A 19-year-old, previously healthy woman comes to the emergency department due to right shoulder pain. The patient fell while skiing an hour ago and landed with most of her weight on her outstretched right arm. The pain is sharp and associated with tingling in the shoulder and arm. Temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, pulse is 122/min and regular, and respirations are 14/min. On examination, the right shoulder is deformed; sensation is diminished over the right lateral aspect of the shoulder but intact throughout the rest of the arm and hand. Peripheral pulses are symmetric between the upper extremities. X-ray of the right shoulder is shown in the exhibit. Which of the following is the best next step in management?

Question

A 19-year-old, previously healthy woman comes to the emergency department due to right shoulder pain.  The patient fell while skiing an hour ago and landed with most of her weight on her outstretched right arm.  The pain is sharp and associated with tingling in the shoulder and arm.  Temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, pulse is 122/min and regular, and respirations are 14/min.  On examination, the right shoulder is deformed; sensation is diminished over the right lateral aspect of the shoulder but intact throughout the rest of the arm and hand.  Peripheral pulses are symmetric between the upper extremities.  X-ray of the right shoulder is shown in the exhibit.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0c7_9be9_8f63_3385b4c61af9_MD0005_00 This patient with shoulder pain after falling on an outstretched arm has shoulder deformity and an x-ray demonstrating a humeral head that is anterior, medial, and inferior to the glenoid fossa. This is consistent with anterior dislocation of the shoulder. In addition to having a painful and slightly abducted and externally rotated shoulder, some patients (as in this case) experience numbness over the shoulder due to axillary nerve compression. Additional findings include protrusion of the acromion, flattening of the deltoid prominence, and anterior axillary fullness due to the humeral head's displacement. axillary nerve compression Additional findings Diagnosis is confirmed with plain radiograph. Treatment is closed reduction (eg, traction-countertraction, scapular manipulation), which is commonly performed using procedural sedation to minimize the patient's discomfort and increase the likelihood of procedural success because the patient is less likely to resist the manipulation. Successful reduction is accomplished by hearing (and/or feeling) a clunk during the procedure and seeing return of the normal shoulder contour. Postreduction x-ray should be performed to confirm successful reduction and rule out complications that can occur during reduction (eg, glenoid fracture). In addition to improving pain, reduction usually improves the axillary neuropraxia. (Choice B) CT angiography of the upper extremity is helpful to diagnose vascular injury; however, vascular injury is unlikely in this patient who has normal peripheral pulses. (Choice C) Although noncontrast CT scan of the shoulder is sometimes used to confirm diagnosis of shoulder dislocation when x-ray is equivocal, this patient's x-ray is diagnostic of anterior shoulder dislocation. Therefore, reduction is the best next step to minimize pain and address the associated axillary neuropathy. (Choice D) Emergent orthopedic surgical repair is indicated when closed reduction is unsuccessful or when the dislocation is associated with major fracture (eg, humeral neck fracture). This patient has no contraindications to closed reduction (eg, associated fracture, neurovascular compromise), which should be attempted first. (Choice E) Sling immobilization and outpatient orthopedic referral is often appropriate for simple fractures without dislocation (eg, isolated humeral head fracture). However, a shoulder dislocation should be reduced without delay to control pain and prevent ligamentous or neurologic damage. Educational objective: Anterior shoulder dislocations result in anterior, medial, and inferior displacement of the humeral head, which can cause axillary nerve compression. Diagnosis is confirmed with plain radiograph, and treatment is prompt closed reduction with procedural sedation. References: A systematic and technical guide on how to reduce a shoulder dislocation. (http://www.ncbi.nlm.nih.gov/pubmed/27995208) Management of primary anterior shoulder dislocations: a narrative review. (http://www.ncbi.nlm.nih.gov/pubmed/31297678)

A 19-Year-Old, Previously Healthy Woman Comes to the Emergency Department