Shoulder dislocation: Difference between revisions

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==Background==
==Background==
*Cochrane review notes lower complications, equal pain control, and shorter ED stay with intra-articular lidocaine vs. procedural sedation
[[File:Gray326.png|thumb|Left shoulder and acromioclavicular joints with ligaments.]]
**20mL of 1% lidocaine intra-articular injection
[[File:Shoulder_joint_back-en.png|thumb|Shoulder anatomy, anterior.]]
[[File:Shoulder joint back 05r4v.png|thumb|Shoulder anatomy, posterior.]]
*Humerus separates from the scapula at the glenohumeral joint
*Partial dislocation of the shoulder is referred to as subluxation
*Dislocation duration inversely correlated with likelihood of successful ED reduction


==Anterior Dislocation==
{{Shoulder dislocation types}}
===Background===
*>99% are anterior dislocation assoc w/ indirect blow
*Must rule-out axillary nerve injury
*Consider intra-articular lidocaine (10-20mL) as alternative to procedural sedation


===Clinical Features===
==Clinical Features==
*Arm held in abduction w/ shoulder lacking normal rounded contour
*Shoulder pain
*Difficulty (painful) touching ipsilateral arm to contralateral shoulder
*Decreased shoulder range of motion


===Imaging===
===Comparison of Shoulder Dislocation Clinical Features===
*Prereduction radiographs advised for traumatic mechanism (rule-out fx-dislocation)
{| class="wikitable"
*AP
! Finding !! [[Anterior shoulder dislocation|Anterior]] (~95%) !! [[Posterior shoulder dislocation|Posterior]] (~5%) !! [[Inferior shoulder dislocation|Inferior]] (<1%)
**Will show dislocation
|-
*Scapular lateral or "Y"
| Arm position || Arm maintained in abduction and external rotation || Posterior aspect of shoulder unusually prominent || Humerus fully abducted / Hand on or behind head
**Will show whether dislocation is anterior or posterior
|-
| Shoulder appearance || Loss of normal rounded appearance with stretching of the deltoid muscle (i.e., "squared off") || Anterior aspect of shoulder appears flattened ||
|-
| Range of motion || Difficulty touching affected arm to contralateral shoulder due to pain || Inability to rotate or abduct affected arm || Humeral head palpable in axilla or lateral chest wall
|-
| Mechanism || Most common; range of mechanisms || Forceful internal rotation and adduction (e.g., blow to anterior shoulder, seizure, eletric shock) || Forceful hyper-abduction of arm
|}


===Management===
==Differential Diagnosis==
*Reduce (see techniques below)
{{Shoulder DDX}}
*Post-reduction: sling w/ shoulder in adduction/internal rotation
*Ortho referral for 1st-time dislocation


===Complications===
==Evaluation==
#Recurrent dislocation (>90% in age <20yr)
===Workup===
#Bony injuries:
*Plain film X-ray
##Usually do not affect management
**Include anteroposterior, scapular Y, and axillary views
###Hill-Sachs lesion (compression fracture of humeral head)
**Associated fractures include:
###Bankart lesion (injury to inferior glenoid labrum)
***Hills-Sachs: cortical depression in the humeral head
#Axillary nerve (usually temporary) and artery (rare)
***Bankart: glenoid labrum disruption with bony avulsion
#Rotator cuff tear
***Humeral greater tuberosity fracture
*Consider [[Ultrasound: Joint|joint ultrasound]]


===Reduction Techniques===
===Diagnosis===
*Traction-Countertraction
<gallery mode="packed">
[[File:Traction-Countertraction.jpg]]
File:AnterDisAPMark.png|[[Anterior shoulder dislocation]]
*External Rotation (Kocher)
File:AnterDisMark.png|[[Anterior shoulder dislocation]] on Y-view
[[File:External Rotation.jpg]]
File:Luxation epaule.png|[[Anterior shoulder dislocation]] with fracture
*Milch
File:Inferiourdislocation.jpg|[[Inferior shoulder dislocation]]
[[File:Milch.jpg]]
File:Lightbulb sign - posterior shoulder dislocation - Roe vor und nach Reposition 001.jpg|[[Posterior shoulder dislocation]]
*Stimson
</gallery>
[[File:Picture 3.png]]
#Place pt prone on edge of table.
#If pt sedated or intoxicated, secure pt to stretcher with belts or sheets
#Shoulder is placed over floor while the pt is prone so that the arm can fall 90 degrees to pt and floor.
#Attach a 5-kg weight to the arm, and the patient maintains this position for 20–30 min, if necessary.  
#Occasionally, gentle external and internal rotation of the shoulder with manual traction aids reduction.
#Consider combining with scapular manipulation (The inferior tip of the scapula is pushed medially and dorsally with the thumbs while the superior aspect of the scapula is stabilized with the fingers of the superior hand)


*FARES (Fast, Reliable, and Safe) Method: No sedation required!
==Management==
#Apply traction while holding wrist to the affected limb in a neutral position beside on a supine patient
===Reduction===
#Oscillate limp up and down (anteriorly/posteriorly) while continuing to apply traction and start slowly abducting the limb.
*'''Do not attempt to reduce chronic dislocations (>4 weeks) in ED due to risk of arterial injury''' - these require reduction in the OR
#Once abducted to 90 degrees, externally rotate and continue with ongoing traction and oscillations past this position. Reduction is usually achieved once abducted to 120 degrees.
*Lower complications, equal pain control, and shorter ED stay with intra-articular lidocaine vs. procedural sedation<ref>Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults (Review) Cochrane Database Syst Rev. 2011 Apr 13;(4):CD004919 [http://www.update-software.com/BCP/WileyPDF/EN/CD004919.pdf full text]</ref>
**20 mL of 1% lidocaine intra-articular injection
*See individual types for specific techniques:
**[[Anterior shoulder dislocation]]
**[[Posterior shoulder dislocation]]
**[[Inferior shoulder dislocation]]


