Disjointed – a quick update on shoulder dislocations
Glenohumeral joint dislocations are the most commonly dislocated major joint in the body.
Predisposed by a lack of intrinsic bony stability (the joint is very shallow) together with a wide range of motion. Anterior dislocations by far the most common type. Mechanism might help predict the type of dislocation – see below.
Find out about any numbness, tingling, weakness or history of prior dislocations. Identify associated injuries: BP, axillary nerve, radial nerve or axillary artery. Incidence of axillary nerve injuries increase with age (5 – 54%).
Management
Recommendations
- Early restoration on the anatomic position of humeral head – with time reduction success decreases due to local swelling.
- Recognition of other injuries associated with dislocations or reduction.
- Immobilization to prevent recurrent dislocations.
Treatment algorithm
It is very painful and optimal analgesia is indicated as soon as possible. Options include, but are not limited to:
- Perfalgan: 15mg/kg (plus-minus an opioid)
- Fentanyl: 2 – 20mcg/kg
- Ketamine: 0.1 – 0.3mg/kg
- Morphine: 0.1mg/kg
- Penthrop: self-administered inhalation until desired effect is achieved
- Regional block if you are proficient with this skill.
Procedural sedation and full relaxation ensure a smooth and simple reduction. See ERC protocols:
- Procedure Consent Form
- Procedural Sedation Policy
- Obtain written consent prior to procedural sedation and reduction
- Preferably have one doctor for sedation and one doctor to perform the reduction
Minimal mandatory monitoring:
- Blood pressure (frequently during sedation)
- Heart rate (ECG)
- Breath rateETCO2
- Pulse oximetry
Medication options include, but are not limited to:
- Ketamine: 1mg/kg over 2 -3 minutes
- Propofol: 0.5 – 1mg/kg over 1 – 5 minutes and titrated by 10 – 20 mg bolus injections as needed
Options for reduction of anterior dislocations
Kocher:
- Elbow flexed to 90 degrees and the arm then pressed (adducted) against the side of the body.
- After that slowly rotate forearm outward (75 degrees laterally) until resistance is felt, then the point of the elbow is lifted forwards and adducted.
- Finally the arm is rotated medially.
Hippocratic: simplest and most commonly method:
- Downward traction applied by clinician performing reduction.
- Assistant applies counter traction by holding a sheet wrapped around patient’s chest and under patient’s axilla and pulling it towards the patient’s contralateral shoulder.
Stimson: helpful technique if is contra-indicated
- Patient prone, 3-5 kg weight at wrist.
- Apply gentle internal and external rotation. Reduction should occur within 20 minutes.
Milch
- With patient prone, place one hand on patient’s axilla and other hand holding patient’s hand.
- Gently abduct arm fully, then externally rotate and apply gentle traction for reduction
Scapular manipulation: quickest and safest option by repositioning glenoid fossa for reduction.
- With patient upright or prone with arm hanging off table, apply downward traction.
- Rotate inferior tip of scapula medially with direct pressure while rotating superior and medial edges lateral.
Scapular manipulation: quickest and safest option by repositioning glenoid fossa for reduction.
- With patient upright or prone with arm hanging off table, apply downward traction.
- Rotate inferior tip of scapula medially with direct pressure while rotating superior and medial edges lateral.
Reduction of inferior dislocations
- Urgent orthopaedic consultation is necessary.
- Open reduction may be required.
- Closed reduction may be attempted under procedural sedation: traction applied in line with humeral shaft while an assistant applies counter traction. Gentle abduction usually reduces the dislocation.
- Associated brachial plexus- and axillary vessel injury is common.
Reduction of posterior dislocations
- Urgent orthopaedic consultation is indicated.
- Closed reduction may be attempted under procedural sedation: the arm is pulled and rotated laterally, while the head of the humerus is pushed forward.
Post-reduction management
- Urgent orthopaedic consultation is indicated.
- Closed reduction may be attempted under procedural sedation: the arm is pulled and rotated laterally, while the head of the humerus is pushed forward.
Advise to patient
- Do a post-reduction X-ray to ensure that the reduction was effective.
- Ensure that the limb is neuro-vascularly intact post-reduction.
- Immobilisation with a sling: done with arm in internal rotation.
Duration of immobilisation depends on age of patient and complexity:
- Generally 2-3 weeks in older patients
- Up to 6 weeks in younger patients with first dislocation
- Complex cases where there is associated fracture of humerus, rotator cuff tear, axillary nerve injury or recurrent dislocations should be referred to an orthopaedic surgeon early on.
Rehabilitation:
- Refer to physiotherapist for early shoulder exercises prevent adhesive capsulitis.
- Discharge patients on adequate analgesia.
Dislocation – Pearls and critical points
- Document your serial neurovascular examinations.
- Evaluate for associated humeral head fractures.
- Unless urgent conditions contra-indicate pre-reduction films should be obtained in all patients.
- AP, lateral and Y views
- Post-reduction films are required on all reduced dislocations.
- Adequate analgesia and procedural sedation is crucial.
- Joint should be stabilized post reduction.
References
- com [homepage on the Internet]. Johannesburg: Essential Medical Guidance 2020 [cited 2020 Sept 10].
- Hodkinson P, Evans K, editors. Emergency Medicine Clinical Guidance for the Western Cape. 4th Cape Town: Divisions of Emergency Medicine; 2017
- Solomon L, Warwick DJ, Nayagam S. Apley’s Concise System of Orthopaedics and Fractures. 3rd London: Hodder Arnold; 2005
- Wallis LA, Reynolds TA. AFEM Handbook of Acute and Emergency Care. Cape Town: Oxford University Press Southern Africa (Pty) Ltd; 2015