uxación Glenohumeral

DR. OCIEL ACOSTA ESCALONA

CURSO CIRUGIA ARTICULAR Y ARTROSCOPIA
15/ABR/20
Anatomía
 Hombro

A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
 Cabeza humeral
• Radio de curvatura promedio 24mm (19-
28mm)
• Angulo cervico diafisiario 130˚-140˚
• Retroversion 30˚ eje tranespicondilar
• Excentrica 9mm posterior al eje neutro
• 30% cartilago se articula con la glenoides
A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
 Glenoides
• Forma de pera AP 2.5mm SP 9mm
• Inclinación superior de 5
• Retroversión de 7˚ perpendicular al plano de la
escápula
• Área de superficie 1/3 parte de la cabeza humeral
• Estabilidad aumentada por cartílago y labrum

A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
 Labrum glenoideo
• Aumenta un 50% la profundidad de la glenoides
• Compresión de concavidad
• Presión negativa intraarticular
• Sitio de inserción de los ligamentos
glenohumerales al borde glenoideo
• Parachoques antideslizante
R. Lugo, P. Kung, C. B. Ma, (2008), Shoulder biomechanics, European journal of Radiology 68, pp 16-24
 Acromion
• Aproximadamente 7 a 8 mm de profundidad
con la cabeza humeral
• Estabilidad para el ligamento coracoacromial y
acromioclavicular para dar estabilidad

A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
 Clavícula
• Actúa como un puntal de donde se suspende
la articulación glenohumeral
• Antagoniza la acción del pectoral mayor y
trapecio para evitar la medialización de la
articulación

A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
D.J.Magee, (2014), Shoulder Chapter 5, Orthopedic Physical assesment , 6th edition, pp. 252-387
D.J.Magee, (2014), Shoulder Chapter 5, Orthopedic Physical assesment , 6th edition, pp 252-387
 Músculos
• Mango rotador
– Supraespinoso
– Infraespinoso
– Subescapular
– Redondo menor

A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
R. Lugo, P. Kung, C. B. Ma, (2008), Shoulder biomechanics, European journal of Radiology 68, pp 16-24
 Ligamentos
• Extracapsulares
– Coracoacromial
– Coracoclavicular
• Intracapsulares
– Complejo ligamento glenohumeral
• Superior
• Medio
• Inferior
– Coracohumeral
A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
R. Lugo, P. Kung, C. B. Ma, (2008), Shoulder biomechanics, European journal of Radiology 68, pp 16-24
R. Lugo, P. Kung, C. B. Ma, (2008), Shoulder biomechanics, European journal of Radiology 68, pp 16-24
 Intervalo de los rotadores
• Deficiente inestabilidad inferior
• Disminuye la presión intraarticular en rotación
interna

R. Lugo, P. Kung, C. B. Ma, (2008), Shoulder biomechanics, European journal of Radiology 68, pp 16-24
D.J.Magee, (2014), Shoulder Chapter 5, Orthopedic Physical assesment , 6th edition, pp. 252-387
Biomecánica
 Estabilizadores estáticos
– Cabeza humeral
– Glenoides
– Labrum glenoideo
– Complejo ligamentario glenohumeral
– Ligamento coracohumeral

A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
 Estabilizadores dinámicos
– Manguito rotador
– Bíceps
– Posición de la escápula
– Deltoides

