Posterior Subluxation Shoulder

  • Posterior dislocation of the shoulder

Reduction should be attempted soon (e.g., within 30 minutes) after diagnosis of an acute closed posterior shoulder dislocation. However, because posterior dislocations are rare, difficult to reduce, and often complicated by concomitant shoulder injuries (see Contraindications, below), it is recommended that an orthopedic surgeon be consulted before reduction. Associated neurovascular deficit, which is rare in posterior shoulder dislocation, warrants immediate reduction. Open dislocations require surgery, but closed reduction techniques and immobilization should be performed as transitional treatment when an orthopedic surgeon is unavailable and a neurovascular deficit is present. The diagnosis of posterior shoulder dislocation is often made late (sometimes weeks to months after the precipitating event). Delayed closed reduction attempts can be difficult and unsuccessful but are usually recommended (if the dislocation is <3 weeks old) and should include generous procedural sedation and analgesia. Contraindications to simple closed reduction:

  • Fracture of the greater tuberosity with a displacement of > 1 cm.
  • Reverse Hill-Sachs deformity (> 20% deformity of the humeral head due to impaction against the glenoid rim).
  • Surgical neck fracture (below the greater and lesser tuberosity)
  • Bankart fracture (posterior-inferior glenoid margin) with a bone fragment greater than 20% and with glenohumeral instability.

These significant fractures require orthopedic evaluation and treatment because of the risk that the surgery itself will increase the deformity and severity of the injury.

  • Neurovascular injuries that are unusual because of the anterior location of the neurovascular bundle
  • Fractures of the humeral head, glenoid rim, and greater and lesser tuberosity secondary to forcible reduction and manipulation
  • Increased displacement of fractures and aggravation of associated injuries
  • Luxation arthropathy, adhesive capsulitis, stiffness, and chronic pain that are consequences of late diagnosis rather than reduction
  • A bed sheet
  • Intra-articular anesthetic: 20 ml 1% lidocaine, 20-ml syringe, 2-inch 20-gauge needle, antiseptic solution (e.g., chlorhexidine, povidone iodine), gauze swab
  • Required materials and personnel for procedural sedation and analgesia (PSA).
  • Shoulder orthosis or sling and drape

One or two assistants are required.

  • Because posterior shoulder dislocations are rare (< 4% of shoulder dislocations) and often diagnosed late, an orthopedic surgeon should be consulted before reduction.
  • Findings on anteroposterior radiographs may be unremarkable. A Y-view of the shoulder joint or an axillary radiograph should be obtained. If the dislocation is unclear on the x-ray, a CT scan should be performed. A CT may also be needed to diagnose a surgical neck fracture or other fracture or for surgical planning.
  • The luxated humeral head may be jammed against the posterior lip of the glenoid fossa; therefore, reduction requires both distraction and reduction of the humeral head.
  • Place the patient supine on the stretcher. Raise the stretcher to the level of your pelvis; lock the wheels of the stretcher.
  • Stand on the affected side of the patient at abdominal level.
  • Have an assistant stand on the opposite side, somewhat at shoulder level to the patient.

Neurovascular examination Perform a neurovascular examination of the affected arm before the procedure, and repeat this examination after each reduction attempt. In general, testing motor function is more reliable than testing sensation, in part because cutaneous nerve areas may overlap. Assess the following:

  • Distal pulses, recapillarization, cool extremity (axillary artery).
  • Mild tenderness on the lateral aspect of the upper arm (axillary nerve), on the ball of the hand and thumb (median and ulnar nerves), and on the dorsum of the first interdigital space (radial nerve)
  • Abduction of the shoulder against resistance while palpating the deltoid muscle for contraction (axillary nerve): however, if this test aggravates the patient’s pain, it should not be performed until after the shoulder has been reduced.
  • Bringing the thumb and index finger together (“OK” gesture) and flexing the fingers against resistance (median nerve).
  • Finger abduction against resistance (ulnar nerve)
  • Wrist and finger extension against resistance (radial nerve)

