![\"\"](\"\/wp-content\/images\/part1\/shoulderalgo1.gif\")
<\/a><\/p>\nGlenohumeral disorders (adhesive capsulitis: age 40-65, median 50-55; osteoarthritis: Acromioclavicular disease (teenage to 50)<\/strong> Acromioclavicular disease is usually secondary to trauma or osteoarthritis; dramatic joint dislocation can occur after injury(teenage to 30 years). Pain, tenderness, and occasionally swellingare localised to this joint, and there is restriction of passive,horizontal adduction (flexion) of the shoulder, with the elbowextended, across the body. Acromioclavicular osteoarthritismay also cause subacromial impingement.<\/p>\n Referred mechanical neck pain (common)<\/strong> Typically there is pain and tenderness of the lower neck and suprascapular area, referred to the shoulder and upper limb area; shoulder movement may be restricted. Movement of the cervicalspine and shoulder may reproduce more generalised upper back,neck, and shoulder pain. Upper limb paraesthesia may occur.18<\/a> Treatment is with relative rest and analgesia, and return tonormal activities should be encouraged. Physiotherapy may behelpful.<\/p>\n stress test by bringing elbow to opposite shoulder and then palpating<\/p>\n over joint<\/p>\n <\/p>\n Subluxations and Dislocations-loss of coracoclavicular ligament<\/p>\n 1st degree-sprain, pain but no subluxation<\/p>\n 2nd degree-sublux of acromioclav ligament with coracoclav intact.<\/p>\n tenderness with moderate swelling, normal x-rays are normal, stress x-<\/p>\n rays with 15 lb weight suspended at wrist(not in hand). AP film with<\/p>\n separation if distal clavicle by not more than half its diameter.<\/p>\n 3rd Degree-complete dislocation with upward displacement of distal<\/p>\n clavicle. greater than 1\/2 cm between coracoid aqnd clavicle or inf<\/p>\n border of clavicle is above ac joint.<\/p>\n Rx:<\/p>\n type i-sprain of the ac ligs(sling\/swathe)<\/p>\n 2-disruption of ac lig, sprain of cc (reduce clav, kenney-howard sling)<\/p>\n 3-both ligs disrupted<\/p>\n 4-post clav displacemnt<\/p>\n 5-clav displaced far superior<\/p>\n 6-clav displaced downwards<\/p>\n 3-6 ortho consult for possible surgery<\/p>\n <\/p>\n \u0095 Type I (a): Ligamentous strain\u0097no deformity, but tenderness of AC joint<\/p>\n \u0095 Type II (b): Rupture of acromioclavicular ligament\u0097can have slight deformity on physical examination<\/p>\n \u0095 Type III (c): Rupture of both acromioclavicular and coricoclavicular ligament\u0097significant deformity on physical examination, bottom of clavicle at or above top of acromion on x-ray<\/p>\n <\/p>\n <\/a><\/p>\n 1st degree-sprain, mild pain\/swelling. ICE\/Sling<\/p>\n 2nd degree-sublux of clavicle completge rupture of sternoclavicular and<\/p>\n sprain of costaclav. Figure of 8 and sling<\/p>\n 3rd degree-complete rupture c clav dislocation, caused by injuries that<\/p>\n roll shoulder backwards. Posterior dislocations can cause pneumos, or<\/p>\n tracheal compression. Reduce clavicle by (17-9A)<\/p>\n <\/p>\n <\/p>\n Best Site: Shoulderdislocation.net<\/a><\/p>\n <a name="cunningham_technique<\/a>” id=”%3Ca_href%3D%22cunninghamhtm%22%3Ecunningham_technique%3C%2Fa%3E” class=”sectionindex”> <\/a><\/p>\n <\/p>\n There are four types of anteroinferior shoulder dislocation, denoted by the final position of the humeral head. Subcoracoid dislocations constitute 70% of all dislocations.5,6 Subglenoid dislocations (Fig. 2) are the second most common, 30%.5 Subclavicular and intrathoracic dislocations are associated with fractures and violent forces.7 Luxatio erectae is regarded as a pure inferior dislocation and is not discussed here.<\/p>\n <\/p>\n Hill Sachs<\/p>\n <\/p>\n Dislocations-abduction with external rotation.<\/p>\n Can not internally rotate humerus, so to test if reduced, lift arm and<\/p>\n let fall on stomach, if it can fall, back in.<\/p>\n <\/p>\n assoc c axillary nerve injury (test by patch of skin just under ac joint ie. the regiment\u2019s band supplied by the upper lateral cutaneous nerve or better yet, see if the patient can fire their deltoid with even minor arm ABduction) also evaluate distal hand neuro function.