Ver el código de «Anterior shoulder dislocation»

==Background==
[[File:Shoulder_joint_back-en.png|thumb|Shoulder anatomy, anterior.]]
[[File:Shoulder joint back 05r4v.png|thumb|Shoulder anatomy, posterior.]]
*Shoulder dislocations account for 50% of all major joint dislocations, 90-98% are anterior<ref name="Guler">Guler O, Ekinci S, Akyildiz F, et al. Comparison of four different reduction methods for anterior dislocation of the shoulder. Journal of Orthopaedic Surgery and Research. 2015;10:80. doi:10.1186/s13018-015-0226-4.</ref>
*Majority of anterior shoulder dislocations are due to trauma
*Important to rule out [[Axillary neuropathy|axillary nerve injury]]
**Most common finding is 'military patch' (deltoid) anesthesia

{{Shoulder dislocation types}}

==Clinical Features==
*Pain
*Arm maintained in abduction
*Shoulder appears 'squared off' (loss of normal rounded appearance with stretching of the deltoid muscle)
*Difficulty touching affected arm to contralateral shoulder due to pain

===Chronic Anterior Dislocation===
*Risk of axillary artery rupture with reduction of chronic dislocation <ref>Calvet, E et al. [Dislocations of the shoulder and vascular le- sions.] (in French). J Chir (Paris) 1941; 58: 337-346.</ref><ref>Verhaegen F, et al. Chronic anterior shoulder dislocation: as- pects of current management and potential complications. Acta Orthop Belg. 2012 Jun;78(3):291-5. PMID: 22822566.</ref> 
**Patient with shoulder dislocated 3-4 weeks should be reduced only with orthopedic consultation, and likely in the operating theatre<ref>Sahajpal DT, et al. Chronic glenohumeral dislocation. J Am Acad Orthop Surg. 2008 Jul;16(7):385-98.</ref>

==Differential Diagnosis==
{{Shoulder DDX}}

==Evaluation==
===Imaging===
[[File:AnterDisAPMark.png|thumb|Anterior dislocation]]
[[File:AnterDisMark.png|thumb|Anterior dislocation of the right shoulder on Y-view X ray.]]
[[File:Luxation epaule.png|thumb|Anterior dislocation with fracture]]
*Plain film X-ray of shoulder
**At least 3 views
***Axillary lateral or scapular "Y" view can help distinguish between anterior and posterior dislocation
**Rule out associated fracture
*May forego imaging if:
**Age <40
**Atraumatic mechanism
**Multiple past dislocations
**Clinically consistent with dislocation
*Bedside [[ultrasound: Joint|ultrasound]] can be used to assess for both dislocation and successful reduction

==Management==
[[File:Traction-Countertraction.jpg|thumb|Traction-Countertraction]]
[[File:External Rotation.jpg|thumb|External Rotation (Kocher)]]
[[File:Picture 3.png||thumb|Stimson]]
[[File:Milch.jpg|thumb|Milch]]

*Closed reduction (see techniques below)
**'''Note: do not reduce chronic dislocations (>4 weeks) in the ED due to risk of arterial injury''' 
***Consult orthopedics for cautious attempt at closed reduction or open reduction
*[[Procedural sedation]] often required
**Consider intra-articular lidocaine (10-20mL) as alternative to procedural sedation<ref>Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults (Review) Cochrane Database Syst Rev. 2011 Apr 13;(4):CD004919 [http://www.update-software.com/BCP/WileyPDF/EN/CD004919.pdf full text]</ref>

===Reduction Techniques===
====Techniques that generally do not require sedation====
*FARES (Fast, Reliable, and Safe) Method:
#Place the patient supine or prone
#Grasp the affected arm at the wrist
#Gently oscillate the arm anteriorly and posteriorly (up and down as the patient is supine)
#Apply gentle traction to the arm and slowly abduct
#Once abducted to 90 degrees, externally rotate
#Continue with ongoing traction and oscillation until reduction is achieved (generally with 120 degrees of abduction)

*Cunningham Technique: [https://www.youtube.com/watch?v=d9HjtQr0c64&t=41s video] and second [http://www.youtube.com/watch?v=MkdCGV_MOCM video] 
#Stand in front of the seated patient
#Hold the patient's affected arm adducted with the elbow flexed to 90 degrees
#Massage trapezius, deltoid and bicipital muscles
#Instruct the patient to move the shoulder superiorly and posteriorly to facilitate humeral head reduction (bring shoulder back and chest out) <ref>Neil Cunningham, MBBS, FACEM. "Cunningham Technique". Shoulderdislocation.net.</ref>

