The ?irreducible shoulder dislocation

[migm]

Ortho colleagues,

I (ED MD) was asked by one of my midlevels to assist with sedation on a recurrent anterior shoulder dislocation after the midlevel was unable to reduce it with hanging/weight and scapular manipulation. This individual was in quite a bit of pain and spasm. He was an otherwise healthy young guy who had a good amount of upper body muscle mass.

At approximately 3-4 hours into the ED visit, sedation was achieved but the shoulder could not be reduced with multiple methods. Follow up failed reduction CT showed a hill-sachs deformity, intact glenoid, with the dorsal head of the humerus resting on the anterior labrum. Subsequent complete paralysis, intubation, and closed reduction in the OR was successful but showed evidence of joint instability, and the pt was discharged.

My residency had a very strong ortho program (and an ED that used them like a crutch) and I admit that I do not have a lot of shoulder dislocations under my belt. I have read, watched videos, injected the shoulder joint (although not this one as sedation was planned). I feel like this is an area I can improve on. I would be grateful for any tips, tricks, technique suggestions, does and don'ts that you all may offer so I don't have to call you at 3am.

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[OrthoTraumaMD]

Kocher maneuver, look it up. Go slow...the number one reason for failure is haste. Stop whenever you feel spasm. A good one can take 20-30 min to do properly but can be achieved without sedation or injection. I do not hang or do anything crazy. You will not overpower them, especially a muscular guy. Technique always wins over brute force.


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[migm]

thanks for the reply - kocher was attempted by me and did not work. At that point he was sedated and at times briefly apneic but still felt like he was spasms. I suspect I was rushing by that point though so the tip is well taken

 

[militaryPHYS]

I inject every shoulder and then usually do old school foot in their armpit, traction, ER, adduction. Same idea. But the injection I feel provides some pain relief and expands the joint ?? More theory than science, but works for me every time.

 

[Apollyon]

I inject every shoulder and then usually do old school foot in their armpit, traction, ER, adduction. Same idea. But the injection I feel provides some pain relief and expands the joint ?? More theory than science, but works for me every time.

Old school, you say? Hippocrates, is that you??

 

[Southpaw]

anesthesiologist here - stumbled across this and thought 'hell, I'll be willing to come down and give the patient a block' in such a situation. I realize it's not feasible for every dislocation, but for the rare one where you can't get it in and your sedation gets to be so much that you're uncomfortable (if your patient is apneic we typically call this GA) it may be worth giving us a call to help out. I've read SDN long enough to know most ED docs feel we aren't helpful, but personally I always try to keep the patients best interest in mind. If you were to call me I'd certainly be willing to help out. Word of caution though - with a good block you can do whatever the hell you want with that shoulder (even surgery!) so you have to be careful about causing harm to a shoulder that won't give resistance if it's put in an awkward position.

 

[migm]

an ultrasound guided block is well within my scope of practice, however the thought was I could sedate well enough to obviate this need. That didn't work. There was a very thin line between apnea and him fighting us (well aware that apnea is no longer moderate sedation). He was intubated and paralyzed in the OR

 

[VincentAdultman]

I inject every shoulder and then usually do old school foot in their armpit, traction, ER, adduction. Same idea. But the injection I feel provides some pain relief and expands the joint ?? More theory than science, but works for me every time.

lol. Barbarian!

If what you do works that’s great but you can also get an assistant to pull counter traction from the opposite side of the bed with a stockinette wrapped around the torso.

In case you’re worried about strange looks from passersby.