Clinical Case 092: Shoulder Shrugging
It is the end of September. In Australia that means Grand Final season all over the country – the amateur players of all sorts of football codes are not holding back – this is the business end of the season, the time where caution is thrown to the wind and passions are high…. as is the rate of injury on the field! Last weekend I saw 3 nasty shoulder injuries present one after the other in a tightly fought local grand final match. And the odd thing was they were all triaged as “dislocations” but they turned out to be…. a dislocation, an AC disruption and a distal clavicle fracture. Now you don’t want to be pulling on 2 of those!
All this got me thinking about how I approach the acute shoulder trauma in ED.
Now in my ED the normal practice when a young guy walks in holding his arm with a deformed shoulder is that the doctors all start arguing about the best “reduction technique” . It is amazing how passionate we can get over these things! There are traditionalists with their Kocher’s or similar, then the modernists with the Snowbird or Cunningham techniques. In fact there are about a dozen described / eponymous ways to reduce a shoulder – all with varying theory and success rates.
Now I might be a bit of a cynic, but whenever I see that many guys naming things after themselves I can only conclude that none work well, or they all work equally and it is a bit silly discussing the details?
Of course, there is the Anaesthesia technique – which involves a slug of propofol and a firm pull. Never fails in my experience – but has obvious risks in some situations. Though recently I have been using the Cunningham technique a bit and it is probably the safest and requires the least amount of force – so why not use it first line then move on if it fails?
So I have been trying to come up with an idiot-proof approach – a protocol to follow that will get these patients treated quickly, safely and with as few errors as possible.
The basis is a 4 point ultrasound survey – it is quick and simple and you can practice it on your mates.
Here is how it works, a young guy presents with a history of trauma – tackled onto the point of his shoulder etc….
Grab your portable US unit and there are the 4 points that you want to look at:
(Start with the curvilinear probe depth around 7 cm.)
- Proximal humerus – follow the cortex up from mid shaft to the humeral head – you can do this once laterally and once posteriorly to pick a humeral fracture with good reliability.
- Once you have reached the humeral head slide the probe around the back – here is a Mike Stone video demo. You will see the point where the glenoid articulates – in a dislocation this will be abnormal, usually anterior / inferior displacement and a haematoma in the opened joint space.
- If you don’t see that then go onto this step – get the linear probe and place it over the AC joint (see Sonosite video) – you might see a haematoma over the joint, or a widened joint space (compare it to the other side). If unsure – then ask the patient to adduct the arm across te chest – the space will open up is the ligament is disrupted
- Last point is the distal clavicle. Simple continue along from the AC joint and trace along the clavicle (it does curve!) looking for a cortical break.
So that all only takes a few minutes, in that time you can take the history, ask about previous dislocations, check fasting status and arrange some analgesia.
Now I work in a department where radiology is available about half the time – really just in office hours. I can call the Radiographer in from home to confirm an injury if it helps – but this scan will give you all you need to carry on with reduction or just tuck it in a sling and get them back to exclude a Hill-Sachs / Bankart tomorrow… or the next day.
Now I know what you are going to say: “Dude, I can pick a dislocation, I don’t need an Xray!” And I agree – usually we can, but none of us are perfect, and my recent shift showed me how easy it is to get it wrong. So why not spend that extra minute getting it right, confirming your diagnosis and avoiding the occasional embarrassment and agony of dragging on a nasty AC joint lesion!
Any comments welcome. I will try and come up with my own instructional video for you all soon.
great post Casey, much more useful than those PE ones!
SHoulder injuries and bedside USS are a winning combination.
Had a recent retrieval case of collapsed guy who was seen by rural doc in remote location. C/o sore right shoulder++..no xray..no obvious cause of collapse so send into hospital for xray and review.
When I saw him for retrieval, prior to putting in air craft, found very swollen shoulder area and pain ++. Quick USS as you describe here and able to Dx posterior shoulder dislocation and exclude # humerus/clavicle
Even better used USS to do interscalene nerve block and the guy got such pain relief he gave me a thumbs up …with his injured arm!…just kidding ..with his uninjured arm!
Much better than filling him up with morphine so he can vomit in flight!