<\/p>\n Fractures occur in about 30% of cases.9,10 The most common are: 1. Hill Sach\u2019s lesion (Fig. 3), seen in 5476% of cases, is a compression fracture that results in the formation of a groove in the posterolateral aspect of the humeral head.2,911 Also known as a hatchet deformity it is best viewed with internal rotation of the arm.9 2. Fractures of the anterior rim of the glenoid fossa (Fig. 4) or Bankart\u2019s lesion12,13 (a separation of capsule and\/or labrum from the anteroinferior rim, the term is often used to refer to bony disruption).2,10 It is the result of impaction of the humeral head against the anteroinferior glenoid labrum, and is associated with rupture of joint capsule and IGHL damage. It is more common in younger patients and has a strong association with recurrent dislocations (8587%).2,13,14 3. Avulsion fracture of the greater tuberosity (Fig. 5) is seen in 1016% of cases.5,9,10,15,16 4. Uncommonly, the coracoid process can be damaged by the humeral head resulting in painful non-union. 5. Humeral shaft fracture is rare, associated with significant forces.<\/p>\n AP (True AP, not C-XR view), axillary lateral and trans-scapular lateral (Y views.)<\/p>\n Also can get view c plate of x-ray behind butt and pt leaning backwards<\/p>\n just enough to have only shoulder over plate.<\/p>\n Evaluate films for Hill-Sachs deformity (impaction of humeral head in postero-lateral portion.<\/p>\n Also can see Bankart\u2019s fracture, a fracture of the anterior glenoid. This injury needs ortho consult and probably CT scan of the shoulder.<\/p>\n <\/p>\n Modified Axillary View-have patient lean forward (Emerg Radiol 2006;12:227)<\/p>\n <\/p>\n Types of anterior glenohumeral dislocations.<\/p>\n A: subacromial; B: subglenoid; C: subclavicular; D: intrathoracic.<\/strong><\/p>\n <\/p>\n <\/p>\n Rx-Scapular manipulation or Hennipen (externally rotate then abduct, if not successful, slowly adduct and internally rotate) (elderly Hennipen or stimson)<\/p>\n <\/p>\n Hennepin-with patient seated, flex elbow and slowly externally rotate<\/p>\n arm to 90 degrees, stopping for a minute when painful. After reaching<\/p>\n 90 degrees, if not in, slowly elevate arm and then lift humerus into<\/p>\n socket.<\/p>\n <\/p>\n Stimson-place pt prone c armpit padded. strap wrist and add 10-15 lbs<\/p>\n of weight. After 20-30 min, if still not in, internally and externally<\/p>\n rotate arm.<\/p>\n <\/p>\n Scapular Manipulation-Push Tip of scapula medial and superior portion<\/p>\n lateral. can be combined with stimson or Hennepin.<\/p>\n <\/p>\n Cunningham Method (Emerg Med 15:521, 2003)<\/p>\n 1 Inform the patient of the procedure and the fact that it will be painless. It is important to relax the patient and confident reassurance is the first step towards this. 2 Sit the patient up with the back vertical. This can be done on a bed, chair or trolley, but preferably seated on a non-wheeled chair without arm rests. 3 Carefully support the arm while it is moved into the correct position, allowing the patient to help with the other arm. The correct position is with the arm adducted (next to the body) and pointing vertically down, the elbow is flexed at 90 degrees so that the forearm points horizontally and anteriorly. 4 The operator then squats \/kneels to the side of the patient and facing the opposite direction to the patient. The operator then slips the hand between the patients forearm and body so that the patient\u0092s wrist \/ hand is resting on the operator\u0092s upper arm. *Do not make pulling movements at any time as this will elicit pain and result in spasm.* 5 Apply steady, very gentle traction (the weight of the operators forearm is quite enough) directly downwards once the patient is settled and pain free. Keep this gentle weight on the arm throughout, stop if any spasm or pain. Usually resting with the patients arm in this position will start to reduce the pain of spasm. 6 With the other hand, the operator then massages the trapezius, deltoid and biceps muscle sequentially, repeating this process and concentrating on the biceps brachii until the muscles are fully relaxed. A strong kneading of the biceps with the thumb anterior and the four fingers of the operator posterior to the arm is recommended. At this point the humeral head will relocate usually without any clear indication that the shoulder has reduced (no sound or \u0091clunk\u0092 feeling). This means that the shoulder must be observed\/checked regularly to confirm when relocation has occurred (with shoulder exposed movement can be seen as the \u0091step\u0092 disappears.)