THÔNG TIN TÀI LIỆU
Clinical Assessment Findings on physical examination of an anterior dislocation include a palpable defect just inferior to the acromion, with loss of the usual rounded contour of the shoulder On palpation, there is displacement of the humeral head most commonly anterior to the glenoid fossa, with the arm frequently held at the side with inability to tolerate any range of motion Posterior dislocations are rare, and may present with the arm held in adduction with slight internal rotation, a flattened appearance anteriorly, and prominent coracoid process Inferior dislocations are the rarest form of shoulder dislocation, and the patient will often present with the arm maximally abducted and adjacent to the head Complete examination and documentation should include assessment of distal neurovascular status before and after reduction The axillary nerve is the most commonly injured neurovascular structure, reported in up to 42% traumatic anterior dislocations Management In order to define the direction of displacement, an additional axillary (Y) view, should be obtained along with standard views (anteroposterior and axillary) of the shoulder Treatment of anterior dislocation through closed reduction can be accomplished by numerous techniques (see Chapter 130 Procedures , section on Closed Reduction of Dislocations) Pain management is fundamental for a successful reduction A wide range of approaches have demonstrated efficacy from procedural sedation to analgesia with mild sedation to local intra-articular lidocaine injections Repeat radiographs are recommended after reduction to confirm anatomic placement as well as to look for any traumatic fractures such as Hill–Sachs deformities, Bankart lesions, and greater tuberosity fractures ( Fig 111.11 ) The Hill–Sachs deformity is a cortical depression in the humeral head caused by the glenoid rim at the time of dislocation This deformity may destabilize the joint and result in recurrent dislocation A Bankart lesion is an avulsion of a bony fragment during anterior dislocation when the glenoid labrum is disrupted; this lesion is felt to be the primary lesion in recurrent anterior instability Given the rarity of posterior and inferior dislocations, urgent orthopedic consultation in the ED is recommended for these injuries prior to reduction Additional indications for consultation include irreducible dislocations, displaced greater tuberosity fractures, and large bony glenoid lesions After reduction, patients should be placed in a sling and swathe to stabilize the joint at discharge Duration and position of the arm during immobilization is debated Guidelines range from to weeks of immobilization, but data is poor on the relationship between duration of immobilization and outcome in skeletally
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