Free Health Dissertations - Following Reduction In The Young Person Immobilisation In A Sling (though
Following reduction in the young person immobilisation in a sling (though controversial) may be recommended for up to six weeks because of the greater risk of recurrent dislocation. In the elderly a post reduction sling is only necessary for one week. Mobilisation is important thereafter.
The Hippocratic traditional method of reduction is recommended as safe, though it does risk axillary nerve damage. The patient is supine. An assistant restrains the axilla with a sling. The operator pulls the arm in a position of 30 degrees abduction.
Stimson’s technique is a gentle modification. Using analgesia is used to reduce muscle spasm the patient lies prone hanging the affected arm over the side of the bed. When the patient tries to relax the shoulder should reduce. A weight in the hand may help. High success rates 90% at first attempt are achievable. Kocher’s technique involving more active manipulation is not recommended due to the risks of nerve damage and fracture.
Posterior dislocation
This is most often due to forced internal rotation of an abducted arm. Direct impact to the anterior aspect of the shoulder can also cause it as can electrocution and seizures. Posterior dislocations are harder to diagnose and may become recurrent due to ligamentous laxity. (Inferior dislocation is very unusual but can occur with an extreme abducting force.)
The shoulder contour is abnormal with a posterior swelling. The shoulder is locked in internal rotation. A posterior (as opposed to anterior) dislocation is harder to diagnose on X-Ray and may be missed. An AP film typically shows a lightbulb sign where the humeral head can be clearly outlined (in health it is obscured). The AP film will not reveal the abnormal position a lateral view is needed). Reduction is by pulling the arm and laterally rotating it. A sling is used for 1-2 weeks then active movements commenced. It is necessary to avoid combined abduction and lateral rotation for at least 3 weeks.
Recurrent dislocation
Five percent are not due to trauma but occur in teenagers with lax joints. Ninety-five percent are due to trauma often from a Bankart lesion. Some argue that post reduction immobilisation does not influence recurrence risk. The joint may dislocate easily the patient becoming apprehensive on movements which predispose to dislocation.
MRA and arthroscopy are useful in recurrent dislocation. Where the joint has dislocated for a third time surgical correction may help especially if the shoulder is painful or slips slightly out of its socket. For recurrent anterior dislocation the capsule may be repaired. The Bankart operation involves inserting anchors into the bone upon which to tie the ligaments. This has a 90% success rate against further dislocation. If the ligament is overly stretched it is double breasted to shorten it in the capsular shift operation. Following surgery the shoulder should not be rotated outwards for at least three weeks.
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