Analgesia Administer analgesics. Intra-articular injection of a local anesthetic is usually the best choice. Procedural sedation and analgesia (PSA) is also usually required. Intra-articular analgesia:

  • The needle insertion is made approximately 2 cm below the lateral edge of the acromion process (into the depression created by the absence of the humeral head).
  • Dab the site with an antiseptic solution and allow the antiseptic solution to dry for at least 1 minute.
  • Optional: apply a small amount of local anesthetic (≤ 1 ml) to the site.
  • Insert the intra-articular needle perpendicular to the skin, apply counterpressure to the syringe plunger, and advance the needle approximately 2 cm medially and slightly inferiorly.If blood is aspirated from the joint, keep the syringe nozzle immobile, switch to an empty syringe, aspirate all the blood and replace the anesthetic syringe.
  • Inject 10-20 ml of an anesthetic solution (e.g., 1% lidocaine).
  • Wait for the onset of analgesia (up to 15 to 20 minutes) before proceeding.

Administer procedural sedation and analgesia.. Reduction of the shoulder – posterior dislocation.

  • Wrap a sheet around the patient’s torso, passing the sheet under the axilla of the dislocated shoulder, and tie the ends of the sheet around the hips of the assistant standing on the opposite side of the couch. Wrap the sheet around the assistant’s hips (instead of around the waist) to relieve pressure on the back.
  • After the patient assumes position, fully adduct the affected arm under traction and rotate it inward to assist in disengaging the humeral head from the glenoid rim.
  • Have the assistant on the opposite side of the body lean backward against the sheet to create counter traction while manually applying axial traction to the arm.
  • Ask a second assistant to push the posterior portion of the humeral head upward (anteriorly).
  • If needed (when the humeral head is locked to the posterior glenoid), the second assistant can also manually apply a slight lateral force to the superior humerus to lever the humeral head laterally toward the glenoid fossa.
  • Once the humeral head is released, apply slight external rotation to complete the reduction.
  • If muscle spasm occurs or the patient resists the procedure, give more analgesics and/or sedatives.
  • Signs of successful reduction may include extension of the arm, a palpable “clunk,” and brief fasciculation of the deltoid muscle.
  • If multiple attempts to reduce the shoulder have failed, reduction (closed or open) should be performed in the operating room under general anesthesia.
  • Successful reduction is tentatively confirmed by restoration of a normal rounded shoulder contour, diminished pain, and the patient’s renewed ability to reach across the chest and place the palm of the hand on the opposite shoulder.
  • Immobilize the shoulder in external rotation (20°) and in slight abduction with a sling and sling or with a shoulder orthosis.Because the joint may spontaneously luxate after successful reduction, do not delay immobilization of the joint.
  • Perform a neurovascular examination after the procedure. A neurovascular deficit requires immediate orthopedic evaluation.
  • Perform radiographs after the procedure to confirm proper reduction and to identify any fractures that may be present.
  • Arrange for orthopedic follow-up.
  • Posterior shoulder dislocations may occur bilaterally (e.g., during a seizure); in such a situation, bilateral symmetry of physical findings may mask the dislocations.
  • An apparent shoulder dislocation in a child is often a fracture of the growth plate, which usually breaks before the joint is damaged.
  • Given the discomfort of the procedure, adequate sedation and analgesia are paramount.

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Individualized therapy necessary to prevent permanent damage

A shoulder dislocation is a drastic event for the affected person. After receiving emergency care in hospital, the patient often seeks expert advice on the best possible further treatment. Whether conservative treatment, i.e. primarily physiotherapy, should be used or whether shoulder joint surgery is recommended depends on numerous factors. In the following, we would like to give you an overview of the topic of shoulder dislocation and its optimal treatment “from practice for practice”. We hope that our practical information will effectively support your therapeutic work.

