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Shoulder Dislocation, Emergency Medicine

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Shoulder Dislocation, Emergency Medicine

Basics

Description

Dislocation is rare in children: Epiphyseal fractures must be suspected.

Neurovascular injury should be identified and the arm splinted in the position of most comfort.

Make sure to document sensory exam of axillary nerve prior to reduction.

  • Shoulder is a very dynamic joint, prone to injury.
  • Anterior dislocation (90 " “96%):Injury is from direct or indirect forces on the abducted and externally rotated arm.Injury may also result from a direct blow to posterolateral aspect of shoulder.
  • Posterior dislocation:Often missedForces on the adducted and internally rotated arm result in posterior dislocation of humeral head in relation to glenoid fossa.Most common mechanism is seizure and sudden contraction of all the posterior muscle groups.Other mechanisms include electrocution and direct blow to anterior shoulder.
  • Inferior dislocation (rare):Luxatio erectaHyperabduction of arm, tear of rotator cuff, and rotation of arm 180 ‚ ° above headCommonly seen after a fall from a height:Arm has struck object on descent and is thrust above the head.Often accompanied by neurovascular injury and fracture
  • Injury is from direct or indirect forces on the abducted and externally rotated arm.
  • Injury may also result from a direct blow to posterolateral aspect of shoulder.
  • Often missed
  • Forces on the adducted and internally rotated arm result in posterior dislocation of humeral head in relation to glenoid fossa.
  • Most common mechanism is seizure and sudden contraction of all the posterior muscle groups.
  • Other mechanisms include electrocution and direct blow to anterior shoulder.
  • Luxatio erecta
  • Hyperabduction of arm, tear of rotator cuff, and rotation of arm 180 ‚ ° above head
  • Commonly seen after a fall from a height:Arm has struck object on descent and is thrust above the head.
  • Often accompanied by neurovascular injury and fracture
  • Arm has struck object on descent and is thrust above the head.

Etiology

  • Falls from height
  • Impact injuries
  • Distraction injuries of upper arm
  • Seizures
  • Electrocution

Diagnosis

Signs and Symptoms

  • Severe pain in the affected shoulder
  • Anterior dislocation:Shoulder is squared off.Prominent acromion process and palpable anterior fullnessArm is held in slight abduction and external rotation.
  • Posterior dislocation:Coracoid process is prominent, with a palpable posterior bulge.Arm is held in slight adduction and internal rotation.
  • Inferior dislocation (luxatio erecta):Rare but easy to identifyArm is shortened and fixed above head as if raised to ask a question.
  • Head of humerus may be palpable on the lateral chest wall.
  • Shoulder is squared off.
  • Prominent acromion process and palpable anterior fullness
  • Arm is held in slight abduction and external rotation.
  • Coracoid process is prominent, with a palpable posterior bulge.
  • Arm is held in slight adduction and internal rotation.
  • Rare but easy to identify
  • Arm is shortened and fixed above head as if raised to ask a question.

Essential Workup

  • Evaluate neurovascular status of distal arm.
  • Retest neurovascular status after any manipulation.
  • Dislocation requires prompt treatment:Incidence of post-traumatic arthritis increases with time dislocation is untreated.Plain films of the shoulder should be obtained immediately.Even in clinically obvious cases, films should be obtained before manipulation, unless a significant delay will result.An impacted humeral head fracture may be converted to a displaced humeral head fracture if manipulated.
  • Incidence of post-traumatic arthritis increases with time dislocation is untreated.
  • Plain films of the shoulder should be obtained immediately.
  • Even in clinically obvious cases, films should be obtained before manipulation, unless a significant delay will result.
  • An impacted humeral head fracture may be converted to a displaced humeral head fracture if manipulated.

