Orthopaedic Emergencies 277INJURIES TO THE SHOULDER AND UPPER ARMMANAGEMENT
1 Treat minor subluxations with ice, oral analgesics, sling immobilization,
daily range of motion exercises, and refer to the next fracture clinic.
2 Start the same supportive treatment for a full dislocation, but discuss with
the orthopaedic team for consideration of operative intervention.
(i) Sling immobilization may be required for 4–6 weeks.
Sternoclavicular dislocation
DIAGNOSIS
1 This dislocation is rare and is caused by either:
(i) A direct blow to the anteromedial aspect of the clavicle forcing
the clavicle backwards resulting in a posterior dislocation, or
(ii) Transmission of indirect forces from the anterolateral or
posterolateral shoulder, displacing the clavicle either forwards or
backwards.
2 Patients complain of chest and shoulder pain exacerbated by arm move-
ments, particularly when supine.
3 Anterior displacement results in local tenderness and asymmetry of the
media l ends of t he clav icles.
4 Posterior displacement can impinge on the trachea or great vessels and
present with dyspnoea, dysphagia and arm paraesthesiae.
5 The diagnosis is largely clinical. On examination the affected shoulder
appears thrust forward, and the medial aspect of the sternoclavicular joint is
painful to palpate.
6 Plain X-rays are not easy to interpret, although anteroposterior and oblique
views should be requested.
7 A computed tomography (CT) scan is often required, particularly in
posterior displacements.
MANAGEMENT1 Treat subluxations with a triangular sling, oral analgesics and refer to the
next fracture clinic.
2 Refer posterior dislocations with pressure symptoms immediately to the
orthopaedic team.
3 Discuss full anterior dislocations with the orthopaedic team.
(i) As with acromioclavicular dislocations, once reduced they are
difficult to hold in place.
(ii) Following reduction, provide sling immobilization for 4–6 weeks.