Anterior Shoulder Dislocation

1. Anterior Shoulder Dislocation • 17 year old basketball player • Diving for basketball with arm outstretched • Players landing on his posterior shoulder while he was gaining control of ball • The resulting pressure from posterior resulted in subcoracoid(anterior) dislocation • 90-95% are Subcoracoid(ant) or Subglenoid(ant/inf)

2. Didn’t see injury • Was in Training Room at time taking care of another athlete • Player presented himself to training room with arm held over stomach area • Player stated arm was numb and couldn’t move • it

3. The Real Issue • Player- Father in Armed Forces • Legal guardian was grandparents- not at game • Player asked that I reduce shoulder to prevent issues at home • Athletic Director was present at game- agreed

4. Athlete and AD relationships • Knew of the players issues at home • Very good relationship with AD • Know the family/parents when can • Don’t sit in the Training Room or the corner of the gym in isolation

5. Typical Protocol • Will place injured athlete in sling or ace wrap arm to side • Place ice over shirt or wrap • Send to ER for x-rays • Possible issues-- bony injuries, fractures, ligament injuries, neuro damage

6. What did I do • Check pulse and neuro • Palpate shoulder area- clavicle, scapula for any obvious FX • Palpate humeral head for position/ where is it at • Check shoulders bilateral

7. How did I reduce? • Placed athlete prone on stomach/table • Applied 4-5 lbs of manual traction • Shoulder reduced within one minute • Subtle click or visible movement back into glenoid fossa

8. After Reduction • Check pulse and neuro • Palpate shoulder anatomy to check for symmetry • Placed in sling and applied Ice • Sent home athletic instructions of what to look for and call me if any issues • Recheck the athlete daily basis • Asked legal guardians to call me- Never did

9. Follow-up care • After a few weeks we started ROM • Progressed into shoulder strengthening • Athlete ran track in spring with no complaints • Of course don’t forget to document and sit with AD to fill out paperwork

10. Know the athletes/AD • Speak with the kids when the come into the training room • Get on the same page with AD and know the school policies

11. Football Player/Dislocated Shoulder • Athlete was part of a group of players tackling ball carrier • The play ended out of bounds with about 6 players involved • Was about 20 yards away • At the end of the play one player remained on his back

12. Walking upon the player/injury • Player was in supine position with arm on ground outstretched and elevated- chewing on mouth piece • All UE anatomy looked to be normal

13. I think my arm fell off! • Was his first words • Stated his arm was numb and hoped it was still on • I reassured that it was still on

14. Evaluation under shoulder pads • Palpate bilateral shoulder/Cervical • Looking for Scapula FX, Clavicle FX, AC JT, Humeral Head, Cervical Spine • Check elbow, hand and wrist • Check for blood and neuro responses • Trust what you feel

15. Humeral Head felt like in armpit • After palpation determined dislocated shoulder

16. And then the wait began • Will usually rotate this back in position, resting arm on stomach and wait for parents to come down from the stands. • No parent at the game • Good relationship with AD- Policy was that players could not be transported/ambulance without parent knowledge

17. Stuck dislocated shoulder • Attempted to gently rotate arm into resting position on stomach • Arm would not move/ don’t force rotation • Attempted to locate parent at home– No Luck • We waited about 15 minutes with Ice on shoulder • Monitor UE vital signs

18. AD finally made call • Because of no obvious true emergency we waited approx 20 minutes to call Ambulance • The issue was with parents being very upset with medical bills caused by sports and not being able to pay • The AD was willing to take the responsibility of dealing with the aftermath.

19. Didn’t remove shoulder pads • Due to the shoulder being stuck in ext rotation and abduction/didn’t want to injury any further. • Ambulance arrived and had to transport with shoulder in that position • Get to know the AD and discuss policies so you are on the same page.

20. Document • Called AD re injury so we both documented

21. The ring finger vs logic • Football player- finger stuck in opponent players face mask • Finger will go where the opponents facemask goes • Resulting in loss of continuity between the two joints– aka- dislocated finger

22. Visible appearance • Usually obvious-- crooked finger, laterally or resting on top on proximal joint • Palpate carpal, metacarpal, phalanges • Once determined that FX is usually not an issue will reduce. Buddy tape and will play.

23. How to Reduce • Usually players are sweaty from participation • Gauze works will because of the rough surface place a gauze pad over proximal, middle phalanx or metacarpal • Place a separate piece of gauze over the dislocated joint

24. Grasp proximal phalanx or metacarpal firmly • Grasp dislocated phalanx firmly • Lift or pull dislocated finger away from joint– Up/Down or Side • Then pull dislocated finger forward • Finger should slide into place • Check ROM, blood supply, neuro and splint

25. Fran VS The Ring Finger • After attempting to reduce in this manner the finger would not budge • Then I tried put more force/pull into the effort • Then I put more more force/pull into the effort • Finger would not budge

26. Doctor VS The ring finger • Home team doc arrived upon the scene • Attempted to reduce • Then attempted to reduce again • Then attempted to reduce again • The finger Won. We had to splint in the dislocated position and send to ER with parents

27. The reason we lost the battle • Because of the violent twisting and pulling of the joint, soft tissue/ligament had gotten caught between the joint • Other Issues with Dislocated Fingers • Common to have small fractures • Sometimes they when reduced they don’t stay in place. FX

28. Pseudoarthrosis Clavicle • Original thought to be a matchstick fracture due to pressure from birth canal.

30. History • Rare • Etiology Unknown—Subcalvian Artery saws through during development? • Most are occur on right side. • No hx of trauma or tenderness.

31. Shoulder Deformity • Normal ROM • Normal Strength • Slight Depression or forward rounding of shoulder at 9 years old. • Very Mild Lower Scapular Winging.

32. Treatment Options? • Surgery? • Risk of infection • Will bone graft heal/area of poor circulation • Is it worth the price? • History of surgery plate breaking • Other technique is a K wire through bone

33. Clavicle Pseudoarthrosis Complications • Infection • Nonunion • Brachial Plexus Injury • Rare Complications-- Pain at Site, Shoulder Asymmetry, Decreased ROM, Thoracic Outlet Syndrome.

34. What are we doing? • Consulting with Dr Latz • Recommend NO SURGERY