A. J. Felstead, D. Ricketts., (2017), Biomechanics of the shoulder and elbow, Orthopaedics and trauma 31:5, Elsevier, pp. 300-305
 Ritmo escapulotorácico
• Relación de articulación glenohumeral con la
articulación escapulotorácica
• 2:1
• Inestabilidad multidireccional aumentado
• Pinzamiento o desgarro de manguito de
rotador disminuido
R. Lugo, P. Kung, C. B. Ma, (2008), Shoulder biomechanics, European journal of Radiology 68, pp 16-24
D.J.Magee, (2014), Shoulder Chapter 5, Orthopedic Physical assesment , 6th edition, pp. 252-387
M.M. Lefevre-Colau, et. al., (2018) Recent advances in kinematics of the shoulder complex in helathy people, Annals of Physical and Rehabilitation Medicine 61, pp 56-59.
M.M. Lefevre-Colau, et. al., (2018) Recent advances in kinematics of the shoulder complex in helathy people, Annals of Physical and Rehabilitation Medicine 61, pp 56-59.
D.J.Magee, (2014), Shoulder Chapter 5, Orthopedic Physical
assesment , 6th edition, pp. 252-387
Luxación Anterior
 Características
• 90%
• Trauma
• Rotación interna, abducción, fijado con el otro brazo
• Signo de charretera
• Resultado de:
• Fuerza de abducción y rotación externa
• Posterior a anterior en parte proximal de humero
R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert
and Hedge`s Clinical procedures in emergency Medicine and acute care, (2019), pp 980-
1026
Radiografía
Y de escápula
Axilar
R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert and Hedge`s Clinical procedures in emergency Medicine and
acute care, (2019), pp 980-1026
Luxación posterior
 Características
• 2 a 5%
• Trauma (67%), convulsiones (31%),
electrocución (2%)
• Inmovilizado en rotación interna y adducción
• Fuerza aplicada directamente posterior en el
hombro en flexión
R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert and Hedge`s Clinical procedures in emergency Medicine and
acute care, (2019), pp 980-1026
R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert and Hedge`s Clinical procedures in emergency Medicine and
acute care, (2019), pp 980-1026
AP
Oblicua
Y escápula
Axilar
J. Paul, S. Buchmann, K. Beitzel, O. Solovyova, A. B. Imhoff, (2011), Posterior Shoulder Dislocation : Systematic review and treatment algorithm, Arthroscopy: The Journal
of Arthroscopy and Related Surgery, Vol. 17, No. 11, pp 1562-1572.
Luxación inferior (erecta)
 Características
• Menos del 1%
• Trauma de alta energía
• En posición de abducción
• Cabeza humeral en el área infraglenoidea
R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert and Hedge`s Clinical procedures in emergency Medicine and
acute care, (2019), pp 980-1026
AP
M. Banaie, A. Baratloo, (2020), A traumatic inferior shoulder dislocation; two-stepmaneuver for closed reduction, Visual Journal of
Emergency Medicine 18
Complicaciones
R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert
and Hedge`s Clinical procedures in emergency Medicine and acute care, (2019), pp 980-
1026
R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert and Hedge`s Clinical procedures in emergency Medicine and acute care, (2019), pp
980-1026
 Humero
• Lesión Hill Sachs
• Si compromete 25% o mas se recomienda uso
de injerto óseo

R. Lugo, P. Kung, C. B. Ma, (2008), Shoulder biomechanics, European journal of Radiology 68, pp 16-24
R. Lugo, P. Kung, C. B. Ma, (2008), Shoulder biomechanics, European journal of Radiology 68, pp 16-24
 Glenoides
• Una pérdida de mas del 21% S-I causará
inestabilidad
• Una pérdida del 25% anterior se recomienda
procedimiento quirúrgico

R. Lugo, P. Kung, C. B. Ma, (2008), Shoulder biomechanics, European journal of Radiology 68, pp 16-24
Tratamiento conservador
 Bloqueo plexo braquial

M. Kaya, S. Eksert, S. Akay, A.Kantemir, (2017)Interscalene or suprascapular block in patient with shoulder dislocation, American Journal of Emergency Medicine 35, pp
195.e1-195.e3
 Bloqueo nervio supraescapular

M. Kaya, S. Eksert, S. Akay, A.Kantemir, (2017)Interscalene or suprascapular block in patient with shoulder dislocation, American Journal of Emergency Medicine 35, pp
195.e1-195.e3
 Infiltración