Diagnosis Tests & Interpretation

  • At least 2 views should be obtained:Anteroposterior (AP):To visualize dislocation or fractureTrans-scapular Y or axillary view:To visualize if anterior or posterior
  • Anterior dislocation:Posterolateral compression fracture of the humeral head (Hill " “Sachs deformity)Corresponding lesion on anterior glenoid rim is the Bankart lesion:These do not require treatment.Fractures of the greater tuberosity of the humeral head are seen in 15 " “35%:If there is >1 cm displacement after reduction, surgical intervention may be necessary.
  • Posterior dislocation:Often missed on AP film
  • Degree of overlap on radiographic film is smaller and displaced superiorly, producing the meniscus sign.
  • Rotated humerus yields "light bulb on a stick "  finding on AP view:Reverse Hill-Sachs deformity from compression fracture of the anterior medial humeral head may also be seen.
  • Anteroposterior (AP):To visualize dislocation or fracture
  • Trans-scapular Y or axillary view:To visualize if anterior or posterior
  • To visualize dislocation or fracture
  • To visualize if anterior or posterior
  • Posterolateral compression fracture of the humeral head (Hill " “Sachs deformity)
  • Corresponding lesion on anterior glenoid rim is the Bankart lesion:These do not require treatment.
  • Fractures of the greater tuberosity of the humeral head are seen in 15 " “35%:If there is >1 cm displacement after reduction, surgical intervention may be necessary.
  • These do not require treatment.
  • If there is >1 cm displacement after reduction, surgical intervention may be necessary.
  • Often missed on AP film
  • Reverse Hill-Sachs deformity from compression fracture of the anterior medial humeral head may also be seen.

Differential Diagnosis

  • Fracture of the humeral head
  • Fracture of the humeral shaft
  • Acromioclavicular injury
  • Septic shoulder joint
  • Hemarthrosis in shoulder joint
  • Scapular fracture
  • Cervical spine injury

Treatment

Pre-Hospital

Initial Stabilization/Therapy

  • Airway management and resuscitate as indicated.
  • Exclude more serious injuries, especially in multitrauma patient.
  • Ensure no injury to axillary nerve or vessels.

Ed Treatment/Procedures

  • Adequate analgesia and muscle relaxation are essential for successful reduction:Procedural sedation with a short-acting opioid and a benzodiazepine ORMethohexital or etomidate aloneIn the cooperative patient, intra-articular block only (20 cc of lidocaine 1% or bupivacaine 0.5%) into shoulder joint
  • Anterior dislocation reduction techniques:Scapular manipulation:Patient seated, traction to arm in horizontal plane, countertraction with other hand on clavicle2nd person adducts tip of scapula medially, moving glenoid fossaStimson:Patient in prone position with arm dangling over side, hang 10 " “15 lb around wrist; muscle fatigued over 20 " “30 minCan concurrently use scapular manipulationOnly 1 person requiredTraction/countertraction:Patient in supine position with continuous longitudinal traction to affected armCountertraction from sheet wrapped around chestArm internally or externally rotated if unsuccessful after several minutesExternal rotation:Patient supine; elbow at 90 ‚ °; gentle, slow external rotation of armShould be done slowly and with cooperative patient
  • Posterior dislocation reduction techniques:May use Stimson or traction/countertraction techniques with manipulation of humeral head anteriorly
  • Inferior dislocation (luxatio erecta) reduction techniques:Patient in supine position; gentle longitudinal traction to distract humeral headGentle countertraction with sheet draped over trapezius and chestArm slowly rotated from 180 " “0 ‚ °
  • Postreduction care:Postreduction filmsPlace in sling and swath or shoulder immobilizer immediately after reduction.Shoulder should remain immobilized for 2 " “3 wk in young patients.Immobilization time should be less in older patients to avoid frozen shoulder.
  • Procedural sedation with a short-acting opioid and a benzodiazepine OR
  • Methohexital or etomidate alone
  • In the cooperative patient, intra-articular block only (20 cc of lidocaine 1% or bupivacaine 0.5%) into shoulder joint
  • Scapular manipulation:Patient seated, traction to arm in horizontal plane, countertraction with other hand on clavicle2nd person adducts tip of scapula medially, moving glenoid fossa
  • Stimson:Patient in prone position with arm dangling over side, hang 10 " “15 lb around wrist; muscle fatigued over 20 " “30 minCan concurrently use scapular manipulationOnly 1 person required
  • Traction/countertraction:Patient in supine position with continuous longitudinal traction to affected armCountertraction from sheet wrapped around chestArm internally or externally rotated if unsuccessful after several minutes
  • External rotation:Patient supine; elbow at 90 ‚ °; gentle, slow external rotation of armShould be done slowly and with cooperative patient
  • Patient seated, traction to arm in horizontal plane, countertraction with other hand on clavicle
  • 2nd person adducts tip of scapula medially, moving glenoid fossa
  • Patient in prone position with arm dangling over side, hang 10 " “15 lb around wrist; muscle fatigued over 20 " “30 min
  • Can concurrently use scapular manipulation
  • Only 1 person required
  • Patient in supine position with continuous longitudinal traction to affected arm
  • Countertraction from sheet wrapped around chest
  • Arm internally or externally rotated if unsuccessful after several minutes
  • Patient supine; elbow at 90 ‚ °; gentle, slow external rotation of arm
  • Should be done slowly and with cooperative patient
  • May use Stimson or traction/countertraction techniques with manipulation of humeral head anteriorly
  • Patient in supine position; gentle longitudinal traction to distract humeral head
  • Gentle countertraction with sheet draped over trapezius and chest
  • Arm slowly rotated from 180 " “0 ‚ °
  • Postreduction films
  • Place in sling and swath or shoulder immobilizer immediately after reduction.
  • Shoulder should remain immobilized for 2 " “3 wk in young patients.
  • Immobilization time should be less in older patients to avoid frozen shoulder.

