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.
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...
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.
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.
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
Points and Pearls Excerpt
Most Important References
Richard Pescatore, DO; Andrew Nyce, MD
John Munyak, MD; Mark Silverberg, MD, FACEP, MMB
June 1, 2018
June 30, 2021
Physician CME Information
Date of Original Release: June 1, 2018. Date of most recent review: May 10, 2018. Termination date: June 1, 2021.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of the article. (2) Mail or fax the CME Answer And Evaluation Form (included with your June and December issues) to EB Medicine.
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