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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