Morning Report: Shoulder Dislocation

Shoulder dislocation

The most common joint dislocation (approximately 50% of all joints)

	Mechanism	Presentation	Associated injuries
Anterior	Indirect blow with arm in abduction, extension, and external rotation	Arm is held in abduction and slight external rotation with shoulder appearing “squared off.”	Axillary nerve injury Fracture of humeral neck, anterior inferior glenoid rim (Bankart lesion), posterolateral head of humerus (hill sachs fracture) Axillary artery injury
Posterior	Indirect force that produces forceful internal rotation and adduction.	Arm is adducted and internally rotated.	Fracture of posterior glenoid rim, humeralhead, humeral shaft, lesser tuberosity
Inferior	Neck of the humerus is levered against the acromion	Humerus fully abducted, elbow flexed, hand on or behind head	Neurovascular compression injuries Fractures of proximal humerus Rotator cuff tear

Pain control:

Morphine
Procedural sedation
Intra-articular lidocaine: Approximately 20 ml of 1% lidocaine. 2cm below lateral edge of acromion. Allow 15-20 minutes.
US guided interscalene block: Approximately 30ml of 1% lidocaine into brachial plexus. Allow 20 minutes.

Imaging:

X-ray with: Y view, Valpeau view

Reduction techniques:

Traction counter traction: patient supine, arm abducted and flexed to 90 degrees, Clinician>elbow. Assistant >thorax.
Stimpson: Patient prone with 10 lb weight attached to the wrist.
Milch: Patient supine, abduct and externally rotate arm to overhead position with elbow extended
Scapular manipulation: Stimpson, while medially directing tip of lateral scalpula
External rotation: Pt supine, elbow flexed to 90 degrees, arm externally rotated and adducted

References:

Marx: Rosen’s Emergency Medicine – Concepts and Clinical Practice, 8th ed. Chapter 53. Shoulder
Cheok, C. Y., Mohamad, J. A., & Ahmad, T. S. (2011). Pain relief for reduction of acute anterior shoulder dislocations: a prospective randomized study comparing intravenous sedation with intra-articular lidocaine. Journal of orthopaedic trauma, 25(1), 5-10.
Blaivas, M., Adhikari, S., & Lander, L. (2011). A Prospective Comparison of Procedural Sedation and Ultrasound‐guided Interscalene Nerve Block for Shoulder Reduction in the Emergency Department. Academic Emergency Medicine, 18(9), 922-927.
Kahn, J. H., & Mehta, S. D. (2007). The role of post-reduction radiographs after shoulder dislocation. The Journal of emergency medicine, 33(2), 169-173.
Hendey, G. W., Chally, M. K., & Stewart, V. B. (2006). Selective radiography in 100 patients with suspected shoulder dislocation. The Journal of emergency medicine, 31(1), 23-28.