Thursday, June 4, 2015

Is the shoulder in? Use ultrasound!



It was a classic “good news/bad news” sign out.

The  attending who was signing out to me admitted that this wasn't the cleanest sign-out, but they had a plan.


The bad news: the patient likely had a shoulder dislocation, but the read on the X-ray was equivocal.
  
"Can I order a clinical correlation?"
Given this unclear picture, the plan was to try sedation, and pop it back in place. 

The good news: the attending had already tasked a senior resident and the orthopedics PA-C to perform the sedation and (attempted) reduction, and they were champing at the bit to do the procedure. 

My evaluation

I looked at the X-ray, and re-examined the patient. As he was young chubby guy, it was difficult to be sure of the exam. Since both my exam and the X-ray were so unhelpful, I stalled the resident and PA-C while I grabbed the ultrasound.

Now, ultrasound is not usually thought of as a great test for shoulder dislocation. The usual approach to definitively excluding a glenphumeral dislocation (especially posterior dislocation!) is to obtain an axillary view, shooting up through the armpit. And of course we can always get a CT of the joint.

But you can get much the same image with the ultrasound. So, placing the probe on the posterior shoulder, I aimed anteriorly, with the left side of the screen oriented to the lateral aspect, like this:


This produced a clear image of the glenohumeral joint:

 
As usual, US is best appreciated dynamically, with this clip showing the patient rotating his arm:

video

I hope you can see how the head of the humerus is well-seated in the glenoid. But despite this dazzling proof, x-rays and a CT were needed to convince ortho that the shoulder was not dislocated, and that no sedation and tugging were needed.

The (ionizing radiation) proof

The axillary view of the shoulder X-ray (needs to be specifically ordered), oriented similarly to the US:


 The CT of the shoulder, with the slices and orientation similar to the US:


If you want to check out some other US examples of dislocated shoulders, you can also check out this great video from ALiEM:



Ultrasound for the ... Wait, what?!

I would have liked to say this was an ultrasound win, but I'm not so sure. The downsides of this approach, in retrospect, were:
  • The patient didn't get to enjoy some of our high-grade ketamine;
  • We didn't get to high-five each other after our "subtle reduction;" and
  • The resident was cheated out of a procedure!
So, know the downsides ahead of time.

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