Chapter 2 – Shoulder and elbow emergencies



Chapter 2 Shoulder and elbow emergencies




Sanjeev Malik

Molly Weiner

George Chiampas



Glenohumeral dislocations



Key facts





  • Anterior shoulder dislocations are usually clinically obvious



  • Posterior shoulder dislocations can be difficult to identify



  • The shoulder is the most commonly dislocated joint in the body



  • 95% of shoulder dislocations will be anterior



  • Patients < 30 years of age have a high risk of recurrence




Clinical presentation





  • The shoulder is the most commonly dislocated joint in the body



  • 95% of shoulder dislocations will be anterior




    • Patients have a squared-off appearance to the shoulder



    • The arm is held in slight abduction




  • Posterior dislocations can be difficult to detect by appearance alone




    • Patients often hold the arm adducted to the side



    • Seizures are classically associated with posterior dislocations




  • A thorough neurovascular exam of the affected extremity is essential to exclude a neurovascular injury




    • The axillary nerve is most commonly injured





PEARL: Patients over the age of 40 should be evaluated for a possible rotator cuff tear, which may occur in greater than one-third of patients with glenohumeral dislocations.



Diagnostic testing





  • Plain films of the shoulder are the test of choice






PEARL: Failure to obtain a lateral projection can result in missing a posterior dislocation in up to 50% of cases.





Figure 2.1A and 2.1B Radiographs of a posterior shoulder dislocation.


A: An AP projection is shown with no obvious dislocation.


B: A lateral projection (scapular Y-view) for the same patient shows the humeral head to be dislocated posteriorly.


(Reproduced with permission of the Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University.)


Treatment





  • Emergency Department management




    • Provide adequate analgesia




      • Procedural sedation has been the historical mainstay for joint reductions



      • Reduction performed with an intra-articular anesthetic injection is an acceptable alternative




    • Reduce the shoulder




      • There are a multitude of techniques



      • Be familiar with more than one – no technique has a 100% success rate




    • Perform pre- and post neurovascular exams



    • Perform confirmatory radiographs



    • Place the patient in a standard sling or shoulder immobilizer




      • External rotation slings may provide better anatomic alignment but are not often available in many EDs



      • External rotation slings have been shown to reduce the recurrence rate of first-time dislocators




    • Referral to an orthopedic surgeon in 7–10 days is appropriate





PEARL: Reductions performed with intra-articular anesthetic injections have been safely performed with equivalent success rates, similar patient comfort, shorter ED length of stays, and lower complication rates.



Prognosis





  • Most patients can return to a pre-injury level of function after several weeks




    • Patients < 30 years of age have a high risk of recurrence and may benefit from surgical stabilization



    • Patients > 40 years of age may have greater morbidity if the rotator cuff has been injured





Procedures





  • Intra-articular injection of lidocaine (Figure 2.2)




    • Supplies needed




      • 1–3 cc syringe



      • 1–20 cc syringe



      • 2–18-gauge needles



      • 1–27-gauge needle



      • 1–20-gauge 3.5 inch spinal needle



      • Chlorhexidine/betadine scrub



      • 4 × 4 gauze pads



      • Sterile gloves



      • 30 cc vial of 1% lidocaine solution




    • Technique




      • Positioning




        • Place the patient in the seated position with the affected arm adducted to the side




      • Preparation




        • Prep the lateral aspect of the shoulder with betadine or chlorhexidine solution



        • Apply sterile gloves and perform procedure with standard aseptic technique



        • Draw 1 cc of 1% lidocaine into the 3 cc syringe and cap with the 27-gauge needle; set aside for use as local skin anesthesia



        • Draw 15 cc of 1% lidocaine into the 20 cc syringe and cap with the 20-gauge spinal needle



        • Identify the lateral aspect of the acromion (identified by the squared-off shoulder)




          • Make a sterile mark 1 cm below the inferior-most aspect of the acromion





      • Procedure




        • Make a small skin wheal at the marked site using the 3 cc syringe with lidocaine



        • Holding negative pressure, insert the 20 cc syringe with attached spinal needle into the lateral aspect of the shoulder perpendicular to the skin



        • Continue advancing until the glenohumeral joint is entered




          • Hemarthrosis may be apparent



          • Change in resistance from entering the joint space can be felt



          • Inject 15 cc of 1% lidocaine into the joint space



          • Remove the needle and place a sterile dressing



          • Allow 15 minutes for the anesthetic to take effect







  • Glenohumeral reduction




    • Various different techniques exist with excellent success rates (Table 2.1)



