280 Orthopaedic Emergencies
INJURIES TO THE SHOULDER AND UPPER ARM(iii) Spaso technique
(a) hold the affected arm by the wrist with the patient lying
supine
(b) while applying mild traction, slowly lift the affected limb
vertically
(c) achieve reduction by externally rotating the shoulder and
maintaining vertical traction.
(iv) Scapular rotation
(a) with the patient seated or prone, manipulate the scapula
by medially displacing the inferior tip of the scapula using
thumb pressure
(b) keep stabilizing the superior part of the scapular with the
other hand.
4 Place the arm in a sling strapped to the body after reduction, or enclosed
under the patient’s clothes, to prevent external rotation and a recurrent
dislocation. Repeat the shoulder X-ray to confirm the reduction.
5 Test again for neurovascular damage.
6 Give the patient an oral analgesic, instructions to keep the arm initially
adducted and internally rotated, and refer to the next fracture clinic.
(i) Recurrent dislocation occurs in up to 50% or more of patients
aged under 40 within 2 years.
(ii) Immobilization in external rotation appears the only position that
reduces this rate, but it is awkward and cumbersome to achieve.
(iii) Operative repair is suggested after four or more recurrent
dislocations.Posterior dislocation of the shoulder
DIAGNOSIS
1 This dislocation is uncommon and can be bilateral. It occurs classically
during electrocution or a seizure, or from a direct blow (e.g. in boxing), and
is easily missed.
2 The arm is held adducted and internally rotated, and the greater tuberosity
of the humerus feels prominent.
(i) Any attempts at external rotation are severely limited and
painful.
3 Include two X-ray views of the shoulder, as the anteroposterior view will
appear ‘normal’.
(i) Look for the ‘light bulb’ sign on the anteroposterior view, due to
the internally rotated humerus displaying a globular head, and
for an irregular, reduced glenohumeral joint space.
(ii) Look for the humeral head lying behind the glenoid on the lateral
scapular ‘Y’ view.