*Cunningham Technique: No sedation required!
===Post-Reduction===
**Useful single operator method of reducing anterior shoulder dislocations
*Post-reduction film to confirm
**[http://lifeinthefastlane.com/cunninghams-shoulder-relocation/ LITFL Step-By-Step How To]
*Sling and swathe or shoulder immobilizer x1 week / until orthopedics follow-up
**[http://www.youtube.com/watch?v=MkdCGV_MOCM Click HERE for video]
**Encourage daily range of motion exercises (minus abduction + external rotation) to prevent adhesive capsulitis


==Disposition==
*Uncomplicated dislocation can be discharged after reduction


[http://www.youtube.com/watch?v=d9HjtQr0c64 Good all-round shoulder reduction technique lecture]
==Prognosis==
*Recurrence rate around 27% if older than 30 years and 72% if younger than 23 years<ref>Watson S, Allen B, Grant JA. A Clinical Review of Return-to-Play Considerations After Anterior Shoulder Dislocation. Sports Health. 2016; 8(4):336-341.</ref>


==See Also==
*[[Shoulder diagnoses]]


[http://thecentralline.org/?p=1769 Keeping Up in EM Shoulder Reduction Video]
==External Links==
*[http://www.youtube.com/watch?v=d9HjtQr0c64 Good all-round shoulder reduction technique lecture]
*[http://thecentralline.org/?p=1769 Keeping Up in EM Shoulder Reduction Video]
*[https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/shoulder-dislocations?query=shoulder%20dislocation Merk Manual - Shoulder dislocations]


==Posterior Dislocation==
==References==
===Background===
<references/>
*Via forceful internal rotation/adduction (sz, electric shock) or blow to ant shoulder
*Neurovascular and rotator cuff tears are less common than in ant dislocations


===Clinical Features===
[[Category:Orthopedics]]
*Prominence of posterior shoulder and ant flattening of normal shoulder contour
[[Category:Procedures]]
*Pt unable to rotate or abduct affected arm
 
===Imaging===
*Scapular "Y" view shows humeral head in posterior position
 
===Management===
*Reduce
**Traction applied to adducted arm in long axis of humerus
**Assistant pushes humeral head anteriorly into glenoid fossa
*Spling, ortho f/u
 
==Inferior Dislocation==
===Background===
*Assoc w/ significant soft tissue trauma or fracture
*Via hyperabduction force which levers the humeral neck against the acromion
 
===Clinical Features===
*Pt p/w humerus fully abducted with hand on or behind the head
*Humeral head can be palpated on lateral chest wall
 
===Management===
*Reduce
**Traction in upward and outward direction
*Sling, ortho f/u (rotator cuff tear is the norm)
 
==Source==
*Tintinalli
*Roberts:Clinical Procedures in EM. 5th ed
*https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?redfix_url=&implantstype=&segment=Proximal&bone=Humerus&classification=11-A1.3&showPage=redfix&treatment=Operative&method=Closed%20reduction%3B%20screw%20fixation
[[Category:Ortho]]

Latest revision as of 17:21, 20 March 2024

Background

Left shoulder and acromioclavicular joints with ligaments.
Shoulder anatomy, anterior.
Shoulder anatomy, posterior.
  • Humerus separates from the scapula at the glenohumeral joint
  • Partial dislocation of the shoulder is referred to as subluxation
  • Dislocation duration inversely correlated with likelihood of successful ED reduction

Shoulder dislocation types

Clinical Features

  • Shoulder pain
  • Decreased shoulder range of motion

Comparison of Shoulder Dislocation Clinical Features

Finding Anterior (~95%) Posterior (~5%) Inferior (<1%)
Arm position Arm maintained in abduction and external rotation Posterior aspect of shoulder unusually prominent Humerus fully abducted / Hand on or behind head
Shoulder appearance Loss of normal rounded appearance with stretching of the deltoid muscle (i.e., "squared off") Anterior aspect of shoulder appears flattened
Range of motion Difficulty touching affected arm to contralateral shoulder due to pain Inability to rotate or abduct affected arm Humeral head palpable in axilla or lateral chest wall
Mechanism Most common; range of mechanisms Forceful internal rotation and adduction (e.g., blow to anterior shoulder, seizure, eletric shock) Forceful hyper-abduction of arm

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

Workup

  • Plain film X-ray
    • Include anteroposterior, scapular Y, and axillary views
    • Associated fractures include:
      • Hills-Sachs: cortical depression in the humeral head
      • Bankart: glenoid labrum disruption with bony avulsion
      • Humeral greater tuberosity fracture
  • Consider joint ultrasound

Diagnosis

Management

Reduction

Post-Reduction

  • Post-reduction film to confirm
  • Sling and swathe or shoulder immobilizer x1 week / until orthopedics follow-up
    • Encourage daily range of motion exercises (minus abduction + external rotation) to prevent adhesive capsulitis

Disposition

  • Uncomplicated dislocation can be discharged after reduction

Prognosis

  • Recurrence rate around 27% if older than 30 years and 72% if younger than 23 years[2]

See Also

External Links

References

  1. ↑ Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults (Review) Cochrane Database Syst Rev. 2011 Apr 13;(4):CD004919 full text
  2. ↑ Watson S, Allen B, Grant JA. A Clinical Review of Return-to-Play Considerations After Anterior Shoulder Dislocation. Sports Health. 2016; 8(4):336-341.
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