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A 23 yo man presents with pain in his right shoulder after slipping on the wet floor of the men’s room in the local pub. He is right handed. He appears mildly intoxicated and admits to 3 beers and a plate of moussaka 45 minutes ago. Clinically you suspect a right shoulder dislocation.
Part A – three questions :
- what methods are available to you to fix this man’s problem?
- is imaging required? Justify your answer.
- what sequelae may he suffer?
Two weeks later the same young man is back, this time complaining of pain in the left wrist after a fall on an outstretched arm at the local Footy club. His left wrist appears sore over distal radius with some marked swelling & deformity but is neurovascularly intact. He admits to three beers and a party pizza shared with his footy mates some 45 minutes ago.
Part B – three more questions
- what options do you have to prove or disprove the presence of a fracture?
- what are your options to fix his problem if there is an underlying Colle’s fracture ?
- is he unlucky?
Answers invited – click the LEAVE A COMMENT button at top of this post to reply.
The prize for best answer(s) will be an invitation to a future RuralDoctorsNet podcast…
ANSWERS ARE IN !
Congratulations to Dr Bernadette Morris from NSW for supplying answers to Case #1.
He needs his shoulder relocated. Check out the numerous options at shoulderdislocation.net. My favourites include the Zagorski & Cunningham methods.
Whilst plain films are preferred (ideally the AP and lateral/scapular Y views)) this may be difficult for the solo operator or in remote areas. Of course this does not preclude the need for a thorough history and clinical examination prior, especially to avoid causing harm (eg: mistaking a humeral fracture for a dislocation). A non traction/counter-traction method is ideally suited for primum non nocere.
Most shoulder dislocations will be anterior or antero-inferior (subcoracoid & subglenoid respectively). There is an excellent recent review of posterior dislocation at the Blunt Dissection
In terms of associated injuries, don’t forget to check for fractures (30%) including Hill-Sachs, Bankart lesion and SLAP. Ligamentous injury may include glenohumeral ligament and rotator cuff damage. Nerve damage may involve isolated axillary nerve damage or brachial plexus injuries. Vascular injury is also possible and should be excluded.
First time dislocators should have follow-up X-ray, mandatory if neurovascular deficit, suspected fracture fragment or difficulty relocating the joint. Recurrent dislocators may elect to avoid this. Evidence for sling vs full immobilisation is equivocal; most will mobilise the joint as soon as tolerate pain.
Check out shoulderdislocation.net for more FOAMed goodness on this topic.
Classic ‘dinner fork’ deformity (dorsally displaced and angulated) suggests a Colles’ fracture. X-ray can be useful and is relatively straight-forward to perform and interpret.
X-ray does need to be repeated post-reduction – which can take time to develop films and require re-do of carefully applied plaster. Ultrasound can be useful both to diagnose fractures and to confirm adequate reduction – and has advantage of being a quick bedside test. There is a short four minute video on this from Academic Emergency Medicine
In terms of treatment, he is unfasted and so you may prefer to use a regional technique such as either a Bier’s block, axillary block or a haematoma block.
Needless to say sedation in the unfasted patient is not without risk and I would prefer to either wait until adequate gastric emptying or to secure his airway with a formal RSI, GA-ETT-IPPV for the duration of the procedure. Axillary nerve block is possible with ultrasound – but requires some practice!
For the isolated practitioner, haematoma block may be preferred. Tempting though this is, be aware that a Cochrane review suggested poorer pain relief and adequacy of reduction of haematoma vs intravenous regional anaesthetic techniques, data also supported by BestBETS
Is he unlucky? Perhaps. However you may wish to counsel him on alcohol use and associated trauma!
The issue is whether such incidents be classified as accidents or not. It was over 10 years ago that the BMJ ‘banned accidents’ – suggesting that we abandon terminology such as ‘motor vehicle accidents’ in favour of ‘motor vehicle collisions’ or ‘crashes’. If we are serious about trauma, then there is porbably more bang for buck in trauma prevention – it may not be as glamorous as working in ED or the prehospital environment – but perhaps money is better spent on prevention than cure. I was inspired a few years ago hearing Dr Karim Brohi of trauma.org talking on “being the fence at the top of the cliff rather than the ambulance at the bottom!”
Stay tuned for next case…