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Shoulder Anatomy

  1. Four rotator cuff muscles are — supraspinatus, infraspinatus, subscapularis and teres minor
  2. The tendon of rotator cuff muscles blend with the joint capsule and form a musculo tendinous collar that  
  3. surrounds the posterior, superior, and anterior aspect of gleno- humeral joint.
  4. The inferior part of shoulder joint capsule is the weakest area
  5. Rotator interval is interval between leading edge of supraspinatous and superior edge of subscapularis. Coracohumeral ligament passes with in rotator interval.
  1. Position of arm in shoulder dislocation
    1. Anterior Dislocation (Preglenoid, Subcoracoid, Subclavicular type) Abduction and external rotation & internal rotation is restricted
    2. Posterior Dislocation Difficult to diagnose because the patient may have normal contour of shoulder. Holds injured shoulder in internal rotation & examiner cannot externally rotate it.
    3. Inferior Dislocation (Luxatio erecta / Subglenoid) Locked in full abduction / elevation, fixed almost by the side of head.  
  2. Mode Of Injury Causing Shoulder Dislocation
    1. Recurrent Anterior Dislocation - Abduction & External rotation force
    2. Posterior dislocation - Indirect force producing marked internal rotation & adduction
    3. Inferior dislocation - Severe hypera bduction force
  3. Anterior Dislocation of Shoulder
    1. Clinical Feature




Hill Sach lesion
  1. Reproduction of patient’s symptom in a position of abduction, external rotation and extension.
  2. Normal round contour of shoulder is lost & it becomes flat.
  3. Fullness/bulge is seen below clavicle
  4. Dugas test: It is not possible for the patient to bring the elbow close to the body & put the hand on his opposite shoulder.
  5. Callaway’s Test: In dislocation vertical circumference of axilla is increase compared to the normal side.
  6. Hamilton ruler test :Because of flattening of shoulder, it is possible to place a ruler on the lateral side of arm and it touches acromian & lateral condyle of humerus simultaneously (in normal it would not d/t shoulder contour).
  7. A -P X-ray show overlapping shadow of humeral head & glenoid fossa; and lateral view show humeral head Out of line with the socket.
Extra Edge
  1. Recurrent dislocation is most common in shoulder joint, accounting for nearly 50% of all dislocations.
  2. Anterior shoulder dislocation of subcoracoid type is most common type of shoulder dislocation
  1. Management
    1. Commonly used reduction techniques are stimson’s gravity method, Hippocratic method and Kocher’s method.
    2. Reduction, in general (by Kochers method) is done by increasing the deformity the by traction and then doing opposite movements.
    3. So the steps of reduction are traction in slight abduction &external rotation to increase deformity followed by adduction and internal rotation.
    4. In stimson’s method patient is left prone with the arm hanging over the side of bed Thus weight of limb helps in reduction.
    5. In Hipprocatic method, gently increasing traction & counter traction is applied.

  1. Two major lesions in patients with Recurrent Anterior Dislocation
    1. Bankart lesion
      Bankart described the essential lesion as stripping of fibrocartilagenous labrum from anterior glenoid which did not heal. 
    2. Hill- Sachs Lesion
      1. It is compression fracture of the postero lateral articular surface of humeral head (more specifically on superior aspect). These “defects are often referred to as “impression fractures”.
      2. In anterior dislocation these defects are created on the posterolateral aspect of humeral head & referred to as Hill Sachs lesion. And in posterior shoulder dislocation these defects are created on anteromedial aspect of humeral head and referred to as reverse Hill Sachs lesion.
Differences between recurrent & non-recurrent anterior dislocation
Feature Recurrent Non recurrent
Mean age Early 20s Late 40s
Mode of injury Occurs with minimal trauma and reduction may be accompalished with much less effort Caused by severe trauma with increased probability of associated injuries
a. Bankarts lesion i.e. stripping (tear) of labrum
Common (50 - 100%)

Uncommon (20 - 30%)
b. Hill- Sachs lesion Common(50 - 100%) Uncommon (20 - 30%)

c. Redundant (loose) capsule Common


d. Rupture of anterior capsule Uncommon (10 - 20%) Common
Associated Injuries
a. Nerve injury
b. Rotator cuff injury
c. Fracture neck of humerus
d. Fracture of coracoid
e. Fracture of tubercle
Rare Common


Extra Edge

  1. Most common early complication of anterior dislocation of shoulder is nerve injury
  2. Most commonly injured nerve in anterior dislocation of shoulder is circumflex branch of axillary nerve.
  3. The higher frequency of circumflex nerve injury is accounted for by the short fixed course of the nerve round
  4. The humerus which makes it difficult to escape traction when the humerus is displaced forwards.
  5. Loss of axillary nerve function results in denervation of deltoid muscle (extension lag sign) & teres minor, and
  6. Loss of sensation over proximal lateral aspect of arm (regimental batch area).
  1. Recurrent Dislocation of Joints
    1. Commonly involved joints
      1. Shoulder(most common) 
      2. Patella (2nd most common) 
      3. Ankle joint has least chances of recurrent dislocation because the talus cannot be completely dislocated from the joint unless all ligaments are torn. 

Acronyms for Types of Recurrent Shoulder (Glenohumeral) Instability

  1. TUBS
    1. Traumatic
    2. Unidirectional instability
    3. Bankart lesion
    4. Surgery is often necessary
  2. “AMBRI”
    1. Atraumatic
    2. Multidirectional instability
    3. Bilateral
    4. Rehabilitation is the primary mode of treatment.
    5. Inferior capsular shift is often performed if surgery is indicated.
  1. Posterior Dislocation of Shoulder
    1. Mechanism of Injury - Indirect force producing marked internal rotation& adduction, most commonly during a fit, convulsion or an electric shock.
    2. Fall on to the flexed, adducted arm, a direct blow to front of shoulder or a fall on out stretched hand.
    3. Clinical Presentation
      1. Diagnosis is frequently missed because patient may have normal contour to the shoulder
      2. AP X-ray  may look almost normal.

Electric bulb sign
Reverse Hill Sach Lesion
Mnemonic RAMP= Reverse Hill sack, Antero Medial humeral head defect, Mc Laughing lesion and surgery, Posterior dislocation
  1. The classical clinical feature is arm is held in medial rotation and is locked in that position, and an examiner can not externally rotate it.
  2. The front of shoulder may look flat with a prominent coracoid, but swelling may obscure this deformity.
  3. Investigation -In A-P X-ray due to medial rotation head looks abnormal (electric bulb sign) & it stands away some what from glenoid fossa (empty glenoid sign). 
  1. Inferior Dislocation of Shoulder
    1. It is caused by severe hyper abduction force. • It is rare and also called luxatio erecta because the humeral head is subluxated (dislocated inferiorly and humerus shaft points upwards (erected). 
    2. The patient comes with his arm fixed almost by the side of his head. 
    3. Potentially serious consequences eg neurovascular damage is quite common-Axillary nerve is the commonest nerve involved. 
    4. Reduced by pulling upwards in the line of abducted arm with countertraction downwards. 
  2. Tests For Instability
    1. Apprehension test, fulcrum test, crank test, Jobes relocation test, and surprise testsQ are provocative tests to evaluate anterior shoulder instability. 

Load and shift test

Jerk test

Sulcus test
  1. In contrast jerk test is a provocative maneuver for posterior gleno humeral instability. 
  2. Although it is generally used to test for inferior instability (laxity), the sulcus test is also positive in many patients with multidirectional instability.

Luxatio erecta: Inferior dislocation: solute position

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