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Managing Shoulder Injuries in the Emergency Department: Fracture, Dislocation, and Overuse

  

Fractures, dislocations, and overuse syndromes all produce shoulder pain, but a systematic approach to evaluation and treatment will ensure that your diagnosis and treatment plan locates the source of the pain and reduces the chances that the patient will have life-long disability or life-threatening sequelae.

•  Factor age, mechanism of injury, signs, and symptoms to arrive at a diagnosis.
•  Perform must-do musculoskeletal and neurologic evaluations.
•  Offer analgesia that minimizes use of IV procedural sedation and improves chances for successful reduction.
•  Choose a reduction method that is safe and meet the needs of the patient and the ED team.
•  Sling, swathe, reduction, surgery, or benign neglect? Evidence on each is reviewed.

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Author: Richard Pescatore, DO; Andrew Nyce, MD

Peer Reviewers: John Munyak, MD; Mark Silverberg, MD, FACEP, MMB

Publication Date: June 1, 2018

CME Expiration Date: June1, 2021

CME Credits: 4 AMA PRA Category 1 Credits^TM, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2A or 2B Credits. Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits. 

PubMed ID: 29771483

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1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Anatomy
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Radiographic Studies
   2. Computed Tomography and Ultrasound
10. Shoulder Fractures
    1. Clavicle Fractures
    2. Scapula Fractures
    3. Proximal Humerus Fractures
11. Shoulder Joint Dislocations
    1. Sternoclavicular Joint Dislocation
       1. Posterior Sternoclavicular Joint Dislocation
       2. Anterior Sternoclavicular Joint Dislocation
    2. Acromioclavicular Joint Dislocation
    3. Glenohumeral Joint Dislocations
       1. Anterior Glenohumeral Joint Dislocation
       2. Posterior Glenohumeral Joint Dislocations
       3. Inferior Glenohumeral Joint Dislocations (Luxatio Erecta)
12. Treatment
    1. Sedation and Analgesia
    2. Reduction
       1. Basic Principles
       2. Traction Techniques
          • Traction-Countertraction
          • FARES Method
       3. Leverage Techniques
          • The Kocher Method
          • Scapular Manipulation
       4. Relaxation Techniques
          • Cunningham Technique
          • Davos Technique
    3. Management of Posterior Glenohumeral Shoulder Dislocation
    4. Management of Inferior Dislocation (Luxatio Erecta)
    5. Management of Overuse Syndromes
       1. Subacromial Bursitis and Shoulder Impingement Syndrome
       2. Biceps Tendonitis
       3. Rotator Cuff Syndrome
       4. Adhesive Capsulitis and Frozen Shoulder
13. Controversies and Cutting Edge
    1. Controversies
       1. Glenohumeral Reduction Without X-Ray
       2. Emergency Department Utilization of Intra-articular Corticosteroids
       3. Minimizing Opioid Utilization
    2. Cutting Edge
       1. Ultrasound in Glenohumeral Dislocation
       2. Interscalene Nerve Block
14. Summary
15. Risk Management Pitfalls in Shoulder Injuries
16. Time- and Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway for Managing Suspected Anterior Shoulder Dislocation
19. Tables and Figures
    1. Table 1. Bedside Anatomy of the Shoulder
    2. Table 2. Nonorthopedic Causes of Shoulder Pain
    3. Table 3. Common Shoulder Examination Maneuvers
    4. Table 4. Management and Disposition of Shoulder Fractures
    5. Table 5. Management and Disposition of Shoulder Joint Dislocations
    6. Table 6. Additional Shoulder Reduction Techniques
    7. Table 7. Management and Disposition of Shoulder Overuse Syndromes
    8. Figure 1. Anatomy of the Shoulder
    9. Figure 2. Normal Shoulder X-Rays
    10. Figure 3. The “Lightbulb” Sign of Posterior Shoulder Dislocation on X-Ray
    11. Figure 4. Right Posterior Sternoclavicular Joint Dislocation on Computed Tomography
    12. Figure 5. Type I (Middle Third) Clavicle Fracture on X-Ray
    13. Figure 6. Neer Classification of Proximal Humerus Fractures
    14. Figure 7. Right Anterior Sternoclavicular Joint Dislocation on X-Ray
    15. Figure 8. Rockwood Classification System of Acromioclavicular Joint Dislocation
    16. Figure 9. Acromioclavicular Joint Dislocation, Rockwood Type III, on X-Ray
    17. Figure 10. Anterior Subcoracoid Glenohumeral Dislocation on X-Ray
    18. Figure 11. Anterior Subglenoid Glenohumeral Dislocation With Hill-Sachs Deformity of the Humeral Head on X-Ray
    19. Figure 12. Scapular “Y” View of Posterior Shoulder Dislocation on X-Ray
    20. Figure 13. Axillary View of Posterior Glenohumeral Dislocation With Reverse Hill-Sachs Lesion on X-Ray
    21. Figure 14. Inferior Glenohumeral Dislocation on X-Ray
    22. Figure 15. Traction-Countertraction Technique
    23. Figure 16. Scapular Manipulation
    24. Figure 17. Davos Method of Shoulder Reduction
20. References