<\/p>\n <\/p>\n Traction\/countertraction<\/p>\n <\/p>\n Hippocratic Technique-foot in armpit, fraught with peril.<\/p>\n <\/p>\n Spaso technique: Place the patient in prone position and grasp the wrist and elevate the limb until it is vertical, then gently externally rotate the limb. Nudge the head back into the fossa.<\/p>\n Indications for surgery-possibly for glenoid rim fx or greater<\/p>\n tuberosity fx. more than 3 dislocations<\/p>\n <\/p>\n Treatment after reduction-sling and swath for 3 weeks.<\/p>\n <\/p>\n This can be accomplished with a sling and swath or a commercially available shoulder immobilizer. The duration of immobilization differs among different patient groups. Younger patients should be instructed to follow up within 1-2 weeks, and immobilization generally is maintained for approximately 3-4 weeks. Older patients will be immobilized for a considerably shorter period and should be instructed to follow up within 5-7 days to allow for early mobilization.<\/p>\n Complications-humeral head fx, bicipital tendon rupture, axillary or<\/p>\n other nerve injury, fx of humeral head of glenoid lip.<\/p>\n Apprehension Test-abduct to 90, externally rotate, push forward on humeral head.<\/p>\n <\/p>\n 29% had fracture, 76% of these were hill sachs. All of these fractures were successfully reduced in the ED.<\/p>\n 12.6% had nerve dysfunction, 1\/4 of these persisted after reduction. (JEM 24:2. 2003, p. 141-145)<\/p>\n <\/p>\n Reduce c 20 cc 1% lido intra-articular and versed (JEM 22 (3)) and (Emerg Med J 19 (2):142 2002). Use 20 cc of 1% with long 20g needle just off the lateral edge of the acromion.d<\/p>\n <\/p>\n Do we need prereduction films, probably not (Shuster, M., et al, Am J Emerg Med 17(17):653, November 1999 and Can J Emerg Med 4(4):257, July 2002) One argument against is a two part proximal humeral fracture. In this injury, dislocation of the humeral head can cause avascular necrosis of the head.<\/p>\n <\/p>\n <\/p>\n Techniques with the arm in the anatomical position The starting point for these techniques is with the humerus in the anatomical position, adducted against the torso. Adduction can be difficult or unobtainable in obese patients. Kocher\u2019s method Originally described in 1870 Kocher\u2019s method did not involve traction.19,20,32 Many texts have incorporated traction,25,27 which has been associated with complications,2830 yet in various case series the original technique has been used safely.31 Significant traction forces in combination with forced internal or external rotation place undue stress on the humeral shaft and neck. The original technique is: \u2018Bend arm at the elbow, press it against the body, rotate outwards until resistance is felt. Lift the externally rotated upper arm in the sagittal plane as far as possible forwards and finally turn inwards slowly\u2019.19 Variations include: Leidelmeyer\u2019s external rotation technique, which describes the first manoeuvre of Kocher (elbow flexed, adduction of humerus, external rotation) and then adds traction24 Mount Beauty method, which describes downward traction followed by external rotation.33 An assistant stabilizes the scapula Snowbird technique This technique is essentially downward traction with the humerus in the anatomical position.34 The patient is sitting up straight with humerus in anatomical position, elbow flexed, and forearm supported by the unaffected limb or operator. The operator places a foot into a stockinette loop wrapped around the forearm. Downward traction from the foot is applied, with additional rotation or pressure from the operator\u2019s hands if needed. The Cunningham technique This technique addresses static obstruction by posteriorly directed shrugging of the shoulders.35 This uses the rhomboids to retrovert the scapula reducing the obstruction of the glenoid rim and labrum to the returning humeral head. The dynamic obstruction of the spasming biceps is actively