Managing Shoulder Injuries in the Urgent Care: Fracture, Dislocation, and Overuse (Trauma CME)

Table of Contents

 

About This Issue

Shoulder pain can result from fractures, dislocations, or overuse syndromes. A systematic approach to evaluation of shoulder pain in the urgent care setting will help clinicians accurately diagnose the source of pain and minimize the risk of chronic pain and long-term disability. In this issue, you will learn:

How the history, physical examination, and provocative maneuvers are used to diagnose the cause of shoulder pain

Which x-ray views are needed for diagnosis of shoulder injury, based on the suspected injury location

How to select appropriate pain management strategies for acute and chronic shoulder injuries

How to employ selected reduction techniques for dislocations in the urgent care setting

Which injuries require referral for surgical consultation, physical therapy, or emergency department evaluation

CODING & CHARTING: Coding a patient encounter for a shoulder injury is guided by the complexity of the injury and the associated risk. Learn more in our monthly coding column.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Anatomy
6. Differential Diagnosis
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
8. Diagnostic Studies
   1. Radiographic Studies
   2. Other Imaging
9. Shoulder Fractures
   1. Clavicle Fractures
   2. Scapula Fractures
   3. Proximal Humerus Fractures
10. Shoulder Joint Dislocations
    1. Sternoclavicular Joint Dislocation
    2. Anterior Sternoclavicular Joint Dislocation
    3. Posterior Sternoclavicular Joint Dislocation
    4. Acromioclavicular Joint Injuries (Shoulder Separation)
    5. Glenohumeral Joint Dislocations
       1. Anterior Glenohumeral Joint Dislocation
       2. Posterior Glenohumeral Joint Dislocations
       3. Inferior Glenohumeral Joint Dislocations (Luxatio Erecta)
11. Treatment
    1. Analgesia
       1. Minimizing Opioid Utilization
    2. Reduction
       1. Basic Principles
       2. Traction Techniques
          1. Traction-Countertraction
          2. FARES Method
       3. Leverage Techniques
          1. The Kocher Method
          2. Scapular Manipulation
       4. Relaxation Techniques
          1. Cunningham Technique
          2. Davos Technique
    3. Management of Overuse Syndromes
       1. Subacromial Bursitis and Shoulder Impingement Syndrome
       2. Biceps Tendonitis
       3. Rotator Cuff Syndrome
       4. Adhesive Capsulitis and Frozen Shoulder
12. Cutting Edge
    1. Ultrasound in Glenohumeral Dislocation
    2. Ultrasound in Intra-articular Injections
13. Summary
14. Time- and Cost-Effective Strategies
15. Risk Management Pitfalls in Shoulder Injuries
16. Critical Appraisal of the Literature
17. Additional Resources
18. Case Conclusions
19. Coding & Charting: What You Need to Know
    1. Number and Complexity of Problems Addressed
    2. Amount and/or Complexity of Data to be Reviewed and Analyzed
    3. Risk of Complications and/or Morbidity or Mortality of Patient Management
    4. Casts
20. Coding Challenge
21. Clinical Pathways
    1. Clinical Pathway for UrgentCare Management of Suspected Anterior Shoulder Dislocation
    2. Clinical Pathway for Urgent Care Management of Suspected Shoulder Fracture
22. References

Abstract

Shoulder pain is a frequent complaint in urgent care patients. Complaints may be related acutely (due to injury) or chronically (due to overuse). Correct diagnosis of an acute injury is essential to preventing chronic pain, disability, and life- and limb-threatening complications. This review presents a systematic approach to managing shoulder pain in the urgent care setting by providing a framework for classification using mechanism of action and clinical presentation. Appropriate imaging studies and treatment are discussed, along with the indications for immobilization and outpatient referral, versus emergency department evaluation for more serious injuries that need emergent, definitive care.

Case Presentations

A 21-year-old man presents to urgent care after a slip-and-fall accident...

• He appears to have a clavicle fracture with skin tenting.
• You immediately consider whether this patient should be sent directly to the ED…

A 52-year-old man arrives in the urgent care clinic with left shoulder pain and limited mobility...

• The injury was sustained when he was tackled in a game of backyard football.
• The nurse states the shoulder appears dislocated and asks whether you want to “pop it back in” before getting x-rays…

A 55-year-old woman presents to urgent care after falling on an outstretched hand a few weeks prior...

• At the time of the incident, she was treated appropriately for a proximal humerus fracture but did not follow up with orthopedics or physical therapy.
• Today she is complaining of increasing shoulder pain and difficulty with range of motion…

A 60-year-old man with diabetes arrives with right shoulder pain that is worsened when he sleeps on that side...

• The patient states he is a construction worker and uses “vibratory tools” on a daily basis.
• His pain has gradually worsened to the point that daily activities such as putting on a shirt or combing his hair have become intolerable…

Your clinic secretary stops you in the parking lot…

• 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…

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

5. * Ponce BA, Kundukulam JA, Pflugner R, et al. Sternoclavicular joint surgery: how far does danger lurk below? J Shoulder Elbow Surg. 2013;22(7):993-999. (Prospective cohort; 49 patients) DOI: 10.1016/j.jse.2012.10.037

11. * Slaven EJ, Mathers J. Differential diagnosis of shoulder and cervical pain: a case report. J Man Manip Ther. 2010;18(4):191-196. (Case report) DOI: 10.1179/106698110X12804993426884

23. * Rouleau DM, Hebert-Davies J, Robinson CM. Acute traumatic posterior shoulder dislocation. J Am Acad Orthop Surg. 2014;22(3):145-152. (Review article)

26. * Cadogan A, Mohammed KD. Shoulder pain in primary care: frozen shoulder. J Prim Health Care. 2016;8(1):44. (Observational study; 80 patients)

29. * Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964-978. (Systematic review; 32 studies, 7693 patients)

Reid D, Chue WL. Endovascular management of an axillary arterial injury post shoulder dislocation. Emerg Med Australas. 2009;21(6):515-517. (Case report)

44. * Stephens NG, Morgan AS, Corvo P, et al. Significance of scapular fracture in the blunt-trauma patient? Ann Emerg Med. 1995;26(4):439-442. (Retrospective review; 173 patients)

45. Neer CS. Displaced proximal humeral fractures: part II. Treatment of three-part and four-part displacement. J Bone Joint Surg. 1970;52(6):1090-1103. (Observational study; 117 patients) PMID: 5455340

53. * Lenza M, Belloti JC, Andriolo RB, et al. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev. 2014(5):CD007121. (Systematic review; 3 trials, 354 patients) DOI: 10.1002/14651858.CD007121.pub3

65. * Deren ME, Behrens SB, Vopat BG, et al. Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury. Orthop Rev (Pavia). 2014;6(1):5245. (Review article)

94. * Ziradkar R, Best TM, Quintero D, et al. Nonsteroidal anti-inflammatory and corticosteroid injections for shoulder impingement syndrome: a systematic review and meta-analysis. Sports Health. 2023;15(4):579-591. (Systematic review and meta-analysis; 10 studies)

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Keywords: shoulder, injury, fracture, dislocation, overuse syndrome, clavicle, scapula, humerus, joint, glenohumeral, acromioclavicular, sternoclavicular, subacromial bursitis, reduction, rotator cuff, frozen shoulder, adhesive capsulitis, bicep tendonitis, ligament, Neer classification, Rockwood classification, Bankart, Hill-Sachs, luxatio erecta, traction, FARES, Kocher, Davos, intra-articular