*Davos Technique<ref>Stafylakis D, Abrassart S, Hoffmeyer P. Reducing a Shoulder Dislocation Without Sweating. The Davos Technique and its Results. Evaluation of a Nontraumatic, Safe, and Simple Technique for Reducing Anterior Shoulder Dislocations. J Emerg Med. 2016 Apr;50(4):656-9.</ref>,<ref>https://www.youtube.com/watch?v=u2MsnjVNoPM</ref>:
#Place the patient in a seated position on an examination table
#Instruct the patient to flex the knee ipsilateral to the affected shoulder
#Ask the patient to hold the wrist of the affected arm in the hand of the unaffected arm with both looped around the fully flexed knee
#Tie the affected and unaffected wrists together around the fully flexed knee
#Sit on the patient's foot to stabilize
#Keeping the elbows adducted, ask the patient to slowly lean head back and allow shoulder to roll forward
#*Neck extension creates traction on the injured shoulder, which allows it to reduce

*Snowbird Technique
#Place patient in an upright sitting position
#Adduct the affected arm and flex the elbow to 90 degrees
#Create a loop of stockinette
#Hang the loop of stockinette over the flexed elbow
#Position an assistant behind the patient with arms under the axillae to provide countertraction
#Using your hands to maintain flexion of the elbow, place your foot in the loop of stockinette and apply downward pressure to create traction on the elbow

====Techniques that typically require sedation====

*Kocher<ref name="Guler" />: [https://www.youtube.com/watch?v=d9HjtQr0c64&t=21m30s video]
#Place patient supine seated on exam table
#Adduct affected arm and flex 90 degrees at the elbow
#Externally rotate the shoulder (70-85 degrees) until resistance is felt
#Lift arm anteriorly as far as possible
#Internally rotate shoulder, moving hand towards contralateral shoulder
#Humeral head should slip back into place
#*Note that a modified Kocher technique avoids abduction and internal rotation and reduces the dislocated shoulder through external rotation alone

*Milch<ref>Sapkota K, Shrestha B, Onta PR, Thapa P. Comparison Between External Rotation Method and Milch Method For Reduction of Acute Anterior Dislocation of Shoulder. Journal of Clinical and Diagnostic Research : JCDR. 2015;9(4):RC01-RC03. doi:10.7860/JCDR/2015/11850.5738.</ref>
#Place patient supine on exam table<ref>Amar E, Maman E, Khashan M, et al. Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success. J Shoulder Elbow Surg. 2012 Nov;21(11):1443-9.</ref>
#Grasp the wrist of the affected arm
#Slowly abduct and externally rotate the arm until it is in the overhead position
#Using your free hand, manipulate the humeral head laterally and superiorly to achieve reduction

*Scapular manipulation
#Position yourself behind the patient
#Stabilize the superior aspect of the shoulders with your fingers
#Placing your hands on the patient's back, push the inferior tip of the scapular medially and dorsally with your thumbs

*Stimson
#Place patient prone on edge of table (affected shoulder closest to table edge)
#*Note that this is not an ideal technique as it requires a sedated patient to lay face-down, potentially leading to suffocation on the exam table
#Allow hand to drop off table perpendicular to body
#Attach 5 kg weight to arm
#Maintain position for 20 - 30 minutes as needed
#Provide additional scapular manipulation or gentle external and internal rotation to promote reduction

*Traction-Countertraction
#Place patient in a supine position with a sheet wrapped around the torso and under the axilla of the affected arm
#While an assistant provides countertraction by pulling on the sheet, apply longitudinal traction to the affected arm, manipulating the shoulder into reduction

==Disposition==
*Discharge after successful reduction
**Maintain [[sling +/- swath]] or shoulder immobilizer (shoulder in adduction and internal rotation) until seen in follow-up by orthopedic surgery

==Complications==
*Recurrent dislocation
**39% risk of recurrence after traumatic dislocation<ref>Olds, M., Ellis, R., Donaldson, K., Parmar, P., and Kersten, P. (2015) Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: A systematic review and meta-analysis. British Journal of Sports Medicine, 49(14).</ref>
***Risk factors:
****Age <40 (approximately 90% recurrence rate in patients less than 20)
****Male sex
****Hyperlaxity
****Bony Bankart lesion
****Occupation
*Bony injuries 
**Hill-Sachs lession
***Compression fracture of humeral head
***40% of cases
***Most likely with recurrent anterior dislocation
**Bankart lesion 
***Injury to inferior glenoid labrum
***10-20% of cases
**Bony Bankart lesion<ref>https://radiopaedia.org/articles/bankart-lesion</ref>
***Fracture of anteroinferior glenoid rim
*[[Axillary nerve injury]]
**Up to 14% of cases
**Usually self-resolves
*Axillary artery rupture
**Rare
***Increased risk in chronic dislocation
*Rotator cuff tear

==See Also==
*[[Shoulder dislocation]]

==External Links==

==References==
<references/>

[[Category:Orthopedics]]
[[Category:Procedures]]