reduced by massaging the muscle at the mid-humeral level. The patient sits without slouching in a hard backed chair, the affected arm adducted to the body and the elbow fully flexed. The operator kneels next to the patient and places his wrist onto the patient\u2019s forearm, the patient\u2019s hand resting on the operator\u2019s shoulder. The patient is asked to shrug the shoulders superiorly and posteriorly, which \u2018squares off\u2019 the angle of the shoulder (reducing scapular anteversion and the static obstruction of the glenoid rim). The biceps is massaged at mid-humeral level to specifically relax the muscle (removing dynamic obstruction). The head reduces quickly, painlessly and without traction. Techniques with the arm in the zero position Saha originally described the zero position as that \u2018where the humero-scapular aligned axes coincide with the common axis of the cone muscle groups . . . the humerus is 165\u00b0 overhead and 45\u00b0 in front of the coronal plane . . . (the scapula) being at the limit of vertical rotation and forward migration on the chest wall. In this position the glenohumeral joint loses all active rotation\u2019.36 Milch separated the muscles around the shoulder into cone groups.3 He noted that with the arm in elevation (full glenohumeral abduction and full scapular rotation\/anteversion) the cone groups arrange in a similar direction along the humerus and lose their rotatory\/transverse component. Milch\u2019s technique used this overhead position as the critical point at which relocation could most easily occur. This was chosen as \u2018the only position in which a single force, exerted along the axis of the humerus, is accurately directed to overcome each and all of the muscle actions at the same time\u2019. This statement was used to explain the choice of position as a point of theory and not as an endorsement in the use of force during the manoeuvre. Indeed, in the supporting case studies he talks about elevating the arm \u2018with the greatest gentleness\u2019. Traction has been recommended as part of the Milch technique,6,7,37 but the original description does not use traction. Importantly, with the humerus in complete overhead abduction the scapular has rotated fully on the chest. This puts the humerus (in relation to the rotated scapula) in the zero position. The Milch technique \u2018The patient lies in the supine position, while the surgeon takes his position on the side of the dislocation. First manoeuvre in a right sided dislocation the surgeon places his right hand upon the patient\u2019s right shoulder, so that the fingers find firm support on the top of the shoulder, while the thumb is braced against the dislocated humeral head. Second manoeuvre the right hand fixes the head as the left hand gently abducts the arm into the overhead position. During this manoeuvre the head of the humerus is supported so that it cannot move form its dislocated position. As a consequence, instead of moving downward as the arm moves upward, the head rotates in place. Third manoeuvre once the arm has been brought into complete abduction in this overhead position, all cross stresses exerted by all the muscles have been eliminated; the head can be gently pushed over the rim of the glenoid and the dislocation reduced\u2019.3 Variations include: 1. Patient prone with elbow flexed.38 2. Janecki\u2019s \u2018forward elevation\u2019 combination manoeuvre29 begins with forward flexion to 90\u00b0 (step one), then traction is applied and abduction increased (step two). The final position is the overhead position and the humeral head is pushed by direct pressure if reduction has not occurred (step three). 3. \u2018Reduction in the position of maximum muscular relaxation\u2019.6 Gentle traction is applied while the shoulder is abducted to 45\u00b0 (step one). Traction is then increased with further abduction 120\u00b0 and anteversion 30\u00b0 (step two). External rotation is then applied (step three). Finally, direct pressure is applied on the humeral head in the axilla (step four). 