Shoulder dislocation: Difference between revisions
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==Background== | ==Background== | ||
[[File:Shoulder_joint_back-en.png|thumb|]] | [[File:Gray326.png|thumb|Left shoulder and acromioclavicular joints with ligaments.]] | ||
[[File: | [[File:Shoulder_joint_back-en.png|thumb|Shoulder anatomy, anterior.]] | ||
[[File:Shoulder joint back 05r4v.png|thumb|Shoulder anatomy, posterior.]] | |||
*Humerus separates from the scapula at the glenohumeral joint | *Humerus separates from the scapula at the glenohumeral joint | ||
*Partial dislocation of the shoulder is referred to as subluxation | *Partial dislocation of the shoulder is referred to as subluxation | ||
*Dislocation duration inversely correlated with likelihood of successful ED reduction | |||
=== | {{Shoulder dislocation types}} | ||
==Clinical Features== | |||
*Shoulder pain | |||
*Decreased shoulder range of motion | |||
===Comparison of Shoulder Dislocation Clinical Features=== | |||
{| class="wikitable" | |||
! Finding !! [[Anterior shoulder dislocation|Anterior]] (~95%) !! [[Posterior shoulder dislocation|Posterior]] (~5%) !! [[Inferior shoulder dislocation|Inferior]] (<1%) | |||
|- | |||
| Arm position || Arm maintained in abduction and external rotation || Posterior aspect of shoulder unusually prominent || Humerus fully abducted / Hand on or behind head | |||
|- | |||
| Shoulder appearance || Loss of normal rounded appearance with stretching of the deltoid muscle (i.e., "squared off") || Anterior aspect of shoulder appears flattened || | |||
|- | |||
| Range of motion || Difficulty touching affected arm to contralateral shoulder due to pain || Inability to rotate or abduct affected arm || Humeral head palpable in axilla or lateral chest wall | |||
|- | |||
| Mechanism || Most common; range of mechanisms || Forceful internal rotation and adduction (e.g., blow to anterior shoulder, seizure, eletric shock) || Forceful hyper-abduction of arm | |||
|} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
===Workup=== | |||
*Plain film X-ray | *Plain film X-ray | ||
**Include anteroposterior, scapular Y, and axillary views | **Include anteroposterior, scapular Y, and axillary views | ||
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***Bankart: glenoid labrum disruption with bony avulsion | ***Bankart: glenoid labrum disruption with bony avulsion | ||
***Humeral greater tuberosity fracture | ***Humeral greater tuberosity fracture | ||
*[[Ultrasound: Joint| | *Consider [[Ultrasound: Joint|joint ultrasound]] | ||
===Diagnosis=== | |||
<gallery mode="packed"> | <gallery mode="packed"> | ||
File:AnterDisAPMark.png|[[Anterior shoulder dislocation]] | File:AnterDisAPMark.png|[[Anterior shoulder dislocation]] | ||
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==Management== | ==Management== | ||
===Reduction=== | |||
*'''Do not attempt to reduce chronic dislocations (>4 weeks) in ED due to risk of arterial injury''' - these require reduction in the OR | |||
*Lower complications, equal pain control, and shorter ED stay with intra-articular lidocaine vs. procedural sedation<ref>Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults (Review) Cochrane Database Syst Rev. 2011 Apr 13;(4):CD004919 [http://www.update-software.com/BCP/WileyPDF/EN/CD004919.pdf full text]</ref> | |||
* | **20 mL of 1% lidocaine intra-articular injection | ||
*See individual types for specific techniques: | |||
**[[Anterior shoulder dislocation]] | |||
**[[Posterior shoulder dislocation]] | |||
**[[Inferior shoulder dislocation]] | |||
===Post-Reduction=== | |||
*Post-reduction film to confirm | |||
*Sling and swathe or shoulder immobilizer x1 week / until orthopedics follow-up | |||
**Encourage daily range of motion exercises (minus abduction + external rotation) to prevent adhesive capsulitis | |||
==Disposition== | ==Disposition== | ||
*Uncomplicated dislocation can be discharged after reduction | *Uncomplicated dislocation can be discharged after reduction | ||
*Recurrence rate around 27% if older than 30 years and 72% | |||
==Prognosis== | |||
*Recurrence rate around 27% if older than 30 years and 72% if younger than 23 years<ref>Watson S, Allen B, Grant JA. A Clinical Review of Return-to-Play Considerations After Anterior Shoulder Dislocation. Sports Health. 2016; 8(4):336-341.</ref> | |||
