Makindo Medical Notes

Related Subjects: |Shoulder Anterior Dislocations |Shoulder: Posterior Dislocation |Shoulder: Sterno-Clavicular Joint Dislocation

💪 Anterior Shoulder Dislocation — the most common type of shoulder dislocation (≈90–95%). Occurs when the humeral head is displaced anteriorly from the glenoid fossa. ⚠️ Always check for axillary nerve injury and associated fractures.

📌 Introduction

• Accounts for the majority of shoulder dislocations.
• Usually due to external rotation + abduction injury (e.g., sports, fall on outstretched hand).
• Diagnosis: typically confirmed on anteroposterior (AP) shoulder X-ray.

🩻 Diagnosis & Initial Steps

• Establish IV access for analgesia/sedation.
• Give IV morphine or alternative for pain control.
• Request AP X-ray to confirm dislocation.
• Test and document axillary nerve function (badge-patch sensation over deltoid).

⚙️ Dislocation Management Algorithm

🛠️ Post-Reduction Care

• Repeat X-ray to confirm relocation.
• Reassess axillary nerve function.
• If reduction successful:
  • Polysling + axillary pad.
  • Adequate analgesia.
  • Provide post-sedation discharge advice.
  • Arrange fracture clinic (VFC) follow-up.
• If reduction unsuccessful:
  • Maintain analgesia & polysling.
  • Refer to on-call orthopaedics for further management.

🦴 Associated Fractures

Anterior shoulder dislocation is commonly associated with fracture of the greater tuberosity or surgical neck of the humerus.

• Undisplaced greater tuberosity fracture: Reduction may proceed as usual.
• Greater tuberosity displaced >1 cm: ❌ Do not attempt reduction — refer to orthopaedics for surgical management.
• Fracture neck of humerus: ❌ Do not attempt reduction — immediate orthopaedic referral.

🧾 Conclusion

• Anterior shoulder dislocation = common injury requiring urgent reduction & follow-up.
• Pain relief, safe sedation, and post-reduction monitoring are key for successful outcome.
• Always check for associated fractures & nerve injury — these alter management.

Cases — Anterior Shoulder Dislocation

• Case 1: A 22-year-old rugby player is tackled and falls with his arm outstretched. He presents with severe shoulder pain, arm held abducted and externally rotated, with a visible “squared off” contour. Distal pulses and sensation intact. X-ray confirms anteroinferior dislocation, no fracture. Management: IV analgesia, reduction performed under sedation using the Kocher manoeuvre, post-reduction X-ray confirms successful relocation. Sling and physiotherapy arranged. Outcome: Full recovery with physiotherapy; advised to avoid contact sport for 6 weeks. Counselling given about risk of recurrence, especially in young athletes.
• Case 2: A 68-year-old woman trips and falls onto her outstretched hand. She presents with severe shoulder pain, arm abducted and externally rotated, reduced sensation over the “regimental badge” area (axillary nerve). X-ray shows anterior dislocation with a small greater tuberosity fracture. Management: Procedural sedation and reduction achieved, but ongoing axillary nerve deficit noted. Post-reduction films confirm relocation. Orthopaedic team reviews fracture; conservative management chosen. Outcome: Shoulder mobilised in a sling for 3 weeks followed by physiotherapy. Nerve function partially recovers, but some persistent numbness remains.

Teaching Commentary 🧑‍⚕️

Anterior dislocation is the most common shoulder dislocation (>90%). Mechanism is typically fall on outstretched, abducted, externally rotated arm. Key signs are the squared-off contour and arm held away from the body. Always check for neurovascular compromise, especially the axillary nerve. Management is prompt analgesia, reduction, post-reduction X-ray, and physiotherapy. In young patients, recurrence is common; in older patients, associated fractures and nerve injury are more frequent. Tailor rehabilitation and follow-up accordingly.