shoulderdis_ant

Shoulder Dislocation (antero-inferior)

Introduction:

  • an extremely painful dislocation representing 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 causes reflex 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 this fails then pharmacologic such as inhaled 70% nitrous oxide, or, iv fentanyl/midazolam, or iv propofol (only by senior doctor)
  • 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 Xray BEFORE and AFTER reduction primarily to ensure there are no fractures present such as:
    • fracture 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 USS or MRI within 2wks if there is ongoing suggestive symptoms with view to possible surgery within 1 month of injury

Seated reduction technique (Dr Mark Zagorski):

Sedation-free reduction

  • published by Dr Mark Zagorski (Victorian GP) in 1995
  • sit or kneel opposite 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

Spaso technique

  • developed by Spaso Miljesic in Western Hospital ED, Melbourne
  • lie patient supine / semi recumbent
  • gently elevate arm to 90deg forward flexion of the shoulder and maintain gentle steady traction whilst minimising muscle spasm
  • gently externally rotate arm 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.

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

IV sedation options

  • 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 is commonly used to reduce the shoulder once the patient is sedated
  • However, when using propofol the muscle relaxation produced renders most manoeuvres rapidly successful

After care

  • 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.
shoulderdis_ant.txt · Last modified: 2018/09/02 23:49 by wh