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

Download Dislocation Table

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