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How To Reduce Posterior Shoulder Dislocations
Step by Step Description for Reducing Posterior Shoulder Dislocations
Neurovascular examination Do a pre-procedure neurovascular examination of the affected arm, and repeat the examination after each reduction attempt. Generally, testing motor function is more reliable than testing sensation, partly because cutaneous nerve territories may overlap. Assess the following: Distal pulses, capillary refill, cool extremity (axillary artery) Light touch sensation of the lateral aspect of the upper arm (axillary nerve), thenar and hypothenar eminences (median and ulnar nerves), and dorsum of the 1st web space (radial nerve) Shoulder abduction against resistance, while feeling the deltoid muscle for contraction (axillary nerve): However, if this test worsens the patient's pain, omit it until after the shoulder has been reduced. Thumb-index finger apposition ("OK" gesture) and finger flexion against resistance (median nerve) Finger abduction against resistance (ulnar nerve) Wrist and finger extension against resistance (radial nerve) Analgesia Give analgesia. The best choice is usually intra-articular injection of local anesthetic. Procedural sedation and analgesia (PSA) is usually also needed. To give intra-articular analgesia: The needle insertion site is about 2 cm inferior to the lateral edge of the acromion process (into the depression created by the absence of the humeral head). Swab the area with antiseptic solution, and allow the antiseptic solution to dry for at least 1 minute. Optional: Place a skin wheal of local anesthetic (≤1 mL) at the site. Insert the intra-articular needle perpendicular to the skin, apply back pressure on the syringe plunger, and advance the needle medially and slightly inferiorly about 2 cm. If any blood is aspirated from the joint,hold the needle hub motionless, switch to an empty syringe, aspirate all of the blood, and re-attach the anesthetic syringe. Inject 10 to 20 mL of anesthetic solution (eg, 1%lidocaine). Wait for analgesia to occur (up to 15 to 20 minutes) before proceeding. Give procedural sedation and analgesia. Reduce the shoulder — Posterior dislocation Wrap a sheet around the patient’s upper torso, passing the sheet under the axilla of the dislocated shoulder, and tie the ends of the sheet around the hips of the assistant standing at the opposite side of the stretcher. Wrap the sheet around the assistant’s hips (instead of the waist) to help prevent back strain. After the patient is in position, and while applying traction, fully adduct and internally rotate the affected arm to assist in disengaging the humeral head from the glenoid rim. Have the assistant on the opposite side of the body lean backward against the sheet to create countertraction while you manually apply axial traction to the arm. Have a second assistant push upward (anteriorly) on the posterior aspect of the humeral head. If needed (if the humeral head is locked on the posterior glenoid), the second assistant can also manually apply a gentle lateral force to the upper humerus, to leverage the humeral head laterally towards the glenoid fossa. Once the humeral head is dislodged, apply slight external rotation to complete the reduction. If there is muscle spasm or the patient resists the procedure, give more analgesic and/or sedative drugs. The first signs of a successful reduction may include a lengthening of the arm, a perceptible “clunk,” and brief deltoid fasciculation. If multiple attempts to reduce the shoulder have failed, do reduction (closed or open) in the operating room with the patient under general anesthesia. 