    • External rotation method: can be performed safely by a single provider and does not require a lot of strength for success (Figure 2.3)




      • Place the patient in the supine position



      • Hold the affected extremity adducted to the side with the elbow flexed at 90°



      • Bring the shoulder into 20° of forward flexion



      • The physician should hold the patient’s wrist with one hand, stabilize the elbow with the other hand and gently externally rotate the forearm



      • The physician should stop and hold the position when resistance is felt until the muscles relax and then proceed further



      • Once reduction is achieved, the arm can be returned to an internally rotated position and placed in a sling






Table 2.1 Comparison of common glenohumeral reduction techniques.





Data from Ufberg JW, Vilke GM, Chan TC, et al. Anterior shoulder dislocations: beyond traction-countertraction, J Emerg Med. 2004; 27(3):3001–6. Reproduced with permission from Malik, et al. 2010.




Figure 2.2 Intra-articular injection of lidocaine.


After sterile prep, the needle enters the shoulder perpendicular to the skin, just below the lateral edge of the acromion, until the glenohumeral joint is entered.


(Reproduced with permission of the Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University.)







Figure 2.3 The external rotation method for glenohumeral reduction.


A: Place the patient in the supine position with the affected extremity adducted to the side and the elbow flexed at 90° and shoulder forward flexed at 20°. The physician should hold the patient’s wrist with one hand and stabilize the elbow with the other.


B: Gently externally rotate the forearm, stopping periodically when resistance or muscle spasm is felt, to allow for muscle relaxation.


C: Once reduction is felt, the arm should be checked through a range of motion and may be returned to an internally rotated position with a sling.


(Reproduced with permission of the Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University.)


Scapular fractures



Key facts





  • The scapula links the axial skeleton to the upper extremity and serves as the stabilizing platform for arm motion



  • Scapular fractures result from a high-energy mechanism and require a thorough trauma assessment to exclude life-threatening injuries




Clinical presentation





  • Scapular fractures account for only 1% of all fractures and 5% of shoulder fractures




    • The majority of fractures occur in the body of the scapula




  • Scapular fractures often occur with a high-energy mechanism and may be associated with more serious injuries




    • In one series, patients with scapular fractures had an average of 3.9 additional major injuries




  • Mechanism of injury




    • High-energy direct blow/trauma to the shoulder area



    • Fall on to an outstretched arm



    • Shoulder dislocations may result in a glenoid fracture




  • Physical examination findings




    • Injured patients often hold the arm adducted to the side



    • Significant pain with ipsilateral arm motion



    • Localized tenderness over the scapula



    • Swelling, crepitus, and ecchymosis may be present over the scapula



    • Perform a careful neurovascular examination to rule out arterial injury or brachial plexopathy




      • May occur in 13% of scapular fractures






PEARL: Evaluate closely for associated pulmonary contusions that may lead to significant morbidity and mortality.



Diagnostic testing





  • Plain radiography is the initial test of choice in the evaluation of suspected scapular fractures




    • Dedicated scapular series includes an AP/lateral/scapular views



    • Scapular fractures may be obscured by overlying structures



    • Os acromiale may be confused for a mid-acromion fracture




      • Normal variant in 15% of patients



      • Rounded edges and bilateral appearance are reassuring





  • CT scans of the chest or scapula may better identify fractures



  • Electromyogram (EMG) testing can be performed at a later date to evaluate suspected nerve injuries




    • Optimal results > 3 weeks after injury



    • May evaluate the extent of the injury and potential for recovery





Treatment





  • Emergency Department management




    • Pain control



    • Sling



    • Encourage early ROM



    • Referral to an orthopedic surgeon



    • Treat concurrent injuries




  • Long-term management




    • Majority of fractures are treated non-surgically




      • Scapular body fractures




    • Surgical intervention may be considered for




      • Glenoid fractures



      • Displaced scapular neck fractures






Prognosis





  • 86% scapular body fractures heal with excellent or good results



  • 82% glenoid fractures treated operatively heal with excellent or good results



  • Complications are uncommon




    • Glenoid fractures managed non-operatively may lead to shoulder instability




  • Most fractures heal in approximately 6 weeks




    • Full functional recovery may take up to a year




  • Healing with slight non-union does not result in significant disability




    • Associated with fractures of glenoid, acromion, and coracoid





Clavicle fractures



Key facts





  • Clavicle fractures often result from high-mechanism trauma



  • Adequate pain control is a key aspect in the management of clavicle fractures



  • The majority of clavicle fractures can be managed conservatively with a simple sling



  • Displaced mid-shaft clavicle fractures have a higher risk of non-union and should be referred to an orthopedic surgeon for operative consideration (Figure 2.4)





Figure 2.4 Displaced mid-shaft clavicle fracture.


