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A man with shoulder pain after a fall

HKCEM College Tutorial. A man with shoulder pain after a fall. Author Dr. tw wong Revised by Dr. clarence CHU Kwok Keung Nov 2013. Triage. Had a fall during work, shoulder pain BP 130/90 mmHg Pulse 100/min Temp 37℃ RR 15/min. Triage Cat: III. Ask him what happened. History.

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A man with shoulder pain after a fall

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  1. HKCEM College Tutorial A man with shoulder pain after a fall Author Dr. twwong Revised by Dr. clarence CHU Kwok Keung Nov 2013

  2. Triage • Had a fall during work, shoulder pain • BP 130/90 mmHg • Pulse 100/min • Temp 37℃ • RR 15/min Triage Cat: III

  3. Ask him what happened

  4. History • Who—home decorator • When– today • How– fell from a ladder about 5 feet • Why—slipped • Where– workplace • What then– landed on ? Shoulder ? Arm • NKDA, past health good

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

  6. Now proceed to exam patient

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

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

  9. Interpret the Xrays

  10. What about this X-ray ?

  11. What about this X-ray ?

  12. What about this X-ray ?

  13. What about this X-ray ? • A man with this X-ray after a fall. • Unable to move with right upper limb

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

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

  16. Reduction methods • Non-traction options • Spaso • External Rotation (Hennepin) • Scapular manipulation • Stimson’s method • Traction options • Traction-counter traction • Hippocrates • Kocher • The new “FARES” method Neurovascular exam before CR!

  17. 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 )

  18. 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

  19. 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)

  20. 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 )

  21. Hippocrates • Single operator • Foot used as counter-traction

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

  23. 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.

  24. 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 )

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

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

  27. 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

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

  29. The end

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