RIGHT SHOULDER INJURY
A 23-year-old woman is brought to the emergency department having fallen over while on a dry ski slope. She is holding her right arm and is very reluctant to move her shoulder. She has previously had an appendicectomy and is known to have had mild attacks of asthma. She takes salbutamol and beclometasone regularly, and she is allergic to penicillin. She lives with her parents and works in the computer industry.
Her shoulder shows an obvious deformity and looks ‘squared off’, the arm is held in slight abduction and is externally rotated. Both active and passive movement of the shoulder cause pain. The radial pulse and capillary refill are normal.
• What is the diagnosis?
• What are the other essential examination findings that have not been commented on?
• How should this injury be managed?
This patient has sustained an anterior dislocation of her right shoulder. Shoulder dislocations are the commonest joint dislocation, accounting for nearly half of all dislocations.
The glenohumeral joint is a multi-axial ‘ball and socket’ joint and can, therefore, dislocate in any direction. However, in the majority of cases (90–98 per cent) the dislocation is anterior. Posterior dislocation is much less common and is typically secondary to either an epileptic fit or electric shock.
In order to confirm the diagnosis, radiographic assessment should be performed. The commonly used views are the anterior-posterior view in combination with either an axillary or scapular view. The important point is to examine the joint with two different views.
The axillary view has the advantage of showing the glenoid cavity, which may pick up any associated fracture.
An assessment of both the distal vascular and neurological function must be made in any patient with a severe limb injury. The close relationship of the shoulder joint to the brachial plexus makes a nerve injury more likely. At particular risk are the radial and axillary nerves. The incidence of axillary nerve neuropraxias following anterior shoulder dislocation
is quoted at up to 10 per cent. The axillary nerve supplies sensation to the lateral aspect of the upper arm, the ‘regimental badge area’.The majority of anterior shoulder dislocations can be replaced by closed reduction. The key to successful reduction is to ensure adequate analgesia. This will relax the shoulder musculature that is typically in spasm resisting any joint movement. After successful reduction, the patient should be able to touch the contralateral shoulder tip. The shoulder
should be supported in a sling, with radiological confirmation of the reduction.
• A full neurological examination must be performed prior to reduction of any dislocated joint.
• The X-ray should be carefully examined for associated fractures.
• Adequate analgesia is crucial during reduction of the dislocation.