Orthopedic Teaching Cases 2023, Oct, 03 | 12:00 am

The Dislocated Shoulder: Can You Ace This Orthopedic Oral Exam

<p><input alt="Fracture dislocaon shoulder" src="https://hutaifortho.com/upload/1696331831.png" style="height: 281px; width: 400px; float: left;" type="image" /></p> <figcaption class="boxlegend" style="margin: 0px 18.3438px 9.16667px 0px; padding: 4.58333px 0px; width: 431.115px; float: right; line-height: 19.2px; background-color: rgb(41, 113, 113); border-width: 1px; border-style: solid; border-color: rgb(42, 186, 186) rgb(23, 64, 64) rgb(23, 64, 64) rgb(42, 186, 186);"><h4 style="margin: 0px; padding: 4.30208px 4.30208px 4.30208px 8.61458px; border: 0px; outline: 0px; vertical-align: baseline; line-height: 17.6px;"><font color="#ffffff" face="Arial, Trebuchet MS, Helvetica, sans-serif"><span style="font-size: 17.6px;">What is the diagnosis for a left-hand dominant woman, aged 38, who fell on her right arm and went to the accident and emergency department the following day at 4 pm as the pain in her right shoulder had not subsided, shown by X-rays of her right shoulder (Figure 12.1a)?</span></font><br></h4></figcaption> <!DOCTYPE html> <html> <head> <title>Shoulder Dislocation and Greater Tuberosity Fracture Diagnosis and Management</title> <style type="text/css"> /* CSS for the main container */ .container { font-family: sans-serif; width: 1140px; padding: 24px; margin: 0px auto; max-width: 1200px; color: rgb(51, 51, 51); background-color: rgb(255, 255, 255); } /* CSS for the question containers */ .question-container { margin-bottom: 20px; padding-top: 10px; padding-bottom: 10px; background-color: rgb(247, 247, 247); border-radius: 5px; font-weight: bold; color: #3a3a3a; box-shadow: 1px 1px 3px #ccc; } /* CSS for the answer button */ .button { font-family: sans-serif; border-radius: 5px; margin-top: 10px; margin-right: 10px; padding: 5px 10px; background-color: #1976d2; color: white; border: none; cursor: pointer; } /* CSS for the show answer button */ .show-answer-btn { background-color: rgb(76, 175, 80); } /* CSS for the show explanation button */ .show-explain-btn { background-color: rgb(0, 140, 186); } /* CSS for the image wrapper */ .wrapper { display: flex; flex-wrap: wrap; margin: 20px -12px; justify-content: center; } /* CSS for the image wrapper side*/ .image-wrapper.side { flex-basis: 30%; max-width: 30%; margin: 12px; position: relative; box-shadow: 0px 0px 0px #ccc; overflow: hidden; border-radius: 1px; cursor: pointer; } .image-wrapper.side:hover .overlay{ opacity: 1; } /* CSS for the image */ .image-wrapper img { display: block; max-width: 100%; height: auto; } /* CSS for the overlay */ .overlay { position: absolute; top: 0; left: 0; right: 0; bottom: 0; background-color: rgba(0, 0, 0, 0.5); color: white; display: flex; justify-content: center; align-items: center; opacity: 0; transition: opacity 0.25s ease-in-out; text-align: center; padding: 10px; font-size: 18px; } /* CSS for the image explanation */ .image-explanation { text-align: left; margin-top: 5px; padding-top: 5px; border-top: 0px solid #ccc; } /* CSS for the image explanation heading */ .image-explanation h2 { margin: 0; font-size: 24px; color: #3a3a3a; font-weight: bold; line-height: 1.3; margin-bottom: 10px; } /* CSS for the image explanation text */ .image-explanation p { margin: 0; color: #3a3a3a; font-size: 16px; line-height: 1.5; } /* CSS for the details and summary */ details { margin-bottom: 10px; } summary { font-weight: normal; font-size: 18px; cursor: pointer; color: #3a3a3a; } summary:focus { outline: none; } summary::-webkit-details-marker { display: none; } summary:before { content: "+ "; } summary[open]:before { content: "- "; } /*CSS for the questions*/ h1 { font-size: 36px; text-align: center; color: #3a3a3a; margin-bottom: 20px; } h2 { font-size: 24px; text-align: left; color: #3a3a3a; margin-top: 40px; margin-bottom: 20px; } .qa-container { margin-bottom: 20px; } .answer { font-size: 16px; text-align: left; margin-top: 20px; margin-bottom: 20px; } .explanation { font-size: 16px; text-align: left; margin-top: 20px; margin-bottom: 20px; } .show-more { font-size: 22px; text-align: center; cursor: pointer; color: #1976d2; } .show-more:hover { text-decoration: underline; } </style> </head> <body> <div class="container"> <h5>Shoulder Dislocation and Greater Tuberosity Fracture Diagnosis and Management</h5> <!