Shoulder Case #1

Shoulder Case #1

50 yo bicycle vs car going 55 mph, he was wearing a helmet, he is holding his right arm above his head and says he can’t move his shoulder. Numbness in hand, weakness with extensor pollicis longus (EPL). Otherwise, neurovascularly intact. No other injuries reported by the emergency physician. What’s going on? What would you do?

  • Know the context of what happened. The story and social factors are important!

  • High or low energy injury?

    • This was a high energy injury

    • More potential for big problems.

  • When approaching trauma patients always consider ATLS: Airway, Breathing, Circulation (ABCs).

    • Airway and Breathing is usually assessed by the trauma team.

    • Circulation in my mind includes checking the pelvis. 

      • Start with checking the Pelvis: 1 person should push 1 time on the iliac wings to check for stability. Look at the AP pelvis xrays as soon as you can. If it is an open book pelvis, close down the volume by placing a sheet over the greater trochs and cinch it down securing with 4 kocher clamps (multiple ways to do this)

  • Don’t let obvious injuries distract you, because they could be distracting the patient. Distracting injuries are a real thing.

  • Do your Head to toe survey to look for other injuries

    • Ortho needs to always do their own survey, to check for other injuries. This means you have to go from head/neck to toe, looking for anything that would communicate an injury. It is really easy to miss open fractures, wounds, closed fractures.

    •  Then start by looking at skin, pressing over every bone Ortho is in charge of.

        • My system is to remember 5 things to check for each extremity: Skin and bones (palpate bones looking for pain), range of motion (ROM), Nerves (Motor, sensation), vascular. 

 

  • You see an abrasion over his left shin, no pain to palpation. You think to yourself, nah, that doesn’t need an xray… he would have flinched when I pushed on his leg. WRONG! Get an xray, long bone films orders are a good way to survey for other injuries. 

    • In an obtunded trauma patient, the trauma team usually gets a Chest/Abdomen/Pelvis CT, why can’t ortho just screen the extremities?

      • Consider ordering long bone screening xrays: Bilateral humerus views, forearm views, tib/fib, femurs, AP pelvis should have already been done)

  • After you complete your survey. Then order necessary xrays.

  • Remember to review all the xrays you ordered.

Remember to review all the xrays you ordered.  

  • This patient was sent out of the ED with a broken leg because there was a lack of communication regarding xray results.

  • Based on a high fibula fracture, he needed ankle xrays. (3 views, AP, Lateral, Mortise, +/- external rotation stress view). If there was widening of the medial clear space, this would be a Maisonneuve type injury and warrant a short leg splint and non-weight bearing until follow up for a surgical discussion.

Back to the shoulder dislocation.

  • This is Luxatio Erecta, an inferior shoulder dislocation.

    • It is one of the mare rare types of shoulder dislocations

    • It has a high incidence of nerve, soft tissue (rotator cuff) injuries, and vascular injury

    • Knowing that this is Luxatio Erecta, he should get a shoulder MRI

    • Also a good physical exam.

      • Skin and bones

        • Skin intact

        • No other painful areas besides shoulder with palpation (sometimes patients don’t feel broken bones with distracting injuries)

      • Motion?

        • Shoulder stuck in abduction overhead

      • Sensation

        • Sensation to light touch (SILT) limited in dorsum of hand (radial nerve)

      • Motor

        • Weak EPL (radial n./PIN)

        • AIN/Ulnar nerves intact

      • Vascular

        • Radial pulse 2+

        • Capillary refill <2seconds

    • So he is likely having some nerve involvement with his shoulder being dislocated. Check the exam after reduction. In an ideal situation, you should always check the exam before and after a reduction.

  • Luxatio erecta shoulder reduction

    • Technique:

      • Turn an inferior shoulder dislocation into an anterior shoulder dislocation

      • Standing superior to arm, please one hand near elbow and the other near the proximal humerus

      • Apply outward traction as you lever down the arm into an adducted position

      • Now reduce shoulder from anterior shoulder dislocation

      • Traction at a 45degree abduction angle with a sheet around the upper chest wedged into the armpit to control the scapula. The sheet should be pulled to wedge into the armpit as the arm is pulled. This works well with adequate sedation.

    • The proximal humerus can fracture during reductions. Always get repeat shoulder xrays after any reduction (3 view, AP, Grashey, and axillary views)

      • This is why you should always get repeat shoulder xrays if another service tries to hand off a shoulder reduction, mid-attempt.

      • In this case you should get repeat shoulder xrays looking for a fracture before you begin, in case something happens, you won’t question whether you or the other team fractured the humerus.

    • Place in shoulder immobilizer

    • Repeat physical exam

    • Follow up in clinic with the MRI results (this is if there was no suspicion for more emergent problems such as a vascular injury on the exam)

       

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