ANTERIOR SHOULDER DISLOCATION

You are called to the emergency department to see a 60-year-old man who has fallen while running, injuring his shoulder. These are his radiographs.

1. Describe these x-rays.

These are AP and modified axillary views of the shoulder, which show an anterior dislocation. There is no obvious sign of any associated fracture.

2. How would you manage this patient in the emergency department?

I would undertake a full history and examination, confirming the mechanism and acute nature of the injury, hand dominance, occupation and activities and important co-morbidities. My examination would include a careful neurovascular assessment. This condition requires emergent care. If the patient is in pain I would administer analgesia and would plan to undertake closed reduction of the joint. In my unit, this is done in the emergency department under intravenous sedation. The sedation is administered by an anaesthetist or senior emergency department doctor who is able to manage the airway as required while I would perform the joint reduction with the assistance of a second doctor or nurse. For this, my preferred technique is to use gentle but sustained longitudinal traction with counter-traction provided by a second person using a sheet around the body. I would be prepared for the rare situation where it is not possible to achieve joint reduction in this way. In this situa- tion, I would defer further intervention until the next day routine trauma operating list. I would arrange to take the patient to the operating theatre to attempt a closed reduction with a formal general anaesthetic and muscle relaxant with the potential for open reduction of the joint, should this be needed.

Following joint reduction, I would confirm the position with further radiographs and would scrutinise these for signs of any new associated fracture. I would place the patient in a polysling to immobilise him for comfort and protection.

3. When would you see this patient in the fracture clinic and how would you manage him?

The patient is discharged once safe and the effects of the anaesthetic or sedation have worn off. I would review him in the outpatient clinic at 1 week where I would take him out of the sling and repeat my examination, looking specifically to determine that the shoulder is still in joint, ensure there is no neurovascular deficit, to deter- mine his range of movement and any sign of a rotator cuff tear. I would repeat AP and axillary lateral radiographs to confirm enlocation and to identify any fractures. If all is well, I would refer him to start physiotherapy for shoulder rehabilitation and early active movement. I would leave him in the care of the therapists unless there was a problem.

4. Would your management change if the patient was an 18-year-old rugby player who sustained the injury in a tackle?

One of the problems after shoulder dislocation is recurrent instability. There is evi- dence to suggest that this risk is highest for young males. The dislocation involves a capsulolabral avulsion and in most cases, non-operative management and shoulder rehabilitation allow dynamic shoulder stabilisers to compensate for injured static stabilisers. A patient sustaining this injury in a contact sport may be at an increased risk for recurrent instability and I would have a careful discussion in the clinic about this. This is particularly relevant for young males. If the patient would consider the potential for early surgery or wish to continue contact sporting activities, I would