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Shouldering the load: Shoulder dislocations in the ED

The optimal method of reduction is unknown. Remember contraindications, and arm yourself with a toolbox of maneuvers that can be applied at the bedside without procedural sedation. And then have a sequential and step wise approach for the patient that does require sedation.

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 EM@3AM: Anterior Shoulder Dislocation

There are many different techniques for reduction. The processes described are several of the more commonly used techniques. See this post from NUEM Blog and this great video from Larry Mellick.

Articles of Interest

A Recipe for Reduction: Five alternative approaches for reducing an anterior shoulder dislocation

Every emergency medicine physician should know three ways to reduce a shoulder, not including traction-countertraction.

An Easily Missed Shoulder Injury

Reduction technique: Traction-countertraction should be applied on the adducted and internally rotated arm, and posterior-to-anterior pressure should be applied on the humeral head. You may also create leverage by applying lateral pressure to the medial aspect of the proximal humerus to dislodge an impacted humeral head.

Anterior Shoulder Dislocation: Are Prereduction Films Needed?

You get a patient in triage with an anterior shoulder dislocation that happened 10 minutes prior to arrival. It’s happened to him multiple times on the same shoulder and all he did to dislocate it was to push up from a chair. You really want to get it reduced quickly because you are smart enough to know, the quicker you pop it in, the smoother the reduction goes. But shoot, you remember someone told you that for every reduction, you need a pre-reduction xray before you can do anything to it. What do you do?

EM Cases: Commonly Missed or Mismanaged Shoulder Injuries – Approach and Glenohumeral Dislocations

Where do we go wrong when it comes to ordering and interpreting extremity x-rays? How do we know we have adequate shoulder x-ray views? How can we best remember the differential diagnosis of an orthopedic emergency with a normal x-ray? What is the quickest and best way to test neurologic status of patients with shoulder injuries? Why is axillary view of the shoulder so valuable?

Posterior Dislocation of the Shoulder: The Light-Bulb Sign

Posterior dislocation of the shoulder is a rather uncommon injury, while the lack of a traumatic event leads to misdiagnosis in almost half of all cases. Furthermore, the malalignment in the initial X-ray view may not be evident. The present report highlighted the light-bulb sign that should be a red flag for physicians who evaluate these patients or these X-rays. The patient’s history, such as epileptic seizures and examination, especially the locked arm in internal rotation, is of utmost importance for not misdiagnosing these cases.

Posterior Shoulder Dislocation

Posterior shoulder dislocations make up a small minority of total shoulder dislocation cases, accounting for 2-4% of presentations. However because of a low level of clinical suspicion and insufficient imaging, they are often missed. Approximately half of posterior shoulder dislocations go undiagnosed on initial presentation.

Shoulder Dislocations: Reduction and Stabilization

There are a variety of treatment approaches including procedural sedation, intra-articular lidocaine, US-guided brachial plexus or interscalene block, and a plethora of reduction techniques. Generally, the reduction method depends on clinician preference and the patient’s condition. Some notable techniques include scapular manipulation, external rotation, Milch technique, Stimson technique, traction-countertraction, Spaso technique, Davos technique, among others.

Shoulder relocations ( anterior dislocation; posterior dislocation)

Shoulder relocations ( anterior dislocation; posterior dislocation)

Teaching Patients How to Reduce a Shoulder Dislocation

The self-reduction technique results in less pain than, and is as efficient in achieving reduction of anterior shoulder dislocations as, the Spaso technique. These findings favor the use of the self-assisted method as an effective first-line treatment for shoulder dislocations seen in the emergency department as well as its use by patients with recurrent dislocation.

Resources

Core EM

Several methods described.