Shoulder Dislocation (antero-inferior)

see also:

• http://broadcomplex.com.au/2010/05/30/the-shoulder/

• an extremely painful dislocation, and a common challenge for emergency doctors
• sedation-free reduction has benefits for the patient but be mindful that patient selection is key
• with all techniques DO NOT tug at the arm as this only worsens reflex muscle spasm which will make your job harder
• the main aim is to get the humeral head into a suitable position then remove the dynamic obstruction of muscle spasm by getting the patient to release their muscles (pectoralis major, deltoid and long head of biceps):
  • reassurance, encouragement, confidence in the operator, a calm approach, etc.
  • shortening biceps muscle by flexion of the elbow
  • muscle massage
  • if these fail then pharmacologic strategies such as IV fentanyl/midazolam, or IV propofol (only by senior doctor) will likely be required
• adduction techniques may not be possible in obese patients
• remember to test for and document axillary nerve sensory function before and after reduction
• it is customary to X-ray BEFORE and AFTER reduction primarily to ensure there are no fractures present such as:
  • fractured surgical neck of humerus or avulsed humeral tuberosity and not a dislocation
  • Hills-Sachs deformity
• in young adults with first dislocation, consider contacting ortho team post-reduction as may be a candidate for early repair
• in all cases after reduction, patient should avoid external rotation for at least 2 weeks (hence a sling), and be encouraged to perform shoulder and elbow exercises to avoid them becoming stiff.
• consider referral to an orthopaedic service such as a fracture clinic within ~2 weeks to determine need for ongoing physiotherapy, ability to work and need for surgery in the case of recurrent dislocators.
• those over 40yrs in particular, have a high incidence of acute rotator cuff tear which warrants diagnostic US or MRI within 2wks if there is ongoing suggestive symptoms with view to possible surgery within 1 month of injury

• developed (and published) by Spaso Miljesic in Western Hospital ED, Melbourne
• lie patient supine / semi recumbent at 30 degrees
• gently (and very gradually) elevate arm to about 90 degrees forward flexion of the shoulder and maintain gentle steady traction whilst minimising muscle spasm
• gently externally rotate arm (after reaching full flexion) and wait for muscle to relax and enlocation to occur
• NB. note the similarity with the scapular rotation technique - but without the scapular rotation - as that's a bit hard when patient is lying on it.
• the Spaso technique video
• may require IV access and titrated fentanyl/midaz to achieve reduction

• published by Dr Mark Zagorski (Victorian GP) in 1995
• sit the patient on a stable chair with a back-rest
• sit or kneel opposite the patient, facing them
• place patient's palm/fingers on your shoulder so that their elbow is fully flexed to shorten biceps and rest your hand on their forearm
• with your other arm, massage their pectorals, deltoid, and mid-biceps while chatting with patient to provide reassurance and encourage them to sit up and breathe
• reassure the patient that there will not be any sudden or unexpected movements
• take your time - 5 to 10 minutes may be needed before the patient can release the muscle spasm
• an assistant may provide reassurance to the patient and help them focus on breathing and sitting up

• Must take place in a monitored cubicle with dedicated airway staff and full equipment check
• Doctor must have completed procedural sedation training and have advanced airway skills
• Seek consultant supervision for all procedural sedation
• Main options are Fentanyl and Midaz or Propofol alone
• These two strategies have been compared in a blinded trial:

http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2005.tb01471.x/abstract

• Milch manoeuvre or Kocher's manoeuvre are commonly used to reduce the shoulder once the patient is sedated
• However, when using propofol the concomitant muscle relaxation renders most manoeuvres rapidly successful

• rarely required as the above three strategies will allow management of almost all ED shoulder dislocation patients
• may be useful if anaesthetic risk precludes sedation
• strict aseptic technique required
• US localisation of gleno-humeral joint space is an option

• patient should be placed in a broad arm sling and advised to avoid to external rotation and abduction until review by physio / GP / ortho.
• shoulder and elbow exercises to minimise stiff joints developing
• analgesia
• patients with first episode should be referred to ortho. within a few days for consideration for early primary arthroscopic Bankart repair which has been shown to confer a marked benefit
  • this early repair is usually best done within 3-4 days of injury before haematoma has organised which makes repair difficult.
  • PRIMARY ARTHROSCOPIC STABILIZATION FOR A FIRST-TIME ANTERIOR DISLOCATION OF THE SHOULDER. Robinson et al. THE JOURNAL OF BONE & JOINT SURGERY. VOLUME 90-A d NUMBER 4 d APRIL 2008.
• see also Annals of Emergency Medicine. McNeill NJ, Post-reduction management of first-time traumatic anterior shoulder dislocations. Volume 553 (6); 2009: 811- 813.

Addenda:

• Scapular rotation technique
• bring arm to 90deg forward flexion and externally rotated
• apply steady traction without jerking
• have assistant rotate scapula by pushing inferior tip medially while pushing superior aspect laterally
• this can also be achieved prone with patient holding a weight to allow a single operator rotate the scapula

see also:

• orthopaedics in the ED
• posterior dislocation of the shoulder
• Use of US guided intra-articular lignocaine for shoulder reductions instead of sedation
• The Spaso technique
• Neil Cunningham's website on anterior dislocation of the shoulder