Medication

  • Bupivacaine 0.5%: 20 cc intra-articular to shoulder
  • Diazepam: 5 " “10 mg IV (peds: 0.2 mg/kg)
  • Etomidate: 0.2 mg/kg IV (adult and peds)
  • Fentanyl: 50 " “100 Ž Όg IV (peds: 2 " “4 Ž Όg/kg)
  • Lidocaine 1%: 20 cc intra-articular to shoulder
  • Methohexital: 1 " “1.5 mg/kg IV (peds: Not routinely used)
  • Midazolam: 2 " “5 mg IV (peds: 0.035 " “0.1 mg/kg)
  • Morphine: 2 " “8 mg IV (peds: 0.1 mg/kg); use preservative-free formulation.
  • Propofol: 1 " “2 mg/kg IV

Follow-Up

Disposition

  • Failure to reduce shoulder may require admission for reduction under general anesthesia or open reduction.
  • Patients with neurovascular compromise
  • Patients with successful reductions, confirmed by plain films, may be discharged with shoulder in appropriate immobilizer and with orthopedic follow-up.
  • Recurrent dislocation may require elective surgery.
  • Patients with residual neurapraxia from injury or manipulation may be safely discharged with instructions that most symptoms will resolve, but should have neurology follow-up.
  • Patients with residual neurapraxia should be advised to see a neurologist.
  • Routine orthopedic consultation should be advised with all successful reductions.

Pearls and Pitfalls

Additional Reading

  • Hendey ‚ GW. Necessity of radiographs in the emergency department management of shoulder dislocations. Ann Emerg Med. 2000;36(2):108 " “113.
  • Kahn ‚ J. The role of post-reduction x-rays after dislocation. Acad Emerg Med. 2001;8(5):521.
  • McNamara ‚ RM. Reduction of anterior shoulder dislocations by scapular manipulation. Ann Emerg Med. 1993;22(7):1140 " “1144.
  • Perron ‚ AD, Ingerski ‚ MS, Brady ‚ WJ, et al. Acute complications associated with shoulder dislocation at an academic emergency department. J Emerg Med. 2003;24(2):141 " “145.
  • Quillen ‚ DM, Wuchner ‚ M, Hatch ‚ RL. Acute shoulder injuries. Am Fam Physician. 2004;70(10):1947 " “1954.
  • Sileo ‚ MJ, Joseph ‚ S, Nelson ‚ CO, et al. Management of acute glenohumeral dislocations. Am J Orthop (Belle Mead NJ). 2009;38(6):282 " “290.
  • Ufberg ‚ JW, Vilke ‚ GM, Chan ‚ TC, et al. Anterior shoulder dislocations: Beyond traction-countertraction. J Emerg Med. 2004;27(3):301 " “306.

Codes

ICD9

  • 831.00 Closed dislocation of shoulder, unspecified
  • 831.01 Closed anterior dislocation of humerus
  • 831.02 Closed posterior dislocation of humerus
  • 831.03 Closed inferior dislocation of humerus
  • 831.04 Closed dislocation of acromioclavicular (joint)
  • 831.09 Closed dislocation of shoulder, other

ICD10

  • S43.006A Unsp dislocation of unspecified shoulder joint, init encntr
  • S43.016A Anterior dislocation of unspecified humerus, init encntr
  • S43.026A Posterior dislocation of unspecified humerus, init encntr
  • S43.036A Inferior dislocation of unspecified humerus, init encntr
  • S43.086A Other dislocation of unspecified shoulder joint, init encntr
  • S43.109A Unsp dislocation of unsp acromioclavicular joint, init

SNOMED

  • 417076003 dislocation of shoulder joint (disorder)
  • 263021005 Anterior dislocation of shoulder joint (disorder)
  • 263022003 Posterior dislocation of shoulder joint (disorder)
  • 281502009 Luxatio erecta (disorder)
  • 125614009 Closed traumatic dislocation of glenohumeral joint (disorder)
  • 263019000 Dislocation of acromioclavicular joint (disorder)