Emergency Medicine

Orthopaedic Emergencies 279

INJURIES TO THE SHOULDER AND UPPER ARM

(iii) Axillary artery damage

Palpate the radial pulse. Prompt reduction usually restores the circu-

lation.

(iv) Fracture of the upper humerus

Look carefully for this on the X-rays.

6 Always X-ray the shoulder, even if you are sure of the diagnosis, to avoid
missing an associated humeral head fracture. Look for the following features:
(i) The humeral head is displaced medially and anteriorly with loss
of contact with the glenoid fossa on the anteroposterior view.
(ii) Look at the lateral ‘Y’ view in doubtful cases. The humeral head
lies anterior to the ‘Y’ in anterior dislocation.
(iii) Humeral head fracture
(a) fracture of the greater tuberosity does not influence the initial
reduction
(b) refer a fracture through the humeral head, neck or upper humerus
directly to the orthopaedic team. Do not attempt reduction.

MANAGEMENT

1 Give the patient morphine 2.5–5 mg i.v. with an antiemetic such as meto-
clopramide 10 mg i.v. if there is severe pain (unusual in recurrent
dislocations). Reduce t he dose of morphine in elderly patients.

2 Perform the reduction in a monitored area such as a resuscitation bay using
procedura l sedation with diazepam 5–10 mg i.v. or midazolam 2.5–5 mg i.v.
(i) Ensure a second doctor is present, comprehensive monitoring
and resuscitation equipment are available, and dentures, rings,
etc. have been removed.

3 There are many different methods of reduction:
(i) Modified Kocher’s manoeuvre
(a) hold the arm in adduction with the elbow flexed
(b) apply gentle traction and slowly externally rotate. Stop briefly
if muscle resistance is felt, then continue
(c) the shoulder may ‘clunk’ back during external rotation. If
it does not, when 90° is reached, flex the shoulder and then
adduct the arm across the chest in external rotation, and
finally internally rotate it across the chest.
(ii) Milch technique
(a) stabilize the position of the humeral head in the supine or
prone patient with one hand
(b) using the other hand abduct the affected limb to the overhead
position
(c) then externally rotate the affected limb with one hand and
use the other to push the humeral head laterally to achieve
reduction.