Shoulder Dislocation and Reduction



Shoulder Dislocation and Reduction


Olabiyi Akala and Maureen Gang


INDICATIONS



imagesHistory and clinical examination consistent with shoulder dislocation


   imagesAnterior Dislocation (~95%)


      imagesMechanism


        imagesForce applied to an externally rotated, abducted, and extended arm


        imagesRarely secondary to a blow to the posterior shoulder


      imagesExamination


        imagesProminent humeral head anteriorly and a shallow depression inferior to the acromion may be observed


        imagesAffected extremity usually held in abduction and external rotation


   imagesPosterior Dislocation (2%–4%)


      imagesMechanism


        imagesAxial loading of adducted and internally rotated arm


        imagesLess commonly due to direct blow to anterior shoulder or fall on an outstretched arm


        imagesMay result from violent muscle contractions: e.g., seizures, electric shock, psychiatry patients


      imagesExamination


        imagesProminence of posterior shoulder with flattening anteriorly; may be subtle


        imagesAffected extremity typically held in adduction and internal rotation


        imagesPatient usually unable to externally rotate affected extremity


   imagesInferior dislocation (luxatio erecta)—rare


      imagesMechanism


        imagesForceful hyperabduction of the affected extremity


      imagesExamination


        imagesAffected arm is held above the head


        imagesPatient is unable to adduct the affected extremity


imagesRadiographs demonstrate glenohumeral dislocation


CONTRAINDICATIONS



imagesAny associated fracture—particularly fracture of the humeral neck


   imagesObtain orthopedic consultation


imagesAny associated neurologic deficit


   imagesClosed reduction may still be attempted but multiple attempts should be avoided


RISKS/CONSENT ISSUES



imagesRecurrent dislocation


   imagesRisk dependent on age at initial dislocation, with recurrence risk up to 90% for those <20, up to 70% for those between 20 and 40 and between 2% and 4% for those older than 40


imagesIncreased risk of associated rotator cuff injuries in patients >40 years of age


imagesComplications of reduction


   imagesRisks associated with procedural sedation


   imagesNeurovascular injury


   imagesFracture of humerus and glenoid



imagesGeneral Basic Steps


   imagesThorough examination of affected extremity, including neurovascular status


   imagesAnalgesia/sedation/muscle relaxation


   imagesReduction via preferred technique


   imagesPostreduction care and follow-up


LANDMARKS—FIGURE 62.1



imagesTechnique


   imagesPhysical Examination


      imagesCompare both the affected and unaffected extremities


      imagesPerform a thorough neurovascular examination of the injured extremity


        imagesA sensory deficit over the deltoid (the so-called sergeant’s-stripe pattern) or an impaired deltoid contraction implies an axillary nerve injury


        imagesAll major nerves to the arm should be assessed as injuries to the brachial plexus, ulnar, and radial nerves have been reported


   imagesRadiographs


      imagesObtain before reduction if the clinician is unsure of the position/type of dislocation or if there is concern for an associated fracture


      imagesMay defer prereduction films if the clinician is confident of an anterior dislocation based on physical examination, the patient is <40, with a history of recurrent dislocations, and the mechanism of the dislocation is not associated with direct trauma


      imagesAnteroposterior (AP), scapular Y, and axillary lateral view should be obtained


        imagesA single x-ray view should never be used to diagnose a shoulder dislocation


      imagesIn anterior dislocations, the humeral head is anterior in the axillary view (using the coracoid process as a point of orientation, and anterior to the center of Y in the trans-scapular view


      imagesIn posterior dislocations, the AP view may be diagnostic if it shows a partial vacancy of the glenoid fossa (vacant glenoid sign) and >6 mm space between the glenoid rim and humeral head (positive rim sign). The humeral head is posterior on axillary view and posterior to center Y on trans-scapular view.



images


FIGURE 62.1 The essential anatomy of the shoulder. (From Sherman S. Shoulder injuries. In: Wolfson AB, ed. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:248, with permission.)


   imagesSedation, Analgesia, and Muscle Relaxation


      imagesAdequate analgesia, muscle relaxation, and/or sedation help facilitate successful reduction


        imagesA recent systematic review of intra-articular lidocaine vs procedural sedation showed no significant difference in reduction success rates, pain during reduction, and pain after reduction


        imagesIt is reasonable to attempt initial reduction with intra-articular local anesthetic; if unsuccessful, the clinician may consider procedural sedation for subsequent attempts


        imagesEnsure that the patient relates the use of intra-articular lidocaine to the orthopedic surgeon during follow-up


      imagesIntra-articular Injection of Lidocaine


        imagesCleanse the shoulder with povidone–iodine solution


        imagesInsert the needle 2 cm inferiorly and directly lateral to the acromion, in the lateral sulcus left by the absent humeral head


        imagesFill a 20-mL syringe with 1% lidocaine. Attach a 1.5-inch 20-gauge needle to the syringe (FIGURE 62.2).


        imagesWithdraw to ensure you are not in a blood vessel prior to the injection of 15 to 20 mL of lidocaine into the joint space


   imagesShoulder Reduction


      imagesThe guiding principle for all methods of reduction should be a gradual and gentle application of technique (FIGURE 62.3)


      imagesThe treating physician should be comfortable with several methods of reduction because no technique is 100% effective. The following techniques are described in this chapter:


        imagesStimson maneuver


        imagesScapular manipulation


        imagesTraction–countertraction


        imagesMilch technique


        imagesHennepin or external rotation method


        imagesCunningham technique


        imagesPosterior dislocation reduction


   imagesPostreduction Care


      imagesObtain postreduction x-rays


      imagesPerform a postreduction neurovascular assessment and document the findings


      imagesPosition at discharge is controversial. Evidence regarding external rotation splinting is still evolving. Patients should be placed in a shoulder immobilizer or sling and swath for 2 to 3 weeks.


      imagesArrange orthopedic follow-up in 1 to 2 weeks


        imagesOlder patients (<40) should have early follow-up within ~1 week to prevent adhesive capsulitis (frozen shoulder)


imagesStimson Maneuver


   imagesPatient is positioned prone with dislocated arm overhanging the bed


   imagesWeight of 5 to 15 lb (initially supported by the physician) is strapped to the wrist of the affected extremity


   imagesTraction is gradually exerted on the shoulder by slow and steady release of the physician’s support


   imagesUp to 30 minutes of sustained, steady traction may be necessary for reduction


   imagesReduction may be facilitated by delicate external rotation of the affected extremity


   imagesAdvantages: Can be performed by the lone practitioner without assistance


   imagesDisadvantages: Often requires more time and materials (weights and straps) than may be readily available (FIGURE 62.4). Not appropriate for all patients, particularly those with respiratory compromise.



images


FIGURE 62.2 A, B: Normal shoulder joint. C, D: Anterior dislocation of the shoulder. (From Young GM. Reduction of common joint dislocations and subluxations. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:1083, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Shoulder Dislocation and Reduction
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