CASE #1
A 57 year-old Female s/p trip and fall over “dog barrier” p/w left tricep pain.
- Denies head trauma or LOC
- Normal VS, visible L shoulder deformity, LUE w/ posterior lateral numbness, distal pulses intact, radial pulses 2/4
Figure 1
Demonstrates an anterior shoulder dislocation but no clear acute fracture of humerus
In the ED, there were two unsuccessful attempts to reduce shoulder
- Ortho consulted –> CT Upper Extremity
- Transfer to Jacobi (OR) –> ORIF c/b revision
Shoulder Dislocation
Anterior vs Posterior
- Anterior – anteriorly directed force on the arm when arm is abducted and externally rotated
- Posterior – Axial loading of flexed/ adducted/ internally rotated arm, seizures and electric shock
Shoulder Reduction Techniques:
External rotation
Supine position, gentle downward traction of adducted arm, flexed elbow with external rotation 180 degrees, complete with overhead wide arc motion (Milch)
Prone Scapular
Prone position, arm hanging off gurney/ anterior traction, push inferolateral border of scapula medial and upward to base of neck
Fares
Supine position, manipulate shoulder in a 10 degree arc (ceiling to floor) with external rotation outward to 90 degrees, externally rotate arm at 90 and continue 10 degree arc
Sedation
- Minimal medication – oral motrin, IM morphine, relocation at sporting event or ski slope
- Intra-articular injection – 20cc of bupivacaine using posterior lateral approach
- Conscious Sedation – Propofol 1mg/kg (repeat 0.5 mg/kg q5mins), Versed 0.05 mg/kg titrate q3mins, Ketamine 1 mg/kg (titrate 1 mg/kg q10 mins) – monitored event
Documentation
Be sure to perform both 1) a Vascular assessment (distal pulses) and 2) a Sensory assessment (axillary distribution) before and after reduction
Do not forget inspection, palpation and motor exam including clavicle.
Emergencies
- Loss of radial pulses, extremity coolness need for emergent CT angiography and emergent reduction
- CT also required if unable to reduce shoulder in ED, exact location of humeral head is indeterminate on plain films
This presentation was delivered and summarized by Pierre DesAgnes, MD – PGY3