31 July 2022 at 11:14:34
For simple dislocations - Reduce. Broad arm sling, repeat XR.
For dislocations with fracture - CT shoulder and keep patient fasted
For simple dislocations - On-line referral to VFC.
For complex dislocations - refer to ortho on-call
Presentation
The mechanism of injury can give you a clue as to the direction of dislocation. Anterior shoulder dislocation is most common, often from a forced abduction external position. Posterior shoulder dislocations are less common and are associated with seizures and eletric shock, as well as trauma (flexion, adduction, internal rotation). Inferior shoulder dislocation (Luxatio Erecta) are very rare, where the glenohumeral joint becomes locked under the coracoid process. The arm typically is locked in abduction.
Clinical evaulation
The position of the arm would give a clue as to direction of dislocation:
anterior dislocation - arm in slight abduction and external rotation, anterior shoulder fullness
posteior dislocation - arm in slight internal rotation, posterior fullness
inferior dislocation - shoulder locked in abduction
Examination of the neurovascular status
The most common nerve to be affected is the axillay nerve. (supplies deltoid motor function and sensation over the regimental badge area) - these must be tested and documented before and after reduction. Also complete a full peripheral nerve examination of the radial, median and ulnar nerves.
Inital x ray
A trauma shoulder series X rays will allow radiological evaulation of shoulder dislocation. The views include AP, scapular-Y view, axillary. (if patient cannot abduct arm for an axillary view, then ask the radiologist to perform a velpeau view). The axillary or velpeau views are the most useful to determine direction of dislocation.
To learn more about interpreting simple shoulder x rays - visit here
LOOK CAREFULLY FOR AN ASSOCIATED SURGICAL NECK FRACTURE - a surgical neck fracture of the proxima humerus means that the humeral head is not in continuation to the shaft. Attempting to close manipulate these fracture could worsen the fracture displacement! Sometimes it is hard to spot if the neck fracture is undisplaced. If there are other associated fractures such as fracture of the greater tuberosity, then you should be suspicious of a surgical neck fracture. In these cases, it is best to assess further with a CT scan before attempting reduction.
Immediate A&E management
Simple dislocations
All simple dislocations (without fracture) should be managed by A&E
After confirming dislocation pattern, reduction should be a matter of urgency without delay
Document NV status before and after reduction
Closed reduction - there are multiple techniques (speak to your A&E senior if you are not familiar). Tips: give adequate analgesia. Relaxed muscle is key to successful reduction. Do not force and twist as these can lead to fracture
Provide a broad arm sling for comfort
refer to VFC online
Complex dislocations
These are dislocations assocaited with fracture
referr to ortho oncall
CT shoulder is often required to assess fracture pattern
note: if it is obvoius that the surgical neck is not involved, then it is reasonable to attempt CAREFUL closed reduction in ED.