Shoulder

Scenario

A 36 YO male presents after falling onto his left shoulder during a rugby scrum. A primary survey has been performed and there are no life threatening injuries.

Dislocated_shoulder_X-ray_10

This is an AP and Y view of an unknown skeletally mature individuals Left shoulder. The most obvious abnormality is there is an anterior shoulder dislocation.

I would perform a secondary survey. As part of the secondary survey I would assess the orthopaedic injury in question. I would assess and document the neurovascular status of the limb (including axillary, radial, medial, musculocutaneous and ulnar nerves and distal pulses and cap refill). I would then reduce the shoulder with the help of my A+E/anaesthetic colleagues. Following reduction I would reassess the patients neurovascular status and obtain repeat X-Rays to confirm reduction and rule out associated injuries. 

Anterior (90%)

Posterior (10%)

Inferior (<1%)

Traction methods

  • Matsons traction-countertraction
  • Stimpson (patient prone on the table 4kg hanging from the arm)
  • Hippocratic: foot in the axilla, humeral traction with internal or external rotation.

 

Non traction

  • Kochers: arm adducted, flexed to 90, traction + external rotation then forward flexion of the arm and internal rotation across the body
  • External rotation

 

Combined

  • Milch method: Supine, arm abducted followed by external rotation and thumb pressure anteriorly over the humeral head.

I would use the deltopectoral approach.

In an appropriately marked and consented anaesthetised individual. I would complete the WHO checklist. The patient would be in the beach chair position.

The incision is in the deltopectoral groove starting at the coracoid process to the deltoid tuberosity.

The internervous plane is between the pectoral nerve and the axially nerve

Superficial dissection is between the pectoralis major and deltoid. Dissect through deltopectoral fascia and identify the cephalic vein (retract cephalic vein medially or laterally)

Deep dissection. Retract conjoint tendon medially. Detach subscapularis from lesser tubercle.

  • Bankart lesion injury to the inferior glenoid labrum
  • Bony bankart to the inferior glenoid
  • Hill sach’s lesion to posterior lateral humeral head depression fracture
  • Rotator cuff tear
  • Axillary nerve injury

Supraspinatus (Suprascapular nerve)

Infraspinatus (Suprascapular nerve)

Teres Minor (Axillary nerve)

Subscapularis (Subscapular nerve)

Supraspinatus – superior facet

Intraspinatus – Middle facet

Teres minor – Inferior facet