2. A man with shoulder pain after a fall AUTHOR DR. TW WONG REVISED BY DR. CLARENCE CHU KWOK KEUNG NOV 2013 HKCEM College Tutorial

3. Triage Had a fall during work, shoulder pain BP130/90 mmHg Pulse100/min Temp37 RR15/min Triage Cat: III

4. Ask him what happened

5. History Whohome decorator When– today How– fell from a ladder about 5 feet Whyslipped Where– workplace What then– landed on ? Shoulder ? Arm NKDA, past health good

6. What are the ddx ? Shoulder dislocation # lateral end of clavicle Dislocation/ Subluxation of AC Jt Associated injuries e.g. rib #, Head & Neck injuries

7. Now proceed to exam patient

8. Examination Look: squaring of shoulder Feel: tender shoulder Move: limited active movement Measure: Neurovascular:

9. Now, what? Arm Sling X-ray Do not forget pain relief

10. Interpret the Xrays

11. What about this X-ray ?

14. A man with this X-ray after a fall. Unable to move with right upper limb

15. Treatment plan Consent Pain relief Close reduction Post reduction check Post reduction Xray Discharge Advice/ FU care

16. Options for pain relief Fentanyl/midazolam (shorter acting) Etomidate 0.1 mg/kg Propofol Pethidine/valium (look out for complications) Intra-articular LA Entonox

17. Reduction methods Non-traction options Spaso External Rotation (Hennepin) Scapular manipulation Stimsons method Traction options Traction-counter traction Hippocrates Kocher The new FARES method Neurovascular exam before CR!

18. 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 )

19. 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

20. 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)

21. 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 )

22. Hippocrates Single operator Foot used as counter- traction

23. Kochers method Traction External rotation => Adduction => Internal rotation http://www.youtube.com/watch?v=8xibzOM7Hp0 ( from 1:37 to 3:05 )

24. 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.

25. 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 )

26. Post-reduction Plan Re-check X-ray And …

27. Check for complications Repeat neuro- vascular exam Check shoulder abduction to pick up complete rotator cuff tear

28. 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

29. Summary We have covered: Recognition of shoulder dislocation (ant, post) Reduction of shoulder dislocation (ant)various methods Pitfalls related to shoulder dislocation

30. The end