==See Also== | ==See Also== | ||
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*[http://www.youtube.com/watch?v=d9HjtQr0c64 Good all-round shoulder reduction technique lecture] | *[http://www.youtube.com/watch?v=d9HjtQr0c64 Good all-round shoulder reduction technique lecture] | ||
*[http://thecentralline.org/?p=1769 Keeping Up in EM Shoulder Reduction Video] | *[http://thecentralline.org/?p=1769 Keeping Up in EM Shoulder Reduction Video] | ||
*[https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/shoulder-dislocations?query=shoulder%20dislocation Merk Manual - Shoulder dislocations] | |||
==References== | ==References== | ||
Latest revision as of 17:21, 20 March 2024
Background
- Humerus separates from the scapula at the glenohumeral joint
- Partial dislocation of the shoulder is referred to as subluxation
- Dislocation duration inversely correlated with likelihood of successful ED reduction
Shoulder dislocation types
- Anterior shoulder dislocation (~95%)
- Posterior shoulder dislocation (~5%)
- Inferior shoulder dislocation (<1%)
Clinical Features
- Shoulder pain
- Decreased shoulder range of motion
Comparison of Shoulder Dislocation Clinical Features
| Finding | Anterior (~95%) | Posterior (~5%) | Inferior (<1%) |
|---|---|---|---|
| Arm position | Arm maintained in abduction and external rotation | Posterior aspect of shoulder unusually prominent | Humerus fully abducted / Hand on or behind head |
| Shoulder appearance | Loss of normal rounded appearance with stretching of the deltoid muscle (i.e., "squared off") | Anterior aspect of shoulder appears flattened | |
| Range of motion | Difficulty touching affected arm to contralateral shoulder due to pain | Inability to rotate or abduct affected arm | Humeral head palpable in axilla or lateral chest wall |
| Mechanism | Most common; range of mechanisms | Forceful internal rotation and adduction (e.g., blow to anterior shoulder, seizure, eletric shock) | Forceful hyper-abduction of arm |
Differential Diagnosis
Shoulder and Upper Arm Diagnoses
Traumatic/Acute:
- Shoulder Dislocation
- Clavicle fracture
- Humerus fracture
- Scapula fracture
- Acromioclavicular joint injury
- Glenohumeral instability
- Rotator cuff tear
- Biceps tendon rupture
- Triceps tendon rupture
- Septic joint
Nontraumatic/Chronic:
- Rotator cuff tear
- Impingement syndrome
- Calcific tendinitis
- Adhesive capsulitis
- Biceps tendinitis
- Subacromial bursitis
- Cervical radiculopathy
Refered pain & non-orthopedic causes:
- Referred pain from
- Neck
- Diaphragm (e.g. gallbladder disease)
- Brachial plexus injury
- Axillary artery thrombosis
- Thoracic outlet syndrome
- Subclavian steal syndrome
- Pancoast tumor
- Myocardial infarction
- Pneumonia
- Pulmonary embolism
Evaluation
Workup
- Plain film X-ray
- Include anteroposterior, scapular Y, and axillary views
- Associated fractures include:
- Hills-Sachs: cortical depression in the humeral head
- Bankart: glenoid labrum disruption with bony avulsion
- Humeral greater tuberosity fracture
- Consider joint ultrasound
Diagnosis
Anterior shoulder dislocation on Y-view
Anterior shoulder dislocation with fracture
Management
Reduction
- Do not attempt to reduce chronic dislocations (>4 weeks) in ED due to risk of arterial injury - these require reduction in the OR
- Lower complications, equal pain control, and shorter ED stay with intra-articular lidocaine vs. procedural sedation[1]
- 20 mL of 1% lidocaine intra-articular injection
- See individual types for specific techniques:
Post-Reduction
- Post-reduction film to confirm
- Sling and swathe or shoulder immobilizer x1 week / until orthopedics follow-up
- Encourage daily range of motion exercises (minus abduction + external rotation) to prevent adhesive capsulitis
Disposition
- Uncomplicated dislocation can be discharged after reduction
Prognosis
- Recurrence rate around 27% if older than 30 years and 72% if younger than 23 years[2]
See Also
External Links
- Good all-round shoulder reduction technique lecture
- Keeping Up in EM Shoulder Reduction Video
- Merk Manual - Shoulder dislocations
References
- ↑ Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults (Review) Cochrane Database Syst Rev. 2011 Apr 13;(4):CD004919 full text
- ↑ Watson S, Allen B, Grant JA. A Clinical Review of Return-to-Play Considerations After Anterior Shoulder Dislocation. Sports Health. 2016; 8(4):336-341.