-- Questions --> <div class="qa-container"> <div class="question-container"> 1. Can you provide your diagnosis for this case presented? <button class="button show-answer-btn">Show Answer</button> <button class="button show-explain-btn">Show Explanation</button> </div> <div class="question-container"> 2. How would you treat and manage this condition? <button class="button show-answer-btn">Show Answer</button> <button class="button show-explain-btn">Show Explanation</button> </div> <div class="question-container"> 3. What are the risks and complications you anticipate? <button class="button show-answer-btn">Show Answer</button> <button class="button show-explain-btn">Show Explanation</button> </div> <div class="question-container"> 4. What would you do if attempted closed reduction fails and the patient is in extended pain? <button class="button show-answer-btn">Show Answer</button> <button class="button show-explain-btn">Show Explanation</button> </div> <div class="question-container"> 5. How will you perform the shoulder reduction? <button class="button show-answer-btn">Show Answer</button> <button class="button show-explain-btn">Show Explanation</button> </div> <div class="question-container"> 6. Other than the described risk factors, what factors can also prevent closed stable reduction of the dislocation? <button class="button show-answer-btn">Show Answer</button> <button class="button show-explain-btn">Show Explanation</button> </div> <div class="question-container"> 7. The X-ray of the right shoulder, one week later, displays no humeral neck fracture but significant greater tuberosity displacement. What is your management strategy? <button class="button show-answer-btn">Show Answer</button> <button class="button show-explain-btn">Show Explanation</button> </div> <div class="question-container"> 8. Highlight the risks of non-operative management of displaced greater tuberosity fracture. <button class="button show-answer-btn">Show Answer</button> <button class="button show-explain-btn">Show Explanation</button> </div> <div class="show-more">Show More</div> </div> <!-- Image Wrapper --> <div class="wrapper"> <div class="image-wrapper side"> <img src="https://hutaifortho.com/upload/1696284132.png" alt="First image"> <div class="overlay"> <img src="https://hutaifortho.com/upload/1696284505.png" alt="Second image"> </div> <div class="image-explanation"> <h2>Anterior shoulder dislocation - AP view</h2> <p> Humeral head and glenoid surfaces are not aligned The humeral head lies below the coracoid </p> </div> </div> <div class="image-wrapper side"> <img src="https://hutaifortho.com/upload/1696284676.png" alt="Third image"> <div class="overlay"> <img src="https://hutaifortho.com/upload/1696284612.png" alt="Fourth image"> </div> <div class="image-explanation"> <h2>Anterior shoulder dislocation - Y view</h2> <p> The humeral head lies anterior to the glenoid and inferior to the coracoid process</p> </div> </div> <div class="image-wrapper side"> <img src="https://hutaifortho.com/upload/1696288330.png" alt="First image"> <div class="overlay"> <img src="https://hutaifortho.com/upload/1696288533.png" alt="Second image"> </div> <div class="image-explanation"> <h2>Anterior shoulder dislocation - Axial view </h2> <p>The humeral head surface is no longer aligned with the glenoid The humeral head lies anterior to the glenoid</p> </div> </div> </div> <!-- Details for additional images and explanations --> <details> <summary>Click here to see more</summary> <div class="wrapper"> <div class="image-wrapper side"> <img src="https://hutaifortho.com/upload/1696284132.png" alt="First image"> <div class="overlay"> <img src="https://hutaifortho.com/upload/1696284505.png" alt="Second image"> </div> <div class="image-explanation"> <h2>Anterior shoulder dislocation - AP view </h2> <p>Humeral head and glenoid surfaces are not aligned </p><p> The humeral head lies below the coracoid</p> </div> </div> <div class="image-wrapper side"> <img src="https://hutaifortho.com/upload/1696284676.png" alt="Third image"> <div class="overlay"> <img src="https://hutaifortho.com/upload/1696284612.png" alt="Fourth image"> </div> <div class="image-explanation"> <h2>Anterior shoulder dislocation - Y view </h2> <p>The humeral head lies anterior to the glenoid and inferior to the coracoid process </p> </div> </div> <div class="image-wrapper side"> <img src="https://hutaifortho.com/upload/1696208199.png" alt="First image"> <div class="overlay"> <img src="https://hutaifortho.com/upload/1696208691.png" alt="Second image"> </div> <div class="image-explanation"> <h2>Anterior shoulder dislocation - Axial view </h2> <p>The humeral head surface is no longer aligned with the glenoid The humeral head lies anterior to the glenoid</p> </div> </div> </div> </details> <!