3-71
Assessment:
Differential Diagnosis
Acute pain is usually due to trauma. Anterior shoulder dislocations occur when the arm is forcefully abducted
and externally rotated. Fractures occur from forceful, often direct blows.
AC joint separations occur from landing on the shoulder, as when a football or rugby player is tackled and
driven into the ground on their shoulder.
Acute biceps tears present with acute pain and deformity after a sudden lift or catching activity.
Rotator cuff tears occur in the young, healthy population following trauma. Older individuals can get rotator cuff
tears from chronic overuse and impingement if not adequately treated.
Overuse injuries include rotator cuff impingement (tendonitis), AC joint capsulitis, degenerative joint disease
(DJD, osteoarthritis), and subacromial bursitis.
Plan:
Diagnostic Tests
- AP and Lateral x-rays are used to rule out fractures. In high-speed trauma this should include cervical
spine x-rays. There is debate about the need for x-rays prior to reducing an anterior shoulder dislocation. In
the field the shoulder should be empirically reduced. (see Joint Dislocation) - In cases of suspected septic arthritis, the shoulder joint may have to be aspirated to examine the fluid with
Gram stain (see Procedure: Joint Aspiration).
Procedures
Injection of a local anesthetic into the subacromial region or AC joint (injecting the AC joint can be very difficult)
may confirm impingement syndrome or AC joint capsulitis respectively.
Anesthetic and corticosteroid injection may provide longer-term relief, but should not replace PRICEMM
(Protection, Relative Rest, Ice, Compression, Elevate, Medication, Modalities).
Treatment
Overuse injuries without significant damage such as rotator cuff tendonitis (impingement syndrome), AC
joint capsulitis, sprains and strains can be treated with PRICEMM; protect from harm, appropriate activity
modification, icing for twenty minutes three times a day if available, and administration of non-steroidal anti-
inflammatory medicines if not allergic.
Long-term administration of anti-inflammatories may cause serious bleeding ulcers, liver and kidney damage.
Although somewhat controversial, most anterior shoulder dislocations can be reduced prior to obtaining x-rays.
There are many techniques to do this (see Joint Dislocations). Two of the easiest that require no equipment
and no additional help other than the reducer are the “water ski” technique and the external rotation technique.
Both are easy to master and have low risk of complicating matters. Other techniques are available and may be
used depending on the provider’s training. Following reduction, the arm is usually put in a sling for a minimum
of two weeks and then gradual rehabilitation is performed over the next 6-8 weeks.
For almost all fractures, initial treatment should consist of placing the injured extremity in a sling and swathe
and administration of pain medicines. Grossly deformed fractures or those causing neurovascular compromise
may need reduction by in line traction Clavicle fractures and AC joint separations should likewise be placed
in a sling and swathe. Pinning or somehow affixing the arm sleeve to the shirt just above the navel can
accomplish this if no sling or other material is available.
Open fractures should be cleaned of gross debris and covered with a sterile dressing if possible. Do not
reduce open fractures; splint them until definitive surgical care is available. Empirically administer broad-
spectrum antibiotics such as ceftriaxone.
Patient Education
General: The severity of the injury will dictate the length of time necessary for full recovery
Activity: The activity level should be modified to prevent further injuring, often pain can be the guide (“doc,
it hurts to do this” - “so don’t do that”)
Diet: Must eat to take non-steroidal anti-inflammatories.