Differentiated therapy after shoulder dislocation is crucial

Over the past 10-15 years, numerous clinical studies have shown that there is no “one” best treatment after shoulder dislocation. Rather, there are numerous factors that influence optimal healing success. Healing success in this context means that the injured shoulder becomes permanently stable and capable of bearing weight well, and that there is no need to fear premature arthrosis. The main factors that must be taken into account for an optimal individual therapy include the accident mechanism, age and the activity level of the affected person, exact analysis of the joint damage, and the connective tissue condition of the affected person. These factors determine whether the patient should be treated primarily conservatively or primarily surgically, and ultimately exactly how the conservative or surgical therapy should be performed to achieve the best possible outcome.

The anatomy of the shoulder and why it luxates more frequently than other joints

The shoulder joint is the most mobile joint in the human body. The prerequisite for this is the specific anatomy: a large humeral head moves in a relatively small glenoid cavity. On the one hand, this allows the large range of motion of the shoulder joint, but on the other hand, there is a risk of instability due to the small bony guidance in combination with the wide joint capsule surrounding it. The stabilizing components of the shoulder include the shoulder girdle muscles with their tendon insertions at the humeral head and a strong labrum-capsule-ligament complex that extends circumferentially from the glenoid to the humeral head. These anatomical features of the shoulder result in a high incidence of 5-12 dislocations per 100,000 population per year. A distinction is made between anterior, posterior, and multidirectional instability depending on the direction of dislocation. Anterior shoulder dislocation is the more common form (approximately 95%), posterior shoulder dislocations are much less common (approximately 2-4%). Multidirectional instabilities are usually found in association with increased capsular laxity, i.e., hypermobility of the shoulder joint. This pathologic multimobility allows dislocations equally anteriorly and posteriorly (multidirectional instability, approx. 3-5 %). In the following, the treatment options for the by far most frequent shoulder instability, the anterior shoulder dislocation, will be explained in more detail.

Not all dislocations are the same

Numerous studies show that a differentiated view of shoulder dislocation as well as the consideration of numerous factors are of utmost importance for an adequate therapy recommendation. Shoulder dislocations are classified according to the type of dislocation, i.e. how the dislocation occurred, and according to the frequency of dislocation.

Type of dislocation

Of fundamental interest is whether the dislocation was caused by trauma or not. This results in the classification into traumatic luxation and atraumatic luxation. It is important to assess whether there was actually an adequate trauma, i.e. whether the force was strong enough to dislocate a “normal” shoulder or whether it was a minor trauma. In the latter case, one must consider a predisposition to shoulder instability such as hypermobility or connective tissue weakness.

Dislocation frequency

If repeated dislocations occur after primary dislocation, this is referred to as recurrent shoulder dislocation or chronic shoulder instability. If dislocation occurs under everyday stress or even during sleep, it is referred to as habitual shoulder dislocation. If a patient can dislocate his shoulder at will, this is called spontaneous dislocation. Habitual and spontaneous shoulder dislocations occur more frequently in patients with hyperlaxic connective tissue status.

Factors influencing the recommendation of therapy after primary shoulder dislocation

Whether a patient should be treated conservatively or surgically after primary shoulder dislocation to minimize the risk of subsequent dislocation or early osteoarthritis depends largely on the following factors:

  • Accident history
  • Patient age
  • Activity level
  • tissue status (hypermobility, hyperlaxity)
  • exact analysis of the traumatic injury

Accident history

It is important to scrutinize the dislocation event and the reduction. It is particularly important to analyze whether the shoulder dislocation was traumatic or atraumatic, i.e., whether it was preceded by adequate trauma. The circumstances that were necessary for the reduction also provide at least supplementary information. For example, anesthesia required for reduction is more indicative of a traumatically induced dislocation, whereas spontaneous reduction is more indicative of a hyperlaxed capsuloligamentous apparatus and thus an atraumatic dislocation.

Patient age

Young patients statistically have a three- to fourfold higher risk that the shoulder will remain chronically unstable despite conservative therapy. In this case, it is obvious that surgical treatment should be considered sooner after primary dislocation in order to prevent secondary damage.