-- Script for showing/hiding answer and explanation --> <script type="text/javascript"> var showMoreBtn = document.querySelector('.show-more'); var hiddenAnswers = document.querySelectorAll('.answer.hidden'); var hiddenExplanations = document.querySelectorAll('.explanation.hidden'); function showMore() { hiddenAnswers.forEach(function(answer) { answer.classList.remove('hidden'); }); hiddenExplanations.forEach(function(explanation) { explanation.classList.remove('hidden'); }); showMoreBtn.style.display = 'none'; } showMoreBtn.addEventListener('click', showMore); // Answer and explanation text for each question var answers = [ "The X-rays show an anterior dislocation of the right shoulder with an associated greater tuberosity (GT) fracture. The complete loss of joint congruence is visible on the AP view, while the axial view shows the best demonstration of the anterior displacement. Although there is no visible evidence of fracture through the anatomical neck, this injury pattern is more appropriate for the patient's age than surgical neck fracture usually seen in an older demographic.", "The patient should be assessed according to the ATLS protocol to exclude any neurovascular injury as brachial plexus injury often occurs as part of a recognized pattern comprising the ‘terrible triad’ of shoulder. If there is suspicion of an undisplaced neck fracture, I would obtain an emergency CT to confirm and then plan for open reduction and fixation of both the neck and GT fractures. A neurovascular examination of the shoulder is necessary, and the findings must be recorded in the case notes before attempting manipulation. I would reduce the shoulder dislocation under sedation using the scapular manipulation technique, the least painful and most successful method with no reported incidences of fracture. This involves the patient lying prone with a weight applied to the arm while the tip of the scapula is rotated medially and upward. After reduction, I would immobilize the limb in a shoulder immobilizer. Anteroposterior and axial radiographs and repeat neurovascular examination would be necessary.", "During reduction, there is a risk of displacing an unseen humeral neck fracture or propagating the GT fracture through the neck. Other risks include injury to axillary nerve and artery, brachial plexus, and rotator cuff injury.", "I would consider the availability of space on the emergency list, possible neurological symptoms, patient’s pain level, and level of anesthesia risk. If safe and within a reasonable timeframe, I would take the patient for closed reduction under general anesthesia. After reduction, I would reassess the neurovascular status. If there is a new neurovascular deficit resulting from nerve entrapment, I would plan for a shoulder surgeon to explore the nerve and perform an open reduction in the morning. If there is going to be a delay in taking the patient, I would plan for emergent reduction and/or fixation by the shoulder surgeon on the next available list.", "Under complete muscle relaxation, I would use the traction/counter-traction method given that scapular manipulation failed. This is the second most effective technique, and the associated discomfort will not be felt by the anesthetized patient. Because failure of reduction may be due to head impact on the anterior glenoid, this technique also allows controlled external rotation to disengage this.", "A large rotator cuff tear or axillary nerve injury may prevent the shoulder from remaining in joint. On occasion, the long head of the biceps might get caught posterior to the humeral head and prevent reduction. Structural deficits like a bony or soft tissue Bankart lesion or Hill-Sachs lesion might also affect joint stability.", "If the greater tuberosity fragment's posterosuperior displacement is more than 5 