Abstract

The complex structures of the shoulder can be injured by fracture, dislocation, and overuse, and correctly identifying and classifying injury is essential to avoiding pain, disability, and life- and limb-threatening complications. This issue presents a systematic approach to classifying shoulder injuries based on the mechanism of injury and clinical presentation, choosing appropriate imaging, and determining the best strategies for treatment, including reduction, surgical consultation, or outpatient referral. Newer recommendations on intra-articular versus intravenous analgesia are presented to increase patient comfort and improve reduction outcomes.

Case Presentations

You are working in the ED on a July day when the EMS phone blares. The local squad reports that a 21-year-old college student appears to have a clavicle fracture with skin tenting after a slip-and-fall accident. Unsure of the best management for this patient, EMS asks whether they should take the patient to the closest ED, which is a small freestanding facility without orthopedic surgery coverage, or whether the patient needs to be taken to your hospital, which has 24/7 orthopedic surgery consultation availability. Your medical student asks you how you make such a decision...

In the meantime, the next patient you see is a 52-year-old “weekend warrior” with left shoulder pain and limited mobility after being tackled in a game of backyard football. The charge nurse states the shoulder appears dislocated and asks whether you want to “pop it back in” before getting x-rays...

Finally, the ED secretary curbsides you. After suffering what she says was a shoulder sprain nearly a month ago, she reports worsening right shoulder pain and limitation in range of motion. The arm has been carefully guarded in a sling, and she asks if you could write her a prescription for oxycodone...

Introduction

The shoulder has remarkable mobility, yet it generally remains exceptionally stable over an individual’s lifespan. Nevertheless, painful shoulder complaints are the third-largest contributor to workers’ compensation costs and disability, with a lifetime prevalence in the United States as high as 67%.^1,2 A 2010 cross-sectional study by Zacchilli et al demonstrated the incidence of shoulder dislocations at 24 per 100,000 person-years.³ While treatment for most shoulder injuries is straightforward, a detailed understanding of the anatomy, function, and pathologies involving the shoulder mechanism can enhance the emergency clinician’s ability to recognize potentially disabling injuries and facilitate rapid intervention and/or specialist consultation. This issue of Emergency Medicine Practice discusses the evaluation and treatment of common and disabling shoulder injuries, with an in-depth review of the current available evidence.

Critical Appraisal of the Literature 

A literature review was performed with a PubMed search for articles on shoulder injuries published through May 2018. Keywords included shoulder, shoulder pain, shoulder dislocation, clavicle fracture, scapula fracture, humerus fracture, glenohumeral, acromioclavicular, sternoclavicular, subacromial bursitis, rotator cuff, and frozen shoulder. The search was limited to human studies in the English language. This produced 3253 articles, over 300 of which were reviewed and 104 were identified as relevant to this review. The majority of the literature is of poor quality, with very few well-designed prospective studies. The majority of recommendations are based on consensus opinion, retrospective database analyses, and case series. No practice guidelines specific to emergency practice were identified.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted

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93. Ottenheijm RP, Cals JW, Weijers R, et al. Ultrasound imaging for tailored treatment of patients with acute shoulder pain. Ann Fam Med. 2015;13(1):53-55. (Prospective observational study; 129 patients)
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