Mangled Mondays: Dislocated Shoulder

Mangled Mondays: Dislocated Shoulder

Dislocated Shoulder

Excerpted from Blood on the Page: A Writer's Compendium of Injuries, Section 1.4: Blunt Trauma > Appendages

Lethality Index

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What Is It?

The human shoulder is a ball-and-socket joint between the glenoid (socket) and the head of the humerus (ball). Stabilized by muscles, tendons, and ligaments, the joint is fairly complicated. The scapula(shoulder blade) protects it at the rear; the acromion process at the top; and, in part, the clavicle (collarbone) at the front.

But the joint does have a weakness. A strong impact to the extended arm can essentially pop the ball out of the socket, known as a dislocation. (A partial dislocation is known as a subluxation.)

The most common – and least damaging – form of this injury is an anterior dislocation, when the head of the humerus pops forward out of the socket. As we’ll see, this is hardly benign and can involve fractures of the bones involved, but it’s certainly not as damaging as a posterior or inferior dislocation.

Therefore, it’s the anterior dislocation we’ll discuss here.

Clinical Signs:

· Deformity of the upper shoulder.

· Difficulty and pain trying to move the affected arm.

· Humeral head bulging under the skin.

Symptoms:

· Pain.

· Numbness and tingling in the arm, from the bone pressing against a nerve.

How Does It Happen?

There are a number of ways in which a shoulder can become dislocated, but the most common are when the character falls on outstretched arms or when the character suffers a blow to the shoulder with the arm extended.

These often occur in contact sports such as MMA (mixed martial arts) fighting, soccer, rugby, American football, or high-velocity sports such as motocross, cycling, and skiing.

Immediate Treatment

The primary treatment for a character with a dislocated shoulder is to sling and swathe the arm so that it’s tucked against the body, with the wrist across the chest and toward the opposite armpit. This can be done with a scarf, a large triangle bandage (“cravat”), a professional sling, or anything that can be improvised in the field.

Characters should receive the attention of a medical provider, but characters who have undergone reduction (relocation) of a dislocated shoulder will be familiar with the procedure. (Actually, there are a great many ways of reducing a shoulder; a few of the most popular are covered here.)

Definitive Treatment

Surgery / Hospitalization

Characters who have a shoulder reduced won’t require surgery or admission unless imaging determines a fracture; or if reduction in the ER is not possible due to (a) overmuscular upper body and/or (b) delayed presentation to ER, resulting in tight tendons and muscles impairing the physician’s efforts.

Emergency Department: Imaging

Characters with shoulder dislocations will have X-rays taken to ensure that there are no fractures of the glenoid or the humeral head. It’s possible, but unlikely, for these to happen in the process of the dislocation

Emergency Department: Sedation and Analgesia

There are two goals of sedation and analgesia in the ER.

The first goal is reduction of pain before, during, and after the procedure. Most of the pain of the dislocation will be eliminated when the shoulder is reduced, but not all of it.

The second is to reduce spasm of the muscles of the shoulder, which are fairly strong and can get in the way of reduction or make the procedure more difficult.

The simplest, and perhaps the most effective, way in which emergency providers can control pain is with a simple injection of lidocaine into the joint, which will numb the area, reduce pain, and cause the desired relaxation.

However, some providers will give a small dose of morphine and/or a small dose of a sedative like midazolam (Versed).

A low-dose infusion of ketamine can also be used, since it acts as both a sedative and an analgesic and is therefore an excellent single agent. This requires using an IV, whereas other methods are injected into the joint or can be used with oral medication.

However, a great many shoulders can be reduced without any pain medication at all, especially if the muscles haven’t had time to “freeze up” yet.

Emergency Department: Reduction

There are literally dozens of methods of reducing a dislocated shoulder, almost all of which are effective and well tolerated. (These do not include smashing the shoulder into any available wall; I’m looking at you, Lethal Weapon 2.) We’ll take a look at a few of them below, including what characters can do for themselves.

Kocher’s Method

The Kocher’s method of reducing the shoulder is a simple and straightforward one. It involves the provider helping the injured character tuck their elbow against their side with the elbow flexed and the forearm thus parallel to the floor.

The provider will then take the character’s affected wrist and move it laterally (away from the body) until there’s resistance. They’ll pull the elbow and upper arm forward a little bit, and then pull the wrist back across the body toward the opposite side.

The procedure takes less than a minute, and has a good success rate.

Cunningham Technique

This is perhaps the gentlest reduction technique around. The character is instructed to sit up comfortably, with their back fairly straight, and pull their shoulder blades together. The character will tuck the affected elbow against their body while the provider rests the character’s hand on their own elbow and supports the character’s elbow with their hand. The provider will then massage the trapezius, deltoid, and biceps with their free hand. As their thumb moves to the outside of the humeral head and toward the deltoid, they’ll gently nudge the humeral head back into the socket. This technique relies on relaxing the muscles rather than using any kind of force.

The Davos Technique

To perform this reduction technique, the character sits upright and flexes the hip and knee on the side of the dislocation. The character then clasps the fingers of both hands together around their flexed knee, or the provider will tie their wrists together with cravats or an elastic band.

