- Discussion:
- pt w/
anterior dislocation keep affected arm at side of body in external rotation;
- shoulder will loose its usual roundness and will be full anteriorly to palpation;
-
axillary nerve f(x) should be documented;
- rotator cuff is frequently damaged & should be examined after reduction;
- determine direction and degree of instability;
- Rotatory Stress Test:
- test begins on normal side;
- w/ the arm supported in the surgeon's axilla, and one han translates the shoulder anteriorly;
- the shoulder is then abducted and externally rotated;
- the shoulder is again translated anteriorly;
- w/ a normal inferior glenohumeral ligament, anterior translation should decrease markedly;
- Lateral Decubitus - Load and Shift Test: (JP Tasto MD.
The Physician and Sportsmedicine. Vol 26. No 12. Dec 1998. p 75);
- patient is placed in the lateral decubitus position with the injured shoulder up;
- physician stands behind the patient, and immobilizes the elbow between his/her chest and arm which
is hooked around the patients elbow (this hand can alterantively grasp the lower arm for loading);
- the surgeon's free hand is used to perform the anterior / posterior drawer test;
- Sulcus Sign:
- felt to be pathognomonic of
multidirectional instability.
- look for prominent depression below acromion when inferior traction is applied to wrist;
- Anterior Apprehension Sign: (for anterior instability)
- this test has been criticized for being unreliable;
- pts w/ anterior instability may demonstrate loss of external
rotation w/ arms at 90 deg position secondary to apprehension;
- apprehension sign is manifested by guarding and apprehension when the arm is placed and stressed in a provocative position;
- one technique involves having the patient abduct and externally rotate the shoulder while
placing his/her palm against a wall;
- the physician then grabs the shoulder w/ one hand and applies an anterior drawer test
w/ the other hand;
- Posterior Apprehension Sign:
- the patient attempts to touch the low thoracic spine (which places the shoulder in internal rotation
and adduction), and then a posterior drawer test is applied;
- a similar test can be performed with the shoulder in flexion, adduction, and internal rotation;
- Exam the Subscapularis:
- about 5% of shoulders that have had an anterior dislocation will sustain a significant injury to
the subscapularis, which will contribute to further instability;
- Arterial Injuries:
- vascular damage at time of reduction occurs primarily in the elderly,
particularly when an old
Anterior Dislocation is mistaken for acute
injury, and closed reduction is performed;
- artery may not withstand traction forces required to reduce an old dislocation;
Classification and physical diagnosis of instability of the shoulder.
Diagnosis of shoulder instability by examination under anesthesia.
Clinical use of the olecranon-manubrium percussion sign in shoulder trauma.