R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert and Hedge`s Clinical procedures in emergency Medicine and
acute care, (2019), pp 980-1026
Maniobras de reducción
 Anterior

M. Gottlieb, (2019), Shoulder dislocations in the emergency department: A comprehensive review of reduction techniques, The Journal of
Emergency Medicine, pp 1-20.
M. Gottlieb, (2019), Shoulder dislocations in the emergency department: A comprehensive review of reduction techniques, The Journal of
Emergency Medicine, pp 1-20.
 Posterior

M. Gottlieb, (2019), Shoulder dislocations in the emergency department: A comprehensive review of reduction techniques, The Journal of
Emergency Medicine, pp 1-20.
M. Gottlieb, (2019), Shoulder dislocations in the emergency department: A comprehensive review of reduction techniques, The Journal of
Emergency Medicine, pp 1-20.
 Inferior

M. Gottlieb, (2019), Shoulder dislocations in the emergency department: A comprehensive review of reduction techniques, The Journal of
Emergency Medicine, pp 1-20.
 Control postreducción

R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert and Hedge`s Clinical procedures in emergency Medicine and acute care, (2019), pp
980-1026
R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert and Hedge`s Clinical procedures in emergency Medicine and acute care, (2019), pp
980-1026
 Cuidados postreducción
• Adducción y rotación interna
• Abducción y rotación externa
• Mayores de 60 de 5 a 7 días
• Pacientes mas jóvenes 3 semanas
Inmovilización
 Rotación interna

R.M. Naples, J.W. Ufberg, Management of common dislocations; Chapter 49, Robert and Hedge`s Clinical procedures in emergency Medicine and acute care, (2019), pp
980-1026
E. Itoi et.al., (2007), Immobilization in External Rotation After Shoulder Dislocation Reduces the Risk
of Recurrence. A Randomized Controlled Trial, J Bone Joint Surg Am ;89: pp 2124-2131.
J.C. Murray, A. Leclerc, A. Balatri, S. Pelet, (2020), Immobilization in external rotation after
primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized
controlled trial, Orthopaedics & Traumatology: Surgery & Research 106, pp 217–222
J.C. Murray, A. Leclerc, A. Balatri, S. Pelet, (2020), Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young
patients. A randomized controlled trial, Orthopaedics & Traumatology: Surgery & Research 106, pp 217–222
J.C. Murray, A. Leclerc, A. Balatri, S. Pelet, (2020), Immobilization in external rotation
after primary shoulder dislocation reduces the risk of recurrence in young patients. A
randomized controlled trial, Orthopaedics & Traumatology: Surgery & Research 106, pp
217–222
J.C. Murray, A. Leclerc, A. Balatri, S. Pelet, (2020), Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young
patients. A randomized controlled trial, Orthopaedics & Traumatology: Surgery & Research 106, pp 217–222
J-T. Kao, et al., (2018) Incidence of recurrence after shoulder dislocation:
a nationwide database study, J Shoulder Elbow Surg 27, pp. 1519–1525

Tasas de recurrencia
Tiempo de inmovilización
W.H. Paterson, et.al., (2010), Position and Duration of Immobilization After
Primary Anterior Shoulder Dislocation A Systematic Review and Meta-Analysis
of the Literature, J Bone Joint Surg Am. 92: pp 2924-33.
W.H. Paterson, et.al., (2010), Position and Duration of Immobilization After Primary Anterior Shoulder Dislocation A Systematic Review and Meta-Analysis of
the Literature, J Bone Joint Surg Am. 92: pp 2924-33.
W.H. Paterson, et.al., (2010), Position and Duration of Immobilization After Primary
Anterior Shoulder Dislocation A Systematic Review and Meta-Analysis of the
Literature, J Bone Joint Surg Am. 92: pp 2924-33.
W.H. Paterson, et.al., (2010), Position and Duration of Immobilization After Primary
Anterior Shoulder Dislocation A Systematic Review and Meta-Analysis of the
Literature, J Bone Joint Surg Am. 92: pp 2924-33.
Tratamiento quirúrgico
 Tradicional Vs Cirugía

A.Kirkley, R. Werstine, A. Ratjek, S. Griffin, (2005), Prospective Randomized Clinical Trial Comparing the Effectiveness of Immediate
Arthroscopic Stabilization Versus Immobilization and Rehabilitation in First Traumatic Anterior, Arthroscopy: The Journal of Arthroscopic and
Related Surgery, Vol 21, No 1: pp 55-63 Dislocations of the Shoulder: Long-term Evaluation
 Abierto VS Artroscópico
• El objetivo general de tratamiento: Reparar complejo capsulo
ligamentario para restaurar la estabilidad glenohumeral
• Abierto (GS)
– Debilidad muscular
– Osteoartrosis
– Restricción de movimiento glenohumeral
• Artroscopico
– Sutura transglenoidea 49%
– Tachuela de fijación bioabsorbible 23%
– Anclas (GS) y plicación capsular 8 y 11%
E, Hohmann, K. Tetsworth, V. Glatt, (2017), Open versus arthroscopic surgical treatment for anterior shoulder dislocation: a comparative systematic review and meta-
analysis over the past 20 years, J Shoulder Elbow Surg 26, 1873–1880
U. G. Longo, et. al., (2014), Latarjet, Bristow, and Eden-Hybinette Procedures for Anterior
Shoulder Dislocation: Systematic Review and Quantitative Synthesis of the Literature,
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30, No 9: pp 1184-1211
J. Paul, et. al., (2011) Posterior Shoulder Dislocation: Systematic Review and
Treatment Algorithm, Arthroscopy: The Journal of Arthroscopic and Related Surgery,
Vol 27, No 11: pp 1562-1572.
 • Tejidos blandos
– Inestabilidad posterior en ausencia de lesiones óseas
– Fijación artroscópica de la lesión del labrum (GS)
• Injerto óseo (25-40% Hill Sachs)
– Tornillos bioabsorbibles de transferencia
– Injerto óseo autólogo
• Reconstrucción no anatómica
– Transferencia tendón/músculo (McLaughlin) (GS)
• Subescapular
• Osteotomía rotacional de húmero
• Artroplastía
J. Paul, et. al., (2011) Posterior Shoulder Dislocation: Systematic Review and
Treatment Algorithm, Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 11: pp 1562-1572.
Rehabilitación
A.Kirkley, R. Werstine, A. Ratjek, S. Griffin, (2005), Prospective Randomized Clinical Trial Comparing the
Effectiveness of Immediate Arthroscopic Stabilization Versus Immobilization and Rehabilitation in First
Traumatic Anterior, Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 21, No 1: pp 55-63
Dislocations of the Shoulder: Long-term Evaluation

• Estadio 1: Movimiento activo asistido, semana 4 a 6, rotación

externa limitada a 20
• Estadio 2: Ejercicios isometricos, semana 7 a 8, rotación
externa a 45
• Estadio 3: Ejercicios isotonicas, semana 9 a 12, rangos de
movimiento activos completos
• Regreso al deporte en 3 meses
• Semana 16 actividad deportiva completa como sea tolerada
J. Paul, et. al., (2011) Posterior Shoulder Dislocation: Systematic Review and Treatment
Algorithm, Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 11: pp
1562-1572.

• Posición neutra con inmovilizador de hombro

• 6 semanas
• Fisioterapia 1er día postquirúrgico movimientos activos asistidos
por 3 semanas
• A las 6 semanas abducción a 90º, flexión 60º rotación interna 60º,
rotación externa libre.
• Rango de movimiento completo a las 9 semanas
• Movimientos por arriba de la cabeza y deportes de contacto 6 a 9
meses posterior a cirugía