(Can you say dramatic tension? Imagine the physician steps out of the room for a minute, and the villain walks in with the hero’s hands tied and their shoulder still out of place…)

Next, the provider sits on the patient’s foot to hold it stationary. The character is then told to relax their shoulder and arm muscles, let their head fall back, and let their shoulders roll forward with the arms extended. The humeral head should reduce.

In the Austere Environment

Because of its nature, a shoulder dislocation is quite easy to reduce in the field. There are risks and consequences if any of the relevant bones are broken, but the vast majority of shoulder dislocations don’t involve fractures.

Any of the above procedures should work quite well, but without strong analgesics, reducing the shoulder will take longer. The main thing getting in the way of reduction is muscle tension, so reductions should be fairly slow to prevent tightening.

Self-relocation

Sometimes a character will be on their own and won’t have the benefit of an assistant. In this case, they’ll need to help themselves.

The best bet is for the character to find some way of applying weight to their arm. The simplest way is for them to sit facing a doorknob and to grab it with their affected hand. (If they can tie their wrist to it that’s even better, since tension in the hand is part of the problem.) They’ll then lean back and support some of their weight with their arm. This may take several minutes, and isn’t always successful.

Another technique is for the character to reach up and behind the head, then reach for the opposite (“good”) shoulder. This should, theoretically, relocate the shoulder.

Neither of these techniques is foolproof or entirely likely to succeed, and the techniques will likely only be known to those who have dislocated their shoulders before.

However, most other techniques require a second person, and remember that this is fiction: outcomes are determined by what we want to have happen, not what might actually happen, so long as the act is relatively realistic.

The Rocky Road to Recovery

Capabilities Retained

Characters still have some use of their arm during the dislocation, including the hand and wrist, but won’t want to do much except hold their arm in place.

After the dislocation has been reduced, they will still have use of the hand, as well as all other limbs, neurocognitive function, etc.

Disabilities: Temporary

The shoulder that has been dislocated needs time in order to heal. Because of this, the character will need to keep the arm in a sling for at least one to two weeks (but more realistically, four). Failing to do so runs the risk of redislocation.

Disabilities: Permanent

Shoulder dislocations that don’t produce fractures almost never come with any permanent disabilities. However, it’s possible for the character to have damage to the nerves of the arm from either the dislocation or the reduction.

Features of Recovery: Hospital Stay

None.

Features of Recovery: PT/OT

Characters will need to strengthen their shoulder as it heals.

Initial therapy will aim to improve range of motion: raising the arm above the level of the shoulder, and rotating the elbow outward (elbow tucked against the chest, and wrist brought lateral to the body). After range of motion has returned, the goal becomes to strengthen the muscles.

Isometric strengthening:

The character will step up to a wall and almost touch it; they’ll push the thumb side of their wrist against the wall and press for 8–10 seconds. Next they’ll stand perpendicular to the wall and try to abduct their arm, meaning they’ll try to reach their arm out laterally to their body while pressing against the wall, again for 8-10 seconds. Next the character will bend their elbow so their lower arm is parallel to the floor. First they’ll try to externally rotate against the wall or doorway; then they’ll do the same for internal rotation (towards the opposite side of their body).

Weight training.

Characters who progress beyond isometric training will be encouraged to perform similar exercises with weights.

The first exercise will be to hold a weight – a can of soup works well – and will extend their arm laterally to the body and bring their hand toward shoulder height. Next they can lie on their side on the affected arm and hold the can or weight in front of them, and internally rotate the hand (toward the opposite hip).

The New Normal

Characters who completely recover from the injury will likely have no long-term consequences, though if they don’t stabilize their shoulder muscles with PT they may redislocate the arm.

Sometimes there will be some damage to the nerves of the shoulder, which may involve pain, numbness, and/or weakness both in the shoulder and down the arm. Again, physical therapy helps with these.

Future Risks

Your character will be at risk for redislocation of the same arm.

Total Recovery Time (Typical)

Sling: 1–4 weeks

Strength and flexibility:4–8 weeks

Sensory

Sights

The affected shoulder will look “off,” deformed. The humeral head may be visible under the skin, or the anterior aspects of the shoulder may simply look “out of place.”

Smells

None.

Sounds

Characters may hear an audible pop as the shoulder dislocates, and a pop or clunk may be audible as the shoulder relocates.

Sensations

As with sounds, the shoulder pops out and clunks back in. This may be audible only to the character with the dislocation, or may be audible to others too.

Medslang

A subluxation is something of an incomplete dislocation and is managed in the same way.

Abduction is movement away from the body in the same horizontal plane; that is, reaching out directly to the side.

Adduction is the opposite: bringing the body part back along the torso.

Internal rotation is rotation toward (and across) the body.

External rotation is rotation away from the body.

Anterior means forward (toward the front of the body), while posterior means backward or behind.

Reduction can refer to repositioning a dislocated or subluxated joint, or to bringing bone ends back to alignment in a fracture.

Key Points

· Shoulder dislocations are common, dramatic, and have few long-term complications; they are ideal for use in stories.

· Characters with shoulder dislocations might be able to set their own shoulders, but a second person is generally best.

· Setting the dislocation takes only a minute or two, but can be very painful; sudden movements are the enemy, as the goal is to relax the muscles, not tighten them.

· Characters will need a sling for 1-4 weeks (the younger, the longer) and will require PT to strengthen the stabilizer muscles after the fact.