Shoulder / Arm Injuries


Remember analgesia

# clavicle

  • Check distal neurovascular status (± respiratory exam)
  • Treat with sling (or collar & cuff [BestBets] ) and refer to the CUH Fracture Clinic (Referral form)
  • Beware greenstick # in children
  • Admit (for ORIF) if concern re overlying skin necrosis

# scapula

Fracurted Scapula Lateral X-ray
  • Beware other trunk injury as significant trauma needed
  • Always check A B Cs
  • Exclude chest and neck injury
  • ? Associated brachial plexus injury
  • Admit CDU if vitals well but significant other injuries not excluded
  • Treat with sling & analgesia and refer to the CUH Fracture Clinic (Referral form)

AC Joint dislocation

ACJoint measurement on X-ray
  • Usually from falling directly onto tip shoulder
    • e.g. rugby tackle
  • Palpable (visible), tender step at ACJ
  • Request ACJ views (not shoulder)
    • Weight bearing views not needed
  • Note malalignment of inferior surface of ACJ
    • Or ACJ gap of > 8mm
  • Check neurovascular status
  • Beware associated neck / chest injury
  • Treat with analgesics and sling
  • Refer CUH fracture clinic (referral form)

Anterior dislocation of the shoulder

Squared Foor Shoulder With Anterior Geneohumeral dislocation
  • All suspected dislocations triage category 2 (document pain score and neurovascular status)
  • Always X-ray for fracture - except with a recurrent dislocation in a shoulder known to be unstable and which has occurred with minimal force
  • Reduction should be attempted first using Entonox, reassurance and a gentle manoeuvre
  • If this fails then manipulate after premedication with sedative and narcotic (NB follow sedation chart instructions) by an assisting doctor or arrange a GA, particularly in a muscular patient
  • Beware of respiratory depression after use of narcotic and sedative and in frail individuals, request anaesthetic assistance. Full resuscitation facilities must be immediately available
  • Always check x-ray and record neurovascular status after reduction
  • Sling (under clothes for under 40's, outside clothes in older patients) and refer to CUH fracture Clinic.(Referral form)
  • Advise the shoulder will be immobilised for three weeks [Bestbets]

Note Current BAEM guidelines for Dislocated shoulders are:

  • Patients with pain score 7 - 10 should have appropriate analgesia within 20 minutes of arrival
  • Patients with pain score 4 - 6 should have analgesia offered at triage
  • X-ray should be performed within 60 minutes of arrival
  • In 75% of cases 1st attempt at reduction should be within 90 minutes and 90% within 2 hours of arrival

Posterior dislocation of the shoulder

Axillary View X-ray showing posteror subluxation
  • Painful shoulder after direct anterior trauma or after epileptic fit or electrocution
  • May have surprisingly good range of movement (but painful ++)
  • Depression (rather than fullness of humeral head) below acromion
  • Absence of anterior dislocation on examination
  • Check neurovascular status
  • Internal rotation gives 'Light bulb' sign or overlap of glenoid and humeral head on PA view (right)
  • Confirmation on X-ray taken in another plane
  • Discuss with senior ED staff

Fractured neck of humerus

  • Analgeisa (beware NSAIDs in elderly
  • Record neurovascular status
  • Treat with collar and cuff or sling [BestBets] and refer to the CUH Fracture Clinic (Referral form)
  • Sometimes a U-slab is required for extra support
  • Beware Non Accidental Injury in children with proximal humeral fractures [Bestbets]

Rotator cuff lesions

  • Arrange physiotherapy unless complete with review by Consultant

Fractured shafts of humerus

  • Treat with collar and cuff and refer to the on-call Orthopaedic Team
  • Check radial nerve (sometimes a U-slab is required for extra support)

Content by Dr Íomhar O' Sullivan 22/02/2004. Reviewed by Dr ÍOS 17/05/2005, 31/01/2007Last review Dr ÍOS 21/06/21.