shoulder reduction Archives - Emergency Medicine Ireland

Anatomy for Emergency Medicine 023 – Shoulder: Dislocations

December 18, 2012 by Andy Neill · 4 Comments

This is a fun one. We all love a good dislocation.

I cannot recommend shoulderdislocation.net enough. Spend some time there, get a room, enjoy the view. There’s some great stuff on there.

If you’re into papers then this one from Neil Cunningham from a few years ago has some great stuff in it.

Here’s a video of the technique in action

Image credits:

Radiopaedia.org: Shoulder dislocation with fracture greater tuberosity

Shoulderdoc.co.uk: Rupture long head biceps.

PS apologies for audio on this one. Levels were set wrong.

Filed Under: Anatomy in EM, ortho, shoulder reduction · Tagged: AFEM, Dislcoation, shoulder

Anatomy for EM – The Shoulder Part 1

October 25, 2011 by Andy Neill · 5 Comments

This is a series of posts where I’m trying to transfer my anatomy lectures to a blog format, with emphasis on the clinically relevant points.

Images are mainly from the 1918 Grays, freely available and out of copyright here. Forgive the out of date nomenclature…

The shoulder:

You can describe 4 different joints involved in shoulder movement:

anyone spot the pathology here?

In something complex like shoulder abduction, all 4 joints come into play; this is incredibly important to realise both for pathology and even in terms of examination of what’s normal.

The exceptional thing about the glenohumeral joint is its exceptional range of movement, able to cope with such vital human behaviours as climbing trees to run away from bears, to putting on a bra.
It is often described as having 3 degrees of freedom (which is different from 6 degrees of Kevin Bacon) meaning there is movement along 3 axes. In terms of movements this means flexion/extension, abduction/adduction and internal/external rotation.
The shape of the humeral head and the shallow glenoid fossa allow this range of movement. It also leads to its frequent injury and dislocation

What functions to stop the humeral head falling out of the glenoid?

Static

Intrinsic Ligaments
Extrinsic Ligaments

Dynamic

rotator cuff
long head of biceps

There are 3 “intrinsic” (meaning thickenings of the capsule itself) glenohumeral ligaments, helpfully named sup, mid and inf.
All 3 lie in the anterior capsule

Prevents upward displacement of the humeral head

Note the coracoacromial ligament has nothing to do with the AC joint injuries

Dynamic Stability

largely of the rotator cuff, a group of 4 muscles with attachments into the capsule and all around the humeral head.
Their job is to pull the humeral head into the fossa no matter what position the humerus is in
One attached anterior (subscapularis), one on top (supraspinatus) and two posterior (teres minor and infraspinatus)

Here’s a slightly (and then some) unrealistic video showing them in action

The other, often overlooked aspect of dynamic stability is the long head of biceps
This acts to hold the humeral head into the glenoid fossa; it’s pull is inf and medial therefore this is why it’s so important in dislocations as an active long head of biceps acts to keep the head out of the glenoid

Anterior view of the shoulder. Note long head attaches just above the glenoid not the coracoid process

For some truly great info on this check out Neil Cunningham’s shoulderdislocation.net and here’s a video of him in action reducing a dislocation. Note the massage of the biceps and supraspinatus.

and this one too, illustrating the anatomy

This is one of my favourite ways not to reduce a shoulder. Anybody else think he’s got a grade III AC joint injury and not a dislocation?

It’s worth mentioning scapular manipulation as it’s fairly easy and painless. And even I’ve managed to make it work!

Filed Under: Anatomy in EM, shoulder reduction ·

US Scalene Block for Shoulder Reduction

October 17, 2011 by Andy Neill · 1 Comment

A Prospective Comparison of Procedural Sedation and Ultrasound-guided Interscalene Nerve Block for Shoulder Reduction in the Emergency Department Acad Emerg Med. 2011 Sep;18(9):922-7 PMID 21883635

Not only do we have countless methods of reducing the shoulder, we now seem to be developing lots of ways of making the patient aware that we’re doing it.

This neat little study randomised 40 pts to either an US guided interscalene block with lignocaine/adrenaline or sedation with etomidate.

The guys doing it had attended a special course and had done at least 10 each of these blocks before the study began. So they’re a pretty skilled bunch of people.

The main outcome was time in the department and the nerve block won hands down (1.5hrs v 3hrs)

I fancy giving this a shot as setting up a procedural sedation is such a song and dance. Anything that I can get on with and do myself is always nice to have in the back pocket.

A brief review of the anatomy involved:

the scalene muscles are a group of 3 lateral muscles (from vertebra to ribs) in the neck
you’re looking for the space between anterior and middle scalene unfortunately also occupied by the subclavian artery so remember to use your doppler.
NB the subclavian vein lies anterior to anterio scalene, as does the phrenic nerve.
the glenohumeral joint has innvervation mainly from the posterior cord nerves but also from the suprascapular.
the suprascapular has a high origin near the roots in the plexus hence the need to block so high up.
there’s also a pesky lung apex nearby so be careful with the pointy thing in your hand…

area marked red the target

As a brief thought, the Cunningham method shows us that the long head of biceps (the one that runs within the capsule across the superior part of the joint) is one of the main factors keeping the humeral head out of the glenoid fossa. If we could manage to paralyse biceps individually then that mught be enough to getting the shoulder in. Unfortunately the musculocutaneous nerve that supplies it isn’t always in the most consistent position when it pierces the muscle.

Filed Under: Anatomy in EM, critical appraisal, shoulder reduction, ultrasound ·

Scapular manipulation for shoulder reductions

May 18, 2011 by Andy Neill · 5 Comments

I was back up north doing a locum shift in my old stomping ground last week and had an opportunity to try out a new technique for shoulder reduction.

Shoulders are a lot of fun. They tend to be young and fit and that generally makes the sedation a bit easier.

But getting a sedation done seems to be getting increasingly difficult given the increasing patient numbers we’re seeing. Let’s face it, even getting someone with keys to get the morphine out of the cupboard can be a long process

There are a number of analgesia-free and sedation-free reduction techniques out there though I’ve always been a bit suspicious.

Then I watched this video by Billy Mallon (via EMEDhome).

I’d tried scapular manipulation once before, with the guy sitting in the chair but no joy.

The key, it seems, is to get them lying prone on the bed and then try pushing the tip of the scapula medially.

Stay away from their shoulder, if you hurt them this isn’t gonna work. It’ll probably work much better on your young atheletes who are able to turn themselves onto their belly without you having to haul at them

The other important thing to remember is to keep biceps out of play. If you remember your anatomy the tendon of the long head will be bowstringing over the glenoid fossa in the dislocated shoulder and any tension in it will make getting the head back in a real problem.

It took about 30 seconds or so of “massage” at the inf angle of the scapula and when it relocated there was only the faintest of clunks but the patient assured me it was back in.

If you’re interested in more check out shoulderdislocation.net and in particular check out the video of the Cunningham method below. It looks a bit vodoo but it’s impressive