Activity level

The activity level of the affected person also has a significant influence on the reluxation rate after primary shoulder dislocation and thus the therapy recommendation. Sports with contact with opponents, overhead activities, and high-risk sports with frequent falls predispose to reluxation and therefore tend to be stabilized surgically.

Tissue status

The mobility of joints varies greatly between individuals. If joint mobility is pronounced, this is referred to as hypermobility. If a particular elasticity of connective tissue structures is also responsible, this is called hyperlaxity. A pathological genetic change in the connective tissue or collagen fibers with corresponding hypermobility or hyperlaxity is found in Marfan syndrome or Ehlers-Danlos syndrome, among others. Hypermobile shoulders with hyperlaxed connective tissue predispose to shoulder dislocation. Here, one should be cautious with the recommendation for surgical intervention, because the connective tissue status cannot be improved even by surgery.

Exact analysis of the traumatic injury

A shoulder trauma with dislocation inevitably leads to soft tissue damage, but often also to bony injuries. The more precisely one analyzes this damage, the more specifically one can make a therapy recommendation, i.e., predict whether the damage will heal on its own or should be “repaired.” MRI is particularly useful for evaluating soft tissue damage. In the evaluation of bony damage, CT has a prominent role and is clearly superior to radiography. The most common and important soft tissue damage includes: Bankart lesion Bankart lesion refers to the luxation-related traumatic detachment of the glenoid labrum from the glenoid rim. In ventral shoulder dislocation, by far the most common in terms of numbers, the labrum glenoidale tears away from the ventral glenoid rim. This causes the important joint stabilizer to lose its function, resulting in a chronically unstable shoulder. Rotator cuff rupture In older people, damage to the rotator cuff occurs frequently as a result of shoulder dislocation. The tendon of the subscapularis muscle ruptures particularly frequently. Traumatic rupture of the subscapularis tendon leads to a significant functional deficit of the shoulder with weakness of internal rotation and carries the risk of an increased reluxation rate. The most common and serious bony injuries include. Bony Bankart lesion Bony Bankart lesion is a fracture of the ventral glenoid surface. Depending on the size and dislocation of the fragment, chronic instability and early osteoarthritis can be expected if not adequately treated. Hill-Sachs dent Hill-Sachs dent is an impression fracture of the humeral head that occurs cranio-dorsally in ventral dislocation when the dislocated humeral head strikes the ventral glenoid rim. In dorsal luxation, the impression fracture at the ventral humeral head is called a reversed Hill-Sachs dent. With appropriate size and location, the Hill-Sachs dent can hook (engage) on the ventral glenoid rim in external rotation and abduction, leading to chronic instability.

Treatment options after traumatic shoulder dislocation

Whether conservative or surgical therapy is recommended after shoulder dislocation and what this should ideally look like depends on numerous factors, as explained above. The objective of any therapy is to help the patient achieve a fully functional, stable shoulder with as little effort as possible, without the fear of premature arthrosis. The basis for a good and well-founded recommendation are numerous clinical studies that show clear trends. Reduced to the essentials, the following basic treatment recommendations result:

Conservative therapy

– elderly patient (> 40 years) – children and adolescents with open epiphyseal joints – low physical activity level – no significant trauma-induced damage – hypermobile habitus – multidirectional instability – nerve damage (axillary nerve)

Operative therapy

– younger patient (< 40 years) - high level of physical activity (especially contact and high-risk sports) - significant soft tissue injury (Bankart lesion; capsular ligament lesions) - bony injury (especially bony Bankart lesion/glenoid fracture) - tendon rupture (subscapularis muscle) - normomobile habitus - unidirectional instability - chronic instability despite conservative therapy

Conservative therapy after shoulder dislocation

Like all physiological healing processes, healing after shoulder dislocation occurs in phases. It is essential that, in addition to analyzing the extent of the damage, these phases must be considered in conservative therapy planning. It is crucial that the balance between rest and relief on the one hand and movement and stress on the other is found in each of these healing phases. The so-called “target tissue training (ttt)” refers to precisely this approach. While sparing the injured labrum-capsule-ligament complex, mobilization of the shoulder joint is started and, at the same time, muscle maintenance with strengthening is carried out without causing further damage to the healing tissue.

