• Any dislocated shoulder (ie, the humeral head is not in concentric relationship within the glenoid fossa).
| • An anterior shoulder dislocation is most common. The patient holds the arm in abduction and external rotation. |
| • Obtain radiographs, including an axillary view, to detect possible fracture before any reduction maneuvers. |
• Any associated fracture. Patients with fractures should be evaluated by an orthopedic surgeon before a reduction maneuver is performed.
• Medications for muscle relaxation and an appropriate level of conscious sedation.
• A bed sheet.
• An assistant to perform countertraction.
• Inability to reduce the shoulder.
• Additional damage to the humeral head, glenoid, or labrum during the reduction maneuver.
• Traction injury to the brachial plexus and especially the axillary nerve (rare).
• An adequate level of conscious sedation is critical. The patient must have muscle relaxation and should not be “fighting” the reduction maneuver.
• Do not let go once traction is applied to the arm.
• Continuous traction helps relax the muscles that may be holding the humeral head out of the glenoid fossa in a shortened position.
• Perform and document a neurovascular examination both before attempting reduction and after the reduction.
• The shoulder joint consists of the humeral head, which articulates with the glenoid of the scapula (Figure 53–1).
• Although a cartilaginous labrum on the glenoid helps provide additional stability, it is an inherently unstable joint.
• After sedation and muscle relaxation, an assistant provides countertraction while the physician holds the arm at the elbow and applies traction by pulling the arm in a longitudinal direction (Figure 53–2).
• Slight internal and external rotation of the shoulder is used and usually a “clunk” is felt as the humeral head eases into the glenoid and the shoulder reduces.
• Obtain radiographs (2 views) to confirm the reduction.
• The patient is placed in a shoulder immobilizer.
• If an immobilizer is not available, a sling with an elastic bandage wrap holding the arm to the torso can be substituted.
• Recurrent shoulder instability.
• This is related to the age at which the patient has the dislocation.
• Recurrence rates of up to 70% have been reported in patients younger than 22 years.
• Neurologic injury, which often results from traction injuries and generally resolves over weeks to months.
• Fracture.
| • Nursemaid’s elbow, or radial head subluxation, usually occurs in children ages 2–5 and results from longitudinal traction on an extended elbow. This allows the radial head to slip through the annular ligament of the elbow. |
| • The child holds the forearm in pronation and does not allow any supination because of pain. |
• Clinical evidence of radial head subluxation.
• Usually there is a history of a pull to the arm, followed by patient refusal to use the arm.
• The arm is held in a slightly flexed and pronated position against the body. There is no swelling or bruising.
• Swelling or bruising of the arm.
• Witnessed injury (fall) with mechanism unlikely to result in radial head subluxation.
• Perform a neurovascular examination both before and after reduction.
• Perform the reduction maneuver smoothly and decisively so that the reduction is achieved before the patient senses pain.
• The elbow joint consists of the humerus that articulates with the radius and ulna of the forearm.
• The radial head articulates with the capitellum of the humerus, while the ulna articulates with the trochlea of the humerus (Figure 53–3).
• Apply gentle pressure on the radial head (the hand cradles the proximal forearm).
• With the other hand, apply gentle longitudinal traction to the distal forearm, supinate, and flex the arm at the elbow (Figure 53–4A).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
