Today’s Morning Report is presented by Dr. Adal!
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.
For more info check out this great FOAM resource: shoulderdislocation.net
Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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