e the arm is held above and behind the head and patient is
unable to adduct arm.
• Often associated with nerve injury, rotator cuff injury, tears in
the internal capsule, and the highest incidence of axillary nerve
and artery injury of all shoulder injuries.
HISTORY AND PHYSICAL
Patients may report pain, deformity, immobility and instability

• A popping sensation
• Sudden onset of pain with decreased range of motion
• The sensation of joint rolling out of the socket.
• History of previous shoulder dislocations.
HISTORY AND PHYSICAL
Anterior dislocation Posterior dislocations
arm is abducted and externally rotated arm is in internal rotation and adduction.
"squaring" of the shoulder
prominent humeral head felt anteriorly, prominent head can be palpated

and the void can be seen posteriorly in the posteriorly in thin patients
shoulder in thin patients
• Range of motion is diminished and painful

• Axillary nerve neuropraxia – reduced sensation over lateral shoulder
• Rotator cuff injury
• Performing a detailed neurovascular examination before reduction is imperative. Injury to the axillary nerve during shoulder
dislocation is as high as 40%.
REVIEWING SHOULDER XRAYS
Typical shoulder X-ray views include:

• Antero-posterior (AP) view
• Lateral/scapula Y view (named due to the “Y” shape of the scapula in this
view)
• An axial view can also be used as an alternative to the scapula Y view if the
patient is unable to tolerate the positioning required to obtain this view.
REVIEWING SHOULDER XRAYS
Glenohumeral joint, acromioclavicular joint, coracoclavicular joint,

Alignment
acromiohumeral joint, Moloney’s arch
Bones Proximal humerus, clavicle, scapula, rib fractures
Soft Tissues Heterotopic ossification, lipohaemarthrosis

AP SHOULDER
• demonstrates the glenohumeral

joint in the natural anatomical
position
• shows the humeral head
superimposing the glenoid of the
scapula
• displays the entire clavicle, AC
joint, scapula, superior ribs and
proximal humerus
AP SHOULDER
Lateral border of scapula and medial

cortex of proximal humerus form a
smooth convex arch known as
Moloney’s arch (scapulohumeral arch)
AP SHOULDER
humeral head will lie medial and

inferior to the glenoid fossa.
glenohumeral joint will be

widened and the humeral head
will take on a classic “light
bulb” appearance due to forced
internal rotation of the humerus.
Anterior Dislocation Posterior Dislocation
AP SHOULDER
• “trough line” sign –

impaction of humeral head
(arrow)
• Loss of normal half-moon
sign
• “rim sign” – widened
glenohumeral joint >6mm
• Acute angle of Moloney’s
arch Posterior Dislocation
LATERAL SCAPULAR Y VIEW
• Laterally, the body of the scapula, acromion,

and coracoid process all converge at the
glenoid.
• If the humeral head falls in the middle of this
convergence, then it is seated in the glenoid
and there is no dislocation. Posterior
dislocations can be more subtle and may
require an axillary view if the Y view is not
definitive
LATERAL SCAPULAR SHOULDER/Y
VIEW
the humeral head will lie anterior

and inferior to the glenoid fossa.
the humeral head will lie

posterior to the glenoid fossa

INFERIOR-SUPERIOR AXIAL/AXILLARY
VIEW
Patient in supine position and arm abducted

90. Beam over mid glenohumeral joint and
directed in distal to proximal direction while
tilted 15’ towards spine
To evaluate anterior/posterior shoulder

subluxation/dislocation and detection of
Bankart fracture
INFERIOR-SUPERIOR AXIAL/AXILLARY
VIEW
AXILLARY VIEW
the humeral head will lie anterior

to the glenoid fossa, away from
the acromium
the humeral head lies posterior to

the glenoid fossa, towards the
acromium

MODIFIED TRAUMA AXIAL VIEW (VELPEAU)
This projection is performed on patients

with a shoulder sling (Velpeau bandage)
in place, often in the context of post-
operative or a post-reduction
presentation whereby the patient is
unable to abduct the arm.
Patient in erect or sitting position away

from table. Cassette is place on table
behind the patient beneath the shoulder
Patient leans 30’ backwards and
centering point over shoulder joint from
superior to inferior

Shoulder Dislocation

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SHOULDER DISLOCATION

• Has the greatest ROM of any joint in the body

Complete displacement of the humeral head out of the glenoid

Anterior dislocation : most common, 97%

• With anterior dislocation, the posterosuperior head contacts the anteroinferior

• First time dislocation in a young person usually results in a tear or avulsion of

• Account for 2% to 4% of shoulder dislocations.

• the most uncommon type (less than 1%).

Patients may report pain, deformity, immobility and instability

Anterior dislocation Posterior dislocations

prominent humeral head felt anteriorly, prominent head can be palpated

• Range of motion is diminished and painful

Typical shoulder X-ray views include:

Glenohumeral joint, acromioclavicular joint, coracoclavicular joint,

Bones Proximal humerus, clavicle, scapula, rib fractures

Soft Tissues Heterotopic ossification, lipohaemarthrosis

• demonstrates the glenohumeral

Lateral border of scapula and medial

humeral head will lie medial and

glenohumeral joint will be

• “trough line” sign –

• Laterally, the body of the scapula, acromion,

the humeral head will lie anterior

the humeral head will lie

Anterior Dislocation Posterior Dislocation

Patient in supine position and arm abducted

To evaluate anterior/posterior shoulder

the humeral head will lie anterior

the humeral head lies posterior to

Anterior Dislocation Posterior Dislocation

This projection is performed on patients

Patient in erect or sitting position away

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