A man with shoulder pain after a fallAUTHOR

DR. TW WONG

REVISED BY

DR. CLARENCE CHU KWOK KEUNG

NOV 2013

HKCEM College Tutorial

Triage

▪ Had a fall during work, shoulder pain

▪ BP 130/90 mmHg

▪ Pulse 100/min

▪ Temp 37℃

▪ RR 15/min

Triage Cat: III

Ask him what happened

History

▪ Who—home decorator

▪ When– today

▪ How– fell from a ladder about 5 feet

▪ Why—slipped

▪ Where– workplace

▪ What then– landed on ? Shoulder ? Arm

▪ NKDA, past health good

What are the ddx ?

▪ Shoulder dislocation

▪ # lateral end of clavicle

▪ Dislocation/ Subluxation of AC Jt

Associated injuries e.g. rib #, Head & Neck injuries

Now proceed to exam patient

Examination

▪ Look: squaring of shoulder

▪ Feel: tender shoulder

▪ Move: limited active movement

▪ Measure:

▪ Neurovascular:

Now, what?

Arm Sling

X-ray

Do not forget pain relief

Interpret the Xrays

What about this X-ray ?

What about this X-ray ?

What about this X-ray ?

What about this X-ray ?

▪ A man with this X-ray after a fall.

▪ Unable to move with right upper limb

Treatment plan

▪ Consent

▪ Pain relief

▪ Close reduction

▪ Post reduction check

▪ Post reduction Xray

▪ Discharge Advice/ FU care

Options for pain relief

▪ Fentanyl/midazolam (shorter acting)

▪ Etomidate 0.1 mg/kg

▪ Propofol

▪ Pethidine/valium (look out for complications)

▪ Intra-articular LA

▪ Entonox

Reduction methods▪ Non-traction options

▪ Spaso▪ External Rotation (Hennepin)▪ Scapular manipulation▪ Stimson’s method

▪ Traction options▪ Traction-counter traction▪ Hippocrates▪ Kocher

▪ The new “FARES” method

Neurovascular exam before CR!

Spaso technique▪ Maintain gentle traction perpendicular to table

▪ When patient has relaxed, gently external rotate

▪ A clunk signifies reduction

▪ http://www.youtube.com/watch?v=8xibzOM7Hp0

( from 3:05 to 3:50 )

External Rotation

▪ Arm should be adducted (with help by operator)

▪ When patient is relaxed, gently external rotate (best to let gravity does its job)

▪ A clunk and full abduction signifies reduction

The Stimson technique for reduction of anterior dislocation of the shoulder.

▪ With the patient in the prone position, a weight is applied to the dislocated shoulder. The humerus returns to its normal position over a period of time.

▪ http://www.youtube.com/watch?v=8xibzOM7Hp0

(from 4:35 to 5:50)

Traction-counter traction

▪ Two operator needed▪ Padding of axilla to prevent excessive pressure▪ Patient relaxed by drug▪ Traction will lever shoulder back

▪ http://www.youtube.com/watch?v=8xibzOM7Hp0

( from 3:50 to 4:20 )

Hippocrates

▪ Single operator

▪ Foot used as counter-traction

Kocher’s method▪ Traction▪ External rotation =>▪ Adduction =>▪ Internal rotation

http://www.youtube.com/watch?v=8xibzOM7Hp0

( from 1:37 to 3:05 )

The new FARES method

▪ From Greece FARES et al 2009 RCT

▪ No sedation / analgesic required▪ Lying supine with elbow fully extended and neutral

position of forearm▪ While maintaining axial traction , apply vertical

oscillation at a rate of 2-3 hertz with a distance of 5 cm above and below the horizontal plane.

▪ Since passing the 90° abduction, the arm is gently externally rotated with the palm now facing upward ,while keeping the vertical oscillation and traction.

▪ Reduction usually occurs at 120° abduction▪ http://www.youtube.com/watch?v=8xibzOM7Hp0

( from 00:00 to 1:35 )

Post-reduction Plan

Re-check X-ray

And …

Check for complications

▪ Repeat neuro-vascular exam

▪ Check shoulder abduction to pick up complete rotator cuff tear

Post reduction immobilisation

▪ New cases vs recurrent cases

▪ Young pt vs old pt

▪ Arm sling vs Shoulder immobiliser

▪ For 3 weeks vs early mobilisation

▪ Surgery: Early vs Late

Summary

We have covered:

▪ Recognition of shoulder dislocation (ant, post)

▪ Reduction of shoulder dislocation (ant)—various methods

▪ Pitfalls related to shoulder dislocation

The end