4. Russell placed the patient supine with back at 30\u00b0.39 The patient moves his arm slowly to the overhead position and places his hand behind his head. Gentle traction is then applied to the flexed elbow while the humeral head is guided over the glenoid rim. The author uses a new modification of the technique that fixes the scapula. This limits the rotation (around a vertical axis) and anteversion (tilting forward) of the scapula that ordinarily occurs with glenohumeral movement during abduction past 30\u00b0. This allows the \u2018zero position\u2019 (used here to describe the critical angle between glenoid fossa and humeral head at point of relocation rather than Saha\u2019s classically described position with the scapula in full rotation and anteversion) to be reached more easily, at about 100\u00b0 abduction (no more than 120\u00b0 abduction is possible at the glenohumeral articulation4). This technique is usually performed with the patient seated but has been used in the supine position and, as in the original, no traction is used. Modified Milch technique (for a right-sided dislocation) The patient is seated in a hard backed chair, the operator standing behind the affected limb. The left hand is placed over the trapezius and spine of scapula. This fixes the scapula and detects any scapular movement. The right arm is held by the wrist and gently abducted to 100\u00b0. External rotation is applied gradually as the arm is lifted. The humeral head can be gently pushed in a supralateral direction if relocation has not occurred. For a larger patient an assistant might be employed to fix the scapula, the operator in front of the patient using the left hand, leaving the right free to push the humeral head if needed. Techniques with the arm in lateral flexion Eskimo technique40 The patient is placed on the ground lying on the non-dislocated shoulder. Two persons now lift the patient by the dislocated arm, keeping the opposite shoulder suspended a couple of centimetres from the ground. If no reduction occurs direct pressure on the humeral head is applied. Stimson also described this technique as the \u2018pendle method\u2019.41 Hippocratic method The patient lies supine while the surgeon holds the arm applying traction. A \u2018well stockinged foot\u2019 in the axilla applies countertraction and is also used to lever the humeral head supralaterally. This technique is still recommended in some texts.25,26,37 Traction countertraction7,32,37,42 Traction is applied to the arm with the shoulder in abduction; an assistant applies firm countertraction to the body using a folded sheet. Techniques with the arm in forward flexion Stimson\u2019s hanging arm technique13,43,44 The patient lies prone on a table with the affected arm hanging downward. A weight of 10 lb is applied to the wrist. Reduction occurs secondary to fatigue of the spasming muscles. Variations include: Step two of Janecki\u2019s \u2018forward elevation\u2019 combination manoeuvre29 Lippert\u2019s \u2018modification of the gravity method\u201943 has the patient prone with the affected arm hanging vertically and the elbow flexed. Downward traction to the humerus is then applied through the forearm by the operator Rollinson used the hanging method in combination with a supraclavicular nerve block44 Spaso technique30 With the patient supine the arm is gently lifted vertically. While applying traction rotate the shoulder externally. Push the head of the humerus in the axilla. Techniques with the arm in forward flexion plus scapular manipulation Scapular manipulation This technique was described by Bosley in 1979:22 The patient is placed prone on the examining table with the shoulder in a position of 90 degrees of forward flexion and external rotation. The forearm is suspended from the table with the wrist secured and the elbow flexed. Traction on the forearm is maintained with 5 to 15 lbs for a variable period, usually less than five minutes. After the patient begins to relax, the surgeon pushes on the tip of the scapula medially (lifting it on occasion), while simultaneously rotating the superior aspect of the scapular laterally. The technique works by applying constant traction to the externally rotated humerus to reduce pressure of the humeral head on the glenoid rim (sitting supralateral to the dislocated head). This allows the abducted inferior tip of the scapula to be