(Reproduced with permission of the Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University.)



Clinical presentation





  • The majority of patients will present with pain over the clavicle or shoulder region



  • Males between the ages of 15–30 years are the most likely to suffer this injury



  • Mechanism of injury




    • Young patients generally require a high-impact direct trauma




      • Sporting injuries



      • Falls



      • Motor vehicle collisions




    • Elderly patients may have a more minor mechanism such as a simple fall from standing height




  • Physical examination findings are straightforward




    • Affected limb held adducted to the side



    • Tenderness over the clavicle



    • Limited shoulder abduction and forward flexion because of pain



    • Deformity is often apparent because of the subcutaneous location of the clavicle




  • A thorough neurovascular examination of the affected extremity is essential to exclude an associated neurovascular injury




Diagnostic testing





  • Plain radiographs are the preferred test for evaluation of suspected clavicle fractures




    • Standard clavicle plain films




      • AP and 45° cephalic tilt views




    • Serendipity view: 40° cephalic tilt view




      • Better evaluates the medial clavicle




    • Zanca view: AP view where the x-ray beam is directed at the acromioclavicular joint with 10-degree cephalic tilt




      • Better evaluates the distal clavicle and AC joint






Classification





  • Middle-third fractures (Allman Type I)




    • Most common type (69–80%)




  • Lateral-third fractures (Allman Type II)




    • 21–25% of clavicle fractures



    • More common in elderly




  • Medial-third fractures (Allman Type III)




    • Rare (2%)



    • More common in elderly





Treatment





  • Emergency Department management for all clavicle fractures




    • Adequate pain control



    • Sling for comfort



    • Figure-of-8 bandages are an alternative




      • Reports of greater discomfort



      • Higher risk of brachial plexus injury




    • Restrict from overhead activity




  • Long-term management




    • Majority of clavicle fractures can be managed non-operatively with recovery in 6–8 weeks




  • Referral to an orthopedic specialist in 1–2 weeks




PEARL: Shortened or displaced (> 2 cm), mid-shaft clavicle fractures or fractures of the lateral third have a higher risk of non-union and should be referred early to an orthopedic surgeon for consideration of operative management.



Prognosis





  • The majority of patients have an excellent recovery from clavicle fractures




Sternoclavicular injuries



Key facts





  • Sternoclavicular (SC) injuries are relatively rare



  • Anterior dislocations are unstable and often remain so after treatment



  • Posterior sternoclavicular dislocations may result in concurrent injuries to mediastinal structures in 30% of cases



  • Reduction of a posterior SC dislocation is best performed in the operating room with orthopedic and cardiothoracic surgery support




Clinical presentation





  • SC dislocations are uncommon



  • Injuries to patients < 25 years of age are often physeal injuries as opposed to true dislocations



  • Patients present complaining of shoulder and/or chest pain



  • Both anterior and posterior dislocations may occur



  • Mechanism of injury:




    • Anterior dislocations




      • Anterolateral force resulting in posterior pressure on the shoulder and medial directed pressure on the clavicle




    • Posterior dislocations




      • Posterolateral force resulting in an anterior directed pressure on the shoulder and a simultaneous medial directed force on the clavicle



      • Direct hit to the medial clavicle





  • Physical examination findings




    • Tenderness at the SC joint



    • Painful shoulder ROM



    • Prominent medial clavicle in anterior dislocations



    • Affected arm may be held adducted with elbow flexed




  • A thorough examination is warranted to exclude associated injuries




    • Venous congestion of the neck or ipsilateral arm, hoarseness, cough, shortness of breath may be concerning findings





PEARL: Presence of a posterior SC dislocation should prompt evaluation for associated injuries to the trachea, esophagus, and great vessels, which are in close proximity to the SC joint.



