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:Shoulder_joint_back-en.png|thumb|Shoulder anatomy, anterior.]]
**20mL of 1% lidocaine intra-articular injection
[[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


==Anterior Dislocation==
===Types===
===Background===
*[[Anterior shoulder dislocation]]
*>99% are anterior dislocation assoc w/ indirect blow
*[[Posterior shoulder dislocation]]
*Must rule-out axillary nerve injury
*[[Inferior shoulder dislocation]]
*Consider intra-articular lidocaine (10-20mL) as alternative to procedural sedation


===Clinical Features===
==Differential Diagnosis==
*Arm held in abduction w/ shoulder lacking normal rounded contour
{{Shoulder DDX}}
*Difficulty (painful) touching ipsilateral arm to contralateral shoulder


===Imaging===
==Evaluation==
*Prereduction radiographs advised for traumatic mechanism (rule-out fx-dislocation)
*Plain film X-ray
*AP
**Include anteroposterior, scapular Y, and axillary views
**Will show dislocation
**Associated fractures include:
*Scapular lateral or "Y"
***Hills-Sachs: cortical depression in the humeral head
**Will show whether dislocation is anterior or posterior
***Bankart: glenoid labrum disruption with bony avulsion
***Humeral greater tuberosity fracture
*[[Ultrasound: Joint|Ultrasound]]


===Management===
<gallery mode="packed">
*Reduce (see techniques below)
File:AnterDisAPMark.png|[[Anterior shoulder dislocation]]
*Post-reduction: sling w/ shoulder in adduction/internal rotation
File:AnterDisMark.png|[[Anterior shoulder dislocation]] on Y-view
*Ortho referral for 1st-time dislocation
File:Luxation epaule.png|[[Anterior shoulder dislocation]] with fracture
File:Inferiourdislocation.jpg|[[Inferior shoulder dislocation]]
File:Lightbulb sign - posterior shoulder dislocation - Roe vor und nach Reposition 001.jpg|[[Posterior shoulder dislocation]]
</gallery>


===Complications===
==Management==
#Recurrent dislocation (>90% in age <20yr)
*Reduction
#Bony injuries:
**See individual types for specific techniques
##Usually do not affect management
**'''Do not attempt to reduce chronic dislocations (>4 weeks) in ED due to risk of arterial injury''' - these require reduction in the OR
###Hill-Sachs lesion (compression fracture of humeral head)
*Cochrane review notes lower complications, equal pain control, and shorter ED stay with intra-articular lidocaine vs. procedural sedation
###Bankart lesion (injury to inferior glenoid labrum)
**20 mL of 1% lidocaine intra-articular injection<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>
#Axillary nerve (usually temporary) and artery (rare)
#Rotator cuff tear
 
===Reduction Techniques===
*Traction-Countertraction
[[File:Traction-Countertraction.jpg]]
*External Rotation
[[File:External Rotation.jpg]]
*Milch
[[File:Milch.jpg]]
*Stimson
[[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)
==Posterior Dislocation==
===Background===
*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===
*Prominence of posterior shoulder and ant flattening of normal shoulder contour
*Pt unable to rotate or abduct affected arm
 
===Imaging===
*Scapular "Y" view shows humeral head in posterior position


===Management===
==Disposition==
*Reduce
*Uncomplicated dislocation can be discharged after reduction
**Traction applied to adducted arm in long axis of humerus
*Recurrence rate around 27% if older than 30 years and 72% is 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>
**Assistant pushes humeral head anteriorly into glenoid fossa
*Spling, ortho f/u


==Inferior Dislocation==
==See Also==
===Background===
*[[Shoulder diagnoses]]
*Assoc w/ significant soft tissue trauma or fracture
*Via hyperabduction force which levers the humeral neck against the acromion


===Clinical Features===
==External Links==
*Pt p/w humerus fully abducted with hand on or behind the head
*[http://www.youtube.com/watch?v=d9HjtQr0c64 Good all-round shoulder reduction technique lecture]
*Humeral head can be palpated on lateral chest wall
*[http://thecentralline.org/?p=1769 Keeping Up in EM Shoulder Reduction Video]


===Management===
==Video==
*Reduce
{{#widget:YouTube|id=WPAEBZUOW6c}}
**Traction in upward and outward direction
*Sling, ortho f/u (rotator cuff tear is the norm)


==Source==
==References==
*Tintinalli
<references/>
*Roberts:Clinical Procedures in EM. 5th ed


[[Category:Ortho]]
[[Category:Orthopedics]]
[[Category:Procedures]]

Revision as of 20:25, 21 May 2020

Background

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

Types

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

  • 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
  • Ultrasound

Management

  • Reduction
    • See individual types for specific techniques
    • Do not attempt to reduce chronic dislocations (>4 weeks) in ED due to risk of arterial injury - these require reduction in the OR
  • Cochrane review notes lower complications, equal pain control, and shorter ED stay with intra-articular lidocaine vs. procedural sedation
    • 20 mL of 1% lidocaine intra-articular injection[1]

Disposition

  • Uncomplicated dislocation can be discharged after reduction
  • Recurrence rate around 27% if older than 30 years and 72% is younger than 23 years[2]

See Also

External Links

Video

{{#widget:YouTube|id=WPAEBZUOW6c}}

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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