TDD: Dislocation glenohumeral anteromedial -> 95% of glenohumeral dislocations / sub-coracoid variety (the most common)
1- Clinical signs:
– Arm in abduction and external rotation
– External Chop
– Sign the epaulet (protrusion of the acromion)
– Filling the deltopectoral ant groove. or axilla.
– Widening the shoulder anteroposterior
– External subacromial Empty
– Sign of Berger: vicious attitude in abduction and external rotation irreducible.
Systematic search of an infringement of the axillary nerve resulting in anesthesia of the shoulder and paralysis of the deltoid.
opposite radiology sufficient for the diagnosis and surgical profile (Lamy scapula profile)
2- Complications:
– Compression of the axillary artery (radial pulse)
– Brachial plexus (median and / or ulnar)
– Inability to reduce the dislocation -> surgery
– Immediate Recurrent dislocation -> surgery.
– Bone Complication: see box below
– Complication tendon-muscle (injury to the rotator cuff -> about> 40 years)
Complication remotely
– Stiffness of the shoulder (adhesive capsulitis)
– Reflex sympathetic dystrophy (painful shoulder hand syndrome)
– Dislocation old inveterate
– Chronic instability or recurrent dislocation (see box)
3- Clinical forms:
* Dislocation sub-coracoid: it is the most common form
* The extracoracoïdienne dislocation: it is a subluxation (intracapsular) the reduction is carried out spontaneously. maximum external rotation, abduction is less pronounced.
* Dislocation intracoracoïdienne and subclavicular: are dislocated with great movement (violent trauma) risk vascular and nerve damage. The upper limb is shortened, abduction little pronounced. External rotation is replaced by the internal rotation.
* Lower dislocation of the shoulder: extremely rare, always secondary to very violent trauma. The upper limb is abducted or forward flexion, the arm is in the air irreducible way (dislocation erecta abduction to 120 °). constant lesion of the rotator cuff; neurovascular complications are common. same treatment as previous dislocations.
* Posterior Dislocation: rare (5%). Often unrecognized (subacromial which is actually an intracapsular subluxation).The true posterior dislocation (sub-thorny) is exceptional. The capital sign to look for is the complete loss of active and passive external rotation.
4- recurrent dislocation:
– Shoulder dislocation Recurrences are most frequently the patient is young. frequent before the age of 30 years. Its frequency decreases with age.
– Episodes of more frequent injuries to increasingly minors
– This dislocation is accompanied by various lesions: glenoid labrum injury; capsular injury -> (peeling pocket Broca);lesion of the humeral head impaction, lesions of the glenoid and headdresses of rota-ers.
– Instability is evidenced by two tests: test of apprehension (ma-noeuvre forced abduction and external rotation) and pitcher of the test (active test of apprehension). anterior drawer (anteroposterior laxity abnormal). The groove test (sulcus) in sitting position (hypermobility constitutional multidirectional).
– Specific Considerations: glenoid profile Bernageau
– Treatment: after 2 recurrences -> surgery: 2 Technical
* Latarjet: stop pre-coracoid glenoid
* Bankart: anterior capsular myorrhaphy (reintegration with the bead to glenoid rim)
5- Bone Complications:
* Fracture of the glenoid -> chronic instability
* Posterior edge of the depression fracture of the humeral head (Malgaigne injury or Hill-Sachs) -> extremely common in dislocations -> chronic instability for some
* Greater tuberosity fracture -> common in patients> 40 years. It is an avulsion fracture of the insertion of the cap (the fracture reduction is often achieved by reducing the dislocation)
* Fractures of the humeral head -> elderly subjects (osteoporosis) -> open reduction and osteosynthesis.
6- Treatment:
* Reduction: underwent emergency after eliminating an associated fracture of the humeral neck. Or by simply pulling on the axis of the limb in abduction, or by Kocher maneuver (reduction in bending, adduction and internal rotation).
* Immobilization: immobilization elbow to the body
– About young: Dujarier for at least 3 weeks
– Elderly: Mayo-clinic for 2 to 3-to Maines
* Rehabilitation of the shoulder: it is started soon removal of restraints. Active and should be extended in the elderly to prevent shoulder stiffness.
NB:
– The main complications recidivism in young patients is damage to the rotator cuff, and capsulitis in the elderly
– The mechanism is a fall on the top of the shoulder or trauma in forced abduction-external rotation.
– The risk of injury to the rotator cuff is high in these cases
– In case of fracture of the greater tuberosity, look cephalic meshed fracture whose disengagement upon reduction has important consequences.