Diagnostic testing





  • Plain radiography with a clavicle series or chest radiograph is often non-diagnostic




    • A serendipity view to better evaluate the medial clavicle and SC joint may be obtained




  • CT imaging is the test of choice for evaluation of the SC joint



  • For posterior dislocations, additional evaluation for concurrent injuries should be considered




    • CT angiography



    • Chest radiography



    • Bronchoscopy



    • Endoscopy





Treatment





  • Adequate pain control should be provided for all dislocations



  • Anterior dislocations




    • Anterior dislocations are unstable and may remain so even after treatment



    • Closed reduction should be attempted in the ED



    • Procedural sedation is often required



    • Post reduction, the patient should be placed in a figure-of-8 brace or a clavicle harness for 4–6 weeks



    • Referral to an orthopedic surgeon for follow-up is advised




  • Posterior dislocations




    • Associated injuries should be thoroughly evaluated and treated as appropriate



    • An emergent orthopedic consultation should be obtained



    • Reduction is best performed in the operating room




      • Closed reduction may be successful in the first 48 hours, but open reduction is often required



      • Consultation with a cardiothoracic surgeon is advised to address any complications from the reduction




    • Post reduction, the patient should be placed in a figure-of-8 brace for 6–8 weeks





PEARL: Management of a posterior SC dislocation is best performed in consultation with an orthopedic and cardiothoracic surgeon.



Prognosis





  • Anterior dislocations often remain unstable post treatment but rarely cause any long-term functional impairment



  • Posterior dislocations are generally stable post reduction




    • Associated injuries with a posterior dislocation can result in poorer outcomes





Procedure





  • Closed reduction of anterior SC dislocation




    • Local anesthesia or procedural sedation may be used for analgesia at the provider’s discretion




      • Cardiopulmonary monitoring as indicated




    • Place the patient supine on the gurney with a towel roll or firm pad in between the shoulder blades



    • Technique




      • Bring the affected arm into 90° abduction and 10° extension



      • Apply traction to the affected arm



      • An assistant should provide a posterior force on to the medial aspect of the clavicle until the deformity has resolved




    • After reduction is complete, place the patient in a valpeau bandage or figure-of-8 brace





Acromioclavicular injuries



Key facts





  • Acromioclavicular (AC) injuries are the most common shoulder injuries in contact sports



  • Type I AC injuries are radiographically normal and may be missed without an adequate physical examination



  • Classification of injuries using the Rockwood classification can be helpful in determining management and prognosis (Table 2.2)



  • Emergency department treatment should be focused on adequate pain control and a sling for comfort



  • Early referral to an orthopedic surgeon is advised for Type III–VI injuries (Figure 2.5)




Table 2.2 Rockwood classification of AC injuries.




Abbreviations: AC, acromioclavicular; CC, coracoclavicular; CCD, coracoclavicular distance; D, deltoid attachment at clavicle; T, trapezius attachment at clavicle. *Management of Type III injuries is controversial. Non-operative management is most common but surgical management may be considered in some populations.


Reproduced with permission from Malik, et al. 2010.




Figure 2.5 Grade III AC separation. Note the elevation of the distal clavicle relative to the acromion suggestive of injuries to both the acromioclavicular and coracoclavicular ligaments.


(Reproduced with permission of the Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University.)


Clinical presentation





  • Acromioclavicular injuries involve injuries to the acromioclavicular and coracoclavicular ligaments



  • AC injuries are the most common shoulder injury in contact sports



  • Mechanism of injury




    • Fall directly on the adducted shoulder



    • Fall on outstretched hand (FOOSH)




  • Physical examination findings




    • Tenderness over the acromioclavicular joint



    • Pain with cross-arm abduction test



    • Deformity may be apparent in higher-grade AC injuries




  • A thorough neurovascular examination of the affected extremity is essential to exclude an associated neurovascular injury




Diagnostic testing





  • The diagnosis of AC injuries is often apparent on physical examination



  • Plain radiographs of the shoulder are the preferred test for further evaluation of suspected AC injuries and assist in identifying the severity of the injury




    • Type I AC sprains will be radiographically normal



    • Widening of the AC joint greater than 3 mm is suggestive of an acromioclavicular ligament injury



    • Widening of the coracoclavicular distance greater than 13 mm is suggestive of a coracoclavicular ligament injury





PEARL: A normal shoulder film does NOT exclude the diagnosis of an AC sprain.



Classification



Treatment





  • Emergency Department management for all AC injuries




    • Adequate pain control



    • Sling for comfort



    • Early range of motion



    • Restrict the patient from overhead activity




  • Referral to an orthopedic specialist in 1–2 weeks




    • Consider earlier referral for Type III–VI AC injuries as they may be candidates for operative repair





PEARL: Type III AC separations have controversial management and should be referred to an orthopedic surgeon for further evaluation.



