Information Sheet for candidate:

The ambulance brings into your Emergency

Department a 24 year old young man who came
off his cross country motor bike, He fell over the
handle bar onto his right outstretched and
externally rotated hand. No other injuries. He
complains about severe pain in his shoulder and
can not move it. The ambulance officers gave
him some inhaled analgesia and applied a sling
to the shoulder.
Your tasks are to:
1.Explain to the examiner how you examine
the shoulder. Give running commentaries!
2.Discuss investigations and management

EXAMINATION:
1. Inspection (LOOK: watch the patient undressing, compare sides, swelling,
asymmetry and scars)
2. FEEL: for tenderness and swelling
3. Range of motion, ACTIVE (LOOK + LISTEN !!!)
Flexion
Extension
Abduction
Adduction
Internal and external rotation
Apley scratch test:
Stand behind patient and ask to scratch an imaginary itch over the opposite
scapula, first by reaching over the opposite shoulder, next by reaching
behind the neck and finally by reaching behind the back.
Apprehension test:
tests the anterior stability of the shoulder joint. You stand behind the
patient, abduct, extend and externally rotate the shoulder whilst pushing
the head of the humerus forward with the thumb, a movement similar to
the first phase of dunking a ball in basket ball. This manouvre will be
resisted if there is impending dislocation or anterior instability. The
opposite movement, adduction and internal rotation confirms posterior
instability.
Active and passive movement, including against resistance!
4. Examination of axillary nerve:
Muscle wasting and function, sensation over outside of upper arm
The shoulder's integrity is maintained by the glenohumeral joint capsule, the
cartilaginous glenoid labrum (which extends the shallow glenoid fossa), and muscles of
the rotator cuff.
Anterior dislocation:
Incidence
Anterior dislocations account for over 95% of dislocations, with posterior dislocations
making up 4% and inferior dislocations about 0.5%.Superior and intrathoracic
dislocations are extremely rare.
Sex distribution is bimodal, with peak incidence in men aged 20-30 years and women
aged 61-80 years.
Shoulder dislocations occur more frequently in adolescents than children, because the
weaker epiphysel growth plates in children tend to fracture before dislocation occurs.

Usually result from abduction, extension, and external rotation, such as when about to
punch a volleyball down over the net.
Falls onto an outstretched arm are a common cause in older adults.
The humeral head is forced out of the glenohumeral joint, rupturing or detaching the
anterior capsule from its attatchment to the head of the humerus, or from its insertion to
the edge of the glenoid fossa. This occurs with or without lateral detatchment.
DIAGNOSIS: X-ray

Findings

This patient presents with an anterior dislocation of the humeral head with respect to
the glenoid as demonstrated.

Discussion
Shoulder dislocation may be anterior or posterior. The vast majority are anterior and the
humeral head is displaced anteriorly and inferiorly. If the anterior dislocation is not
associated with a fracture of the glenoid or humeral head, a closed reduction is performed.
There is frequently long-term ligamentous laxity however, and this predisposes to chronic
anterior dislocations.

Treatment:

(!document neurovascular status, pre-reduction X-ray, explanation,

sedation, analgesia, slow and steady)
Reduction by Kochers method: elbow bent to 90 degrees, gentle
traction on shoulder, external rotation, adduction and internal rotation
Stimsons method: patient prone, 5-10 kg weight fastened to arm, left
hanging for about 20 min, leading to spontaneous reduction. Can be
enhanced by scapular rotation by fixing the superomedial angle of the
scapula with one hand and pushing the inferior angle medially with the
other hand.
Hippocratic method: traction with foot in axilla (discouraged)

Aftercare:
Wool pad into axilla and broad arm sling. Prevent external rotation by body
bandage/netting or clothes, immobilization for 4 weeks. However, shorter and early
physiotherapy for elderly patients because of risk of stiffness.
COMPLICATIONS:
Recurrence (high in patients under 40 years
Stiff shoulder (mainly in elderly)
Axillary nerve palsy with loss of deltoid function and loss of sensation over regimental
badge area on the outside of upper arm

Fig. 1