Shoulder / Arm Injuries
Remember analgesia
# clavicle
- Check distal neurovascular status (+/- respiratory exam)
- Treat with sling (or collar & cuff [BestBets] ) and refer to the CUH Fracture Clinic (Referral form)
- Beware greenstick # in children
- Admit (for ORIF) if concern re overlying skin necrosis
# scapula
- Beware other trunk injury as significant trauma needed
- Always check A B Cs
- Exclude chest and neck injury
- ? Associated brachial plexus injury
- Admit CDU if vitals well but significant other injuries not excluded
- Treat with sling & analgesia and refer to the CUH Fracture Clinic (Referral form)
AC Joint dislocation
- Usually from falling directly onto tip shoulder
- e.g. rugby tackle
- Palpable (visible), tender step at ACJ
- Request ACJ views (not shoulder)
- Weight bearing views not needed
- Note malalignment of inferior surface of ACJ
- Or ACJ gap of > 8mm
- Check neurovascular status
- Beware associated neck / chest injury
- Treat with analgesics and sling
- Refer CUH fracture clinic (referral form)
Anterior dislocation of the shoulder
- All suspected dislocations triage category 2 (document pain score and neurovascular status)
- Always X-ray for fracture - except with a recurrent dislocation in a shoulder known to be unstable and which has occurred with minimal force
- Reduction should be attempted first using Entonox, reassurance and a gentle manoeuvre.
- If this fails then manipulate after premedication with Midazolam and narcotic (NB follow sedation chart instructions) by an assisting doctor or arrange a GA, particularly in a muscular patient.
- Beware of respiratory depression after use of narcotic and sedative and in frail individuals, request anaesthetic assistance. Full resuscitation facilities must be immediately available.
- Always check x-ray and record neurovascular status after reduction.
- Sling (under clothes for under 40's, outside clothes in older patients) and refer to CUH fracture Clinic.(Referral form)
- Advise the shoulder will be immobilised for three weeks [Bestbets]
Note Current BAEM guidelines for Dislocated shoulders are:
- Patients with pain score 7 - 10 should have appropriate analgesia within 20 minutes of arrival
- Patients with pain score 4 - 6 should have analgesia offered at triage
- X-ray should be performed within 60 minutes of arrival
- In 75% of cases 1st attempt at reduction should be within 90 minutes and 90% within 2 hours of arrival.
Posterior dislocation of the shoulder
- Painful shoulder after direct anterior trauma or after epileptic fit or electrocution
- May have surprisingly good range of movement (but painful ++)
- Depression (rather than fullness of humeral head) below acromion
- Absence of anterior dislocation on examination
- Check neurovascular status
- Internal rotation gives 'Light bulb' sign or overlap of glenoid and humeral head on PA view (right)
- Confirmation on X-ray taken in another plane.
- Discuss with senior ED staff.
Fractured neck of humerus
- Treat with collar and cuff or sling [BestBets] and refer to the CUH Fracture Clinic (Referral form)
- Sometimes a U-slab is required for extra support.
- Beware Non Accidental Injury in children with proximal humeral fractures [Bestbets]
Rotator cuff lesions
- Arrange physiotherapy unless complete with review by Consultant.
Fractured shafts of humerus
- Treat with collar and cuff and refer to the on-call Orthopaedic Team.
- Check radial nerve (sometimes a U-slab is required for extra support).