Prognosis





  • Recovery may be 2–6 weeks depending on the severity of injury



  • The majority of patients with lower-grade AC injuries will have a complete recovery of prior function




Proximal humerus fractures



Key facts





  • More than 80% of proximal humerus fractures are non-displaced (Figure 2.6) or minimally displaced and do not require surgery



  • The rotator cuff tendons are at risk for concurrent injury given their insertion on to the greater and lesser tuberosities



  • Early range of motion exercises improve functional recovery





Figure 2.6 Non-displaced proximal humerus fracture.


(Reproduced with permission of the Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University.)



Clinical presentation





  • Proximal humerus fractures are the third most common fractures in the elderly




    • Increased incidence with elderly age and female gender




  • Mechanism of injury




    • Fall on to an oblique angle on an outstretched hand



    • Fall on to the shoulder from a standing height



    • High-impact direct trauma to the shoulder in young patients




  • Physical examination findings




    • Distinct point of tenderness over the proximal humerus



    • Painful range of motion



    • Arm often held in slight abduction



    • Deformity not often apparent



    • A thorough neurovascular examination of the affected extremity is essential




      • Axillary nerve injuries are associated with displaced fractures or fracture–dislocations



      • Brachial plexus also at risk of injury






PEARL: Fractures of the anatomic neck compromise the blood supply to the humeral head and are at risk of avascular necrosis.



Diagnostic testing





  • Plain radiographs are the test of choice to evaluate the shoulder




    • AP view of the scapula and glenohumeral joint



    • Axillary view and lateral Y-view of the scapula




  • Findings




    • Pseudo-subluxation of the humeral head inferiorly suggests hemarthrosis



    • Greater tuberosity fractures are associated with anterior shoulder dislocations




      • Should raise suspicion for concurrent rotator cuff tear






Classification




Table 2.3 Neer classification of proximal humerus fractures.




The Neer classification separates the humerus into four anatomic parts based on old epiphyseal lines (anatomic neck, surgical neck, greater and lesser tuberosities). A fragment is defined as being displaced if separation is > 1 cm or angulation > 45°. *Note: Two-part anatomic neck fractures and four-part fractures are at highest risk for AVN.



Treatment





  • Emergency department management




    • Adequate pain control



    • Immobilize with sling for 1–3 weeks



    • Encourage early range of motion



    • Urgent orthopedic consultation is advised for:




      • Anatomic neck fractures



      • Four-part fractures



      • Fracture/dislocations





  • Long-term treatment




    • Definitive treatment based primarily on the number of segments involved and degree of displacement




      • Non-displaced fractures managed conservatively with immobilization in a sling, early motion and orthopedic follow-up




        • Recovery may be 2–3 months




      • Multiple part fractures may benefit from operative management




        • Elderly patients may have acceptable results with non-operative treatment







PEARL: Early range of motion exercises can decrease pain and result in improved functional outcomes.



Prognosis





  • The majority of patients have adequate recovery from proximal humerus fractures




Humeral shaft (diaphyseal) fractures



Key facts





  • Humeral shaft fractures typically occur by direct trauma to the arm or shoulder in the middle-age population



  • Humeral shaft fractures associated with an ipsilateral forearm fracture result in a floating elbow that requires urgent intervention



  • Associated radial nerve injuries can lead to wrist drop



  • Pain control and adequate immobilization are the key aspects to the emergent care of humeral shaft fractures




Clinical presentation





  • Humeral shaft fractures are much less common than proximal humerus fractures



  • Mechanism of injury




    • Transverse fractures




      • Benign fall with a direct strike to the elbow producing a bending force




    • Spiral fractures




      • Fall on to an outstretched hand with axial loading





  • Physical examination findings




    • Localized tenderness and swelling



    • Painful deformed arm



    • Arm shortening in the setting of displacement




      • Associated radial nerve palsy (wrist drop) occurs in 15–18%



      • Extension of the wrist and digits should be examined






PEARL: Perform a careful neurovascular examination. Radial nerve injury following a humerus shaft fracture may occur.



Diagnostic testing





  • Plain radiographs are the preferred test for evaluation of suspected humeral shaft fractures (Figure 2.7A, B)




    • AP and lateral views of the humerus



    • Trans-thoracic and axillary views of the shoulder



    • Both the shoulder and elbow should be visualized radiographically




PEARL: Consider additional forearm views to exclude concurrent fractures.


Jan 19, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 2 – Shoulder and elbow emergencies
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