Dislocated shoulder: what to do when the usual position hurts?

[JakeEMTP]

The reason in my mind for not reducing a dislocation is the possibility of fracture. Even ER docs don't reduce shoulder fractures without x-rays and we shouldn't be doing that either.

What happens if it's not a dislocation but a humeral head neck fracture with that presentation? Try to put that one back in place and you are not going to be successful and more than likely sued big time.

I've never seen a doctor reduce a shoulder dislocation without an x-ray first. Never. But I'm sure others have.

Exactly why I haven't done it Ruff. Like ERDoc said, if and only if, there appeared to be vascular compromise, I might attempt it. As Bones would say " Damn it Jim! I'm only a Paramedic!"

[scubanurse]

I have had a few docs reduce without x-rays, but I'm a special case. Often the patient if they have dislocated multiple times can tell you if it feels the same or different than the times before. The times I've known it's been exactly the same pain/circumstance for dislocation the ER doc will usually just reduce it. But if it feels even slightly different, I tell them and insist on x-rays so that I can be sure my bone graft hasn't cracked.

[zippyRN]

The second picture is probably the best way to sling a dislocated shoulder. That is what I know as the neutral position for the shoulder or the position of use. How often do we have our forearms lay flat against our bellies versus having our arms out a little and to the side? Even as I type this there is a little space in my armpit and my forearms are facing forward.

Think about how when a shoulder dislocates what happens. The humeral head in most cases will roll anteriorly and drop inferiorly a little bit. (I'm guessing your friend had an anterior dislocation so I won't go into inferior or posterior dislocations unless you want me to.) When you try to move the forearm across the abdomen and it is still dislocated, you are putting a tremendous amount of stress and pressure on that humeral head. By abducting (moving the humerus away from the body) the shoulder by about 15 degrees, you are relieving that pressure and more often than not easing the patients pain and reducing the muscle spasms.

After shoulder surgeries, depending on the type, you will see more and more often now people being placed in what is called an Ultra Sling which has that padding and holds the arm at a more natural position.

All in all when it comes to splinting, it's hard to do the wrong thing medically if your patient is more comfortable.

ETA: more info.

Pillows as splints, or for filling voids, can be useful, even with "sling and swath" crevats.

I agree with Kate and Richard here - support in the most comfortable position for the patient - pillows, rolled blankets all have their place - until we know what the dislocation is - forcing it into a text book position may do more harm than good.

For a dislocated shoulder? With proper pain control and sedation, I've had a zero failure rate. Next time it happens to you, give me a call and I'll make sure it goes back in. It should be a piece of cake so don't worry.

the number of anterior dislocations i have seen reduce 'spontaneously' in my care whether that's in an ambulance or in the ED is remarkable... getting the patient well and truely floating on the entonox helps immensely and if it;s still reluctant MSO4 + midaz or a spot of the 'milk of amnesia' in the ED and a quick pull by someone who knows what they are doing will sort 99.99% of anterior dislcations and are significant proportion of inferiors and even posterior dislocations - sometimes you need surgery but that's usually when the shoulder has been reduced to a jigsaw puzzle of a fracture / dislocation ...

Are paramedics allowed to pop back shoulders into place?

circulation critical = time for the first confident and competent provider to reduce ... also encouraging them back in via good analgesia and support doesn't go a miss ... but if it;s none circulation critical it'll wait to get imaging before pulling or for it to pop back into place becasue of the analgesia

[Richard B the EMT]

I just remembered something. Under NYS DoH and FDNY protocols, if unable to "get" a pulse distal to an angulated fracture, as in one where you know the limb don't bend THERE, as being the only time, and as a one shot only deal, EMTs and Paramedics are allowed to attempt reducing the angle of a fracture, otherwise, we are to attempt to splint it as it lies.

[systemet]

Agreed with Ruff. I've never reduced a shoulder without an xray. Shoulder dislocations are pretty obvious but an additional fracture may not be so obvious. I beleive NYS allowed us to reduce a dislocation in the field if there was vascular compromise (this was back in the 90s).

How do you feel about patellar dislocations? Or if the patient has a history of repeated anterior shoulder dislocations?

I just ask because I've dealt with a few situations where I've been filling people full of fentanyl / morphine +/- benzos, and felt like I've just created a bigger problem for the ER once they reduce it, and end up with a somnolent patient.

[DwayneEMTP]

The ER doc let me reduce a patellar dislocation once. It was really simple, and went it just exactly as he said it would. And the instant relief from "Oh My God" to, "Hell, I can go play ball!" was shocking. This may be a case where manipulation over medication would be a superior treatment.

I do tend to agree with you in theory about creating bigger problems by just running drugs and letting the edema develop, but again, I'm not sure if that is a true issue or just one I've come to believe. In my last service, as with this one, we use narcs and benzos together on dislocations. That seems to bring a lot of relief, and in theory will help with the spasm from the dislocated joint, but I have no evidence to support this either.

Great question. But as the doc said, unless we can be sure that a dislocation is not also, or instead, a fracture, then it seems a ton of damage can be done in the field. Though I've had one on myself, and transported several patellar dislocations and it's tough to imagine confusing it for anything else.

Dwayne

Edited August 24, 2011 by DwayneEMTP

[ERDoc]

systemet, I'd rather have a sedated/lethargic pt who has to sit around a little longer in the ER than someone who is in that much pain. I start with 2mg Dilaudid and 5mg Valium as soon as they hit the door. That usually holds them over until the xrays are done and I am ready to hit them with propfol. Even if they are a little lethargic after it has been reduced, as long as they aren't vomiting, desating and have a responsible adult who will be with them, I'm okay letting them go if they are a little loopy. There are methods for reducing shoulder dislocations that don't involve procedural sedation but if you have someone with lots of muscle mass they will require so much medicine that you might as well just go for the sedation. I always sedated for any other dislocation.

Dwayne, yeah, dislocations are pretty obvious. In a shoulder dislocation, you can feel the glenoid fossa. With a patellar dislocation, the patella is looking at the walls. The associated fracture may not be so obvious, which is why I always get xrays. Also, with a shoulder you can get a Hill-Sach's fracture which is a compression fracture of the humeral head that happens when the head pops out of the fossa. It doesn't change what you do but it is good to document beforehand.

[croaker260]

Just food for thought... :Boss-Holzach-Matter self-reduction method

ANyway, A trick a ski patroller actually showed me many many years ago is to use a sling, a pillow, and two slathes. the first swath holds a blanket roll or a pillow in place against the body under the affected shoulder next to the chest wall.

The second one actually slings and swaths/stablilizes the arm over the blanket/pillow, but stabilizing/ keeping it in a position away from the body.

I dont know if this makes sense, I used to have a picture but I cant find it currently.

[Kiwiology]

I wouldn't be too keen to have a pull on it; pillow the void and tie it in place; give him some ketamine and take to hospital

[HERBIE1]

Always position of comfort for a dislocation, which means most ready-made splints probably won't work. It sometimes calls for creative splinting and the filling of voids, but pain management is key since we do not reduce in the field unless there is vascular compromise (never seen that happen with a dislocation). I've accidentally reduced a dislocated knee once. Attempting to make the patient comfortable and applying a splint, I think the patient had a muscle spasm and suddenly went from agony to screaming OH MY GOD, and let out a huge sigh- he was damn near orgasmic. LOL Scared the crap out of me. After undoing all my splinting handiwork, I saw the patella had indeed returned to it's normal position.