This is the terminology given to those who dislocate the shoulder joint. Some individuals don’t dislocate as such but get an insecure feel of shoulder coming out of the joint anteriorly (front) on performing certain movements.
A severe injury, or trauma, is often the cause of an initial shoulder dislocation. During the injury, usually the shoulder comes out in the front as a result of a forceful manoeuvre that resulted in extreme sideward elevation of the arm combined with the outwards rotation of the arm. (Medically called as Abduction and External rotation). This puts the structures in the anterior aspect of the shoulder joint in extreme stress and when the stress level exceeds their capacity to withstand it gives away and shoulder joint loses the stability and dislocates.
The shoulder is the most moveable joint in our body. This has given an ability for the shoulder joint to perform lot of function above the level of head and also in sporty activities such as throwing, bowling, swimming etc. But the downside of this is that the shoulder can also dislocate. Normally the shoulder dislocation is prevented by ligaments, capsules and muscles surrounding it. But during a sporting injury the ligaments in the front of the shoulder joint can rupture and lead on to dislocation. Often the ruptured ligaments in the front of the shoulder joint does not heal and hence results in recurrent episodes of shoulder dislocation. Sometimes even repetitive activity above the level of the head can strain these ligaments (that is the ligament will elongate and become lax). This can cause subtle anterior shoulder instability but not real dislocation.
Once a shoulder joint dislocates, it loses the stability normally offered by the ligaments, hence it is vulnerable to dislocate repeatedly. Number of pathologies has been identified in recurrent shoulder dislocation. The successful treatment depends on identifying the exact nature of the pathology. The pathologies are described in relation to the structure inside the shoulder joint that got injured while the shoulder dislocated.
The key structures that can be injured while a shoulder dislocates anteriorly (in the front) are:
The commonest injury of all the above is to Glenoid labral attachment of the Inferior glenohumeral ligament (Bankart lesion). But it is important to keep in the mind the possibility of other structure injury while treating this condition.
Acute dislocation: Initial treatment consists of relocating the shoulder joint in place. This should be performed as an emergency procedure under sedation (injection to make you to sleep). A correct manoeuvre to manipulate the shoulder would relocate the joint. Once the joint is in place, the pain relief is tremendous. A check X ray will confirm that the shoulder is relocated. A rest in sling for 2-3 weeks and then mobilising the shoulder is the usual mode of treatment.
Recurrent Dislocaiton:The treatment requires surgery. The aim of the surgery is to fix the ruptured structure usually the Bankart lesion. The surgery is called Anterior shoulder stabilisation surgery. This is usually performed through small stab incisions with the help of arthroscope. Occasionally, some of the injury character may necessitate an open surgery.
We also ensure that the whole team is included in process and that no one is left out during the turnaround. The most crucial part is ensuring some degree of financial stability.
Frozen shoulder probably would get better over time. But this could take up to 3 years. It is essential to start some exercises in order to get movements. Anti inflammatory medications and injection into the shoulder joint with steroid can give short-term moderate relief.
Stretching, Massaging and Range of motion exercises under the supervision of a trained physiotherapist will be much useful in the management of this condition.
Those who do not improve with physiotherapy a surgical procedure called Arthroscopic capsular release with manipulation of shoulder can improve the condition. After surgery, all of them need physiotherapy to preserve the range of motion that was acquired during surgery. The total recovery of the condition could be as long as 6 months despite having a surgery.
We also ensure that the whole team is included in process and that no one is left out during the turnaround. The most crucial part is ensuring some degree of financial stability.
This will be the procedure of choice in those who dislocate the shoulder recurrently as a result of anterior structures damage and also fracture in the back of the humeral head. If there is fracture in the back of the upper arm bone, then it is called as Hill sach lesion. This lesion pivots around the glenoid margin while doing outward rotation movement of the shoulder. Hence dislocation occurs recurrently.
Elective patients may be suitable for an arthroscopic surgery even in the presence of Hillsach defect. In such patients after doing anterior stabilisation surgery as mentioned above, the remplissage procedure helps in preventing further dislocations.
The principle of remplissage surgery is to fill the gap of the hillsach lesion with the rotator cuff muscle. Hence it will act as a physical restraint when the provocative manoeuvres for dislocation are undertaken.
The procedure is performed as an arthroscopic procedure. Tiny stab incisions of less than 1cm are made around the shoulder joint. Initial anterior shoulder stabilisation is done. Then the camera is focussed on the hill sach lesion. The hill sach lesion can be easily made out as a dent in the back of the head of the arm bone (Posterolateral aspect). The dent is freshened with the help of mini tubular 4.2mm shavers and bone edges are burred with a special burr. Usually over the hill sach lesion one could visualise the infraspinatus muscle (a part of rotator cuff muscle). With a miniature drill two small holes are made in the dent. Absorbable screws with fibre wire are fixed in these holes. The fibrewires attached to these holes are retrieved through the infraspinatus muscle and the knot is applied to fix the infraspinatus muscle to the hill sach lesion.
Immediately after the procedure, a sling will be given to rest the arm. The movements that can put tension on the repaired structures are prevented for a duration of 4 – 6 weeks. Further to that the movements are encouraged. A systematic physiotherapy programme will be initiated to get the full function back.
The arthroscopic procedure is pretty safe. The pain is minimal as the procedure is done through tiny stab incisions. Infection, chondral damage, nerve damage is possible complications but the reported incidences are rare.
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