mm, I would offer the patient reduction and fixation. Arthroscopic fixation with a double row of anchors may be possible, and it is less invasive than ORIF and has demonstrated superior postoperative range of motion.", "The risks of non-operative management of displaced greater tuberosity fracture include non-union, malunion, leading to effective narrowing of the subacromial space, mechanical impingement, and consequent rotator cuff atrophy." ]; var explanations = [ "The X-rays clearly show an anterior dislocation of the right shoulder with an associated greater tuberosity fracture. The complete loss of joint congruence is visible on the AP view, while the axial view shows the best demonstration of the anterior displacement. Although there is no visible evidence of fracture through the anatomical neck, this injury pattern is more appropriate for the patient's age than surgical neck fracture usually seen in an older demographic.", "The patient should be assessed according to the ATLS protocol to exclude any neurovascular injury. If there is suspicion of an undisplaced neck fracture, CT should be obtained to confirm and plan for open reduction and fixation of both the neck and GT fractures. A neurovascular examination of the shoulder is necessary, and the findings must be recorded in the case notes before attempting manipulation. The scapular manipulation technique is the least painful and most successful method with no reported incidences of fracture. After reduction, it is important to immobilize the limb in a shoulder immobilizer. Anteroposterior and axial radiographs and repeat neurovascular examination would be necessary.", "During reduction, there is a risk of displacing an unseen humeral neck fracture or propagating the GT fracture through the neck. Other risks include injury to axillary nerve and artery, brachial plexus, and rotator cuff injury. If reduction fails and the patient is in extended pain, general anesthesia may be needed. Additional risk factors include neurological symptoms, the level of anesthesia risk and the availability of space on the emergency list.", "If closed reduction fails, reassessment of neurovascular status would be necessary. If a new neurovascular deficit resulting from nerve entrapment is identified, a shoulder surgeon would explore the nerve and perform an open reduction in the morning. If there is going to be a delay in taking the patient, emergent reduction and/or fixation by the shoulder surgeon on the next available list is necessary.", "The traction-counter traction method is the second most effective technique after scapular manipulation. It allows for complete muscle relaxation and controlled external rotation to disengage a glenoid dislocation. It is associated with less discomfort for the anesthetized patient.", "A bony or soft tissue Bankart or Hill-Sachs lesion may also affect joint stability and prevent closed reduction of the dislocation. A large rotator cuff tear or axillary nerve injury may also be factors. On occasion, the long head of the biceps might get caught posterior to the humeral head and prevent reduction.", "If the greater tuberosity fragment's posterosuperior displacement is more than 5 mm, reduction and fixation may be necessary. Arthroscopic fixation with a double row of anchors may be possible and has shown to have superior postoperative range of motion than ORIF. Non-union, malunion, narrowing of the subacromial space, mechanical impingement, and rotator cuff atrophy are the risks of non-operative management." ]; // Hide explanation text initially var explanationText = document.querySelectorAll('.explanation'); explanationText.forEach(function(explanation) { explanation.classList.add('hidden'); }); // Show answer and explanation on button click var showAnswerBtns = document.querySelectorAll('.show-answer-btn'); var showExplainBtns = document.querySelectorAll('.show-explain-btn'); showAnswerBtns.forEach(function(button, index) { button.addEventListener('click', function() { this.parentElement.innerHTML += "<div class='answer'>" + answers[index] + "</div>"; }); }); showExplainBtns.forEach(function(button, index) { button.addEventListener('click', function() { this.parentElement.innerHTML += "<div class='explanation hidden'>" + explanations[index] + "</div>"; }); }); </script> </div> </body> </html>