Phase 1 (1st-3rd week): Acute phase/proliferation phase/rest.

In the acute phase, the shoulder should be protected and supported by a bandage as a “sling for comfort”, i.e. to reduce pain. In addition, studies have shown that immobilization in a shoulder brace for about three weeks immediately after trauma reduces the risk of reluxation by 20-50% compared with treatment without immobilization. In the early healing phase, the proliferation phase, fibroblasts sprout after trauma-induced hemorrhage, especially under the influence of fibrin and growth factors, which are necessary for the healing of the injured labrum-capsule-ligament complex. Gentle mobilization up to about 60° each of abduction and flexion and external rotation up to about 20° is allowed. Internal rotation is not limited. Isometric tension exercises in the neutral position should be performed in all directions of motion. Depending on the findings, lymphatic drainage and, if necessary, detonating measures should be performed in case of secondary tension states of the neck muscles. The primary objective of surgical treatment after shoulder dislocation is to restore the physiological anatomical conditions. Shoulder specialists almost invariably perform the corresponding reconstructions minimally invasively, i.e. arthroscopically, which also allows excellent visualization of the intra-articular damage. We would like to briefly introduce the most important surgical procedures.

Phase 2 (3rd-8th week): Healing phase/reparation phase/gentle mobilization.

Even in the healing or reparation phase, which takes place up to the 8th post-traumatic week, the passive and active range of motion should not be extended beyond 20° of external rotation and 60-80° of abduction. This would place too much tension on the injured structures and interfere with scarring of the healing labrum-capsule-ligament complex. In this phase, limited mobility of the glenohumeral joint is regularly observed clinically, the cause of which is fibrosis of the joint capsule. This is a natural process that spontaneously resolves in phase 3. If mobilization is too intensive in phase 1 and phase 2, sufficient healing cannot occur. Either an insufficient, hypermobile soft tissue situation with a persistent tendency to dislocation or the opposite, a secondary capsulitis adhaesiva, is then to be feared.

Phase 3 (9th week to approximately 6 months): Remodeling/load-building/training phase.

Approximately 8 weeks after the trauma, the “remodeling” phase begins. Fibrotic scar structures are remodeled into elastic capsular tissue. This process is lengthy and takes about 6 months. Remodeling can be supported by adequate tissue loading, i.e. specific rehabilitation training. The goal is to improve strength, endurance, mobility, and coordination, certainly with a special emphasis on coordination training. Resumption of the original sports load is permitted after approx. 6 months, in the case of contact sports after 9 months. The prerequisite for resuming sport-specific training is that the shoulder is largely free to move and the patient can perform sport-specific movements without pain.

Surgical treatment after shoulder dislocation

The primary objective of surgical treatment after shoulder dislocation is to restore the physiological anatomical conditions. Shoulder specialists almost invariably perform the corresponding reconstructions minimally invasively, i.e. arthroscopically, which also allows excellent visualization of the intra-articular damage. We would like to briefly introduce the most important surgical procedures.

Bankart repair

The most common consequence of injury after primary, traumatic shoulder dislocation is damage to the labrum-capsule-ligament complex with avulsion of the ventral glenoid labrum, the so-called Bankart lesion. The goal of Bankart repair is to reattach the torn joint lip (labrum glenoidale) to its original location using special implants made of titanium or bioresorbable materials. At the same time, torn ligaments, especially the main stabilizing ligament, the inferior gleno-humeral ligament (IGHL), are anatomically reconstructed.

Latarjet surgery

When chronic ventral shoulder instability causes the shoulder to repeatedly dislocate, there is progressive damage to the anterior glenoid rim. If the bony damage exceeds a certain size, the shoulder cannot be permanently stabilized with reconstruction of the torn soft tissues alone. For this purpose, additional bony stabilization is required. Such a bony reconstruction can be done with the coracoid process of the shoulder. The transfer of the coracoid process to the anterior articular surface compensates for bone loss and enlarges the glenoid cavity, but the transfer of the tendons attached to the coracoid (short biceps tendon and coracobrachialis muscle) through the lower third of the subscapularis muscle is crucial for high stability. This creates an additional “sling effect”, i.e. a new dynamic lower joint capsule, which counteracts the risk of renewed ventral dislocation. This procedure, developed by Latarjet, has been performed openly since 1954 with good long-term results. The development of the surgical technique, which has been performed purely arthroscopically since about 2010, was driven in particular by Laurent Lafosse. The Latarjet operation is technically demanding and only very few specialists are able to perform it arthroscopically. The team of doctors at the Klinik am Ring, Cologne, has been doing this very successfully since 2012 under the leadership of Dr. Alexander Lages and is therefore an official training center for other surgeons.

Follow-up treatment after shoulder dislocation surgery

The follow-up treatment of the operated shoulder after shoulder dislocation is essentially no different from conservative therapy (see page 6), since healing after surgery is also subject to the physiological process outlined above.

From practice for practice

How do I treat an acute shoulder dislocation?

The basic treatment goal for any dislocation is to reduce the dislocated joint as quickly as possible. There are numerous reduction techniques for anterior shoulder dislocation. Until some time ago, we preferred the reduction technique according to Hippocrates. It is one of the oldest and, in our view, quite simple reduction techniques. In the Hippocrates’ reduction technique, the practitioner applies traction to the patient’s extended arm while creating a kind of abutment (hypomochlion) in the patient’s axilla with his foot. With persistent traction on the forearm and slight external rotation followed by internal rotation of the arm, the humeral head is placed back in the glenoid. The patient remains supine on a couch or, if necessary, on the floor for the entire duration of the reduction. The practitioner sits on a chair or stands. A better reduction technique than the one according to Hippokrates was introduced some time ago by our partner Dr. Jan Vonhoegen as a standard procedure in the KLINIK am RING. He was able to gain extensive experience with traumatic shoulder dislocations during his work in sports medicine with professional football players in the USA, where he became familiar with the reduction technique according to Zahiri. The Zahiri method is performed in the prone position. The patient lies on the edge of a couch with the affected arm hanging down to the side. Then the elbow is bent 90° and the practitioner stabilizes the injured person’s wrist in a neutral position. Subsequently, the practitioner positions his free hand in the crook of the elbow and applies axial downward pressure. It is important that this traction is performed with constant force and not jerkily. Then the practitioner performs a careful external rotation followed by an internal rotation under persistent axial pressure. The Zahiri reduction method is based on anatomical studies. Great advantage of this method is that it addresses all anatomical and pathological obstacles to reduction such as biceps tendon, subscapularis tendon as well as the tense fibers of the deltoid muscle. The Zahiri method allows for painless reduction due to maximum relaxation and is therefore extremely safe and successful. Analgesia is rarely required, and anesthesia is virtually never necessary. After successful reduction, it is essential to check the sensitivity, motor function and circulation of the arm. Immediately after reduction, the shoulder should be immobilized with a triangular cloth, or better, if available, with a bandage. In addition, cooling and oral anti-inflammatories (diclofenac 2 x 75 mg or ibuprofen 3 x 800 mg) are indicated. A subsequent x-ray of the shoulder in two planes is strongly advised to verify correct shoulder joint position and to exclude fracture. Cave: If reduction of the luxated shoulder is not successful after two attempts, it should be performed under I.v. analgesia or short anesthesia under clinic conditions.

Which brace is most suitable after shoulder injuries?

A bandage is required for the treatment of numerous shoulder injuries and shoulder diseases. On the one hand, it is intended to support and relieve the upper extremity in order to reduce pain (sling for comfort). On the other hand, the brace should secure the shoulder or arm, if necessary, to prevent incorrect movements or incorrect loading. When selecting a shoulder brace, however, functionality and wearing comfort are also very important aspects. The Gilchrist bandage, which is still frequently used, seems to us to be unsuitable in the vast majority of cases, especially against this background. We favor almost without exception, including after shoulder dislocation, a fixation bandage such as the one shown below as an example. The advantage of such a bandage over the traditionally frequently used Gilchrist bandage is that the patient can use his or her hand to support numerous everyday movements. The use of the hand and arm can also be extended in the course of the healing process by omitting the part of the bandage in which the forearm rests and securing only the upper arm. This allows for early functional aftercare. It is discussed that after dislocation, immobilization in 0° rotation and 30° abduction with abduction cushion is superior to immobilization without abduction and in slight internal rotation. However, since this does not seem to have been definitively clarified, we do not generally use such a brace for reasons of practicability and wearing comfort.

Neurological quick check after shoulder repositioning

In the case of shoulder dislocation, the axillary nerve in particular, but also the brachial plexus, are at risk. As an orienting neurological quick check after shoulder repositioning, we recommend that the following be routinely checked and documented: Axillary nerve – Sensitivity in the deltoid muscle area in lateral comparison – Innervation of the deltoid muscle by tension test Brachial plexus – Sensitivity of arms and hands in lateral comparison – Innervation of M. biceps- and M. triceps brachii by tensing test – Innervation of hand muscles by spreading and tensing test of fingers

New and noteworthy

Joint injections: Hygiene guidelines must be observed

In the last issue of IM FOKUS under the topic “Omarthrosis” the intra-articular injection technique at the shoulder and the necessary hygiene measures were described. We consider the comments of some of our readers on the hygiene measures mentioned to be very interesting and would therefore like to take them up briefly here and comment on them: Experienced colleagues in particular have stated that they consider the wearing of sterile gloves for intra-articular injections to be obsolete, since they no longer come into contact with the injection area after disinfection has taken place. Even if the objection is certainly correct in principle, we nevertheless urgently recommend wearing sterile gloves. The current recommendations of the professional societies are unambiguous in this regard. This is required by the Association of Scientific Medical Societies (AWMF) Working Group on Hospital and Practice Hygiene and the Robert Koch Institute (RKI) Commission for Hospital Hygiene and Infection Prevention. Incidentally, case law is also based on these recommendations in the event of a legal dispute. The exact guidelines can be found at and respectively under the keyword “intra-articular injections”. We think that the effort of wearing sterile gloves is in a reasonable relation to the safety for our patients and – in case of a legal case – for ourselves.

Skiing accidents: Artificial snow is a problem

Although the risk of accidents on the slopes has decreased in recent years thanks to modern safety bindings, protectors and helmets, at the same time the severity of injuries is obviously increasing. Experts from the German Ski Association (DSV) say that excessive speeds and artificial snow are to blame. The slopes are rolled flatter than before, without hills and humps. Thus, the increasingly scarce snow lasts longer. However, the slope made of machine snow in particular tends to be hard and fast, almost like the downhill run of the pros. In addition, skiers increasingly have to practice their sport on narrow bands of snow between brown ridges. This poses additional dangers – for example, for collisions due to limited space or when winter sports enthusiasts lose control of their skis or snowboard and overshoot the slope. The German Ski Association (DSV) estimates that 4.2 million Germans regularly get on their skis. Extrapolating, around 42,000 winter sports enthusiasts injured themselves in the 2015/2016 season in such a way that they needed medical treatment. The number of those who ended up in hospital rose by around 600 to 7,300 compared with the previous season. Knee and shoulder joints continue to be particularly frequently affected by injuries. However, the gender differences in these injuries are astonishing. For example, the injury rate for the knee joint is 43.3% for women, but only 18.3% for men. The reverse is true for shoulder injuries. Here, the rate for men is 20.5%, but for women it is only 7.7%. No clear explanation can be given for the gender difference. Everyone knows that good preparation, controlled driving behavior and avoiding alcohol on the slopes significantly reduce the risk of accidents. Unfortunately, however, this is still given too little attention. PDF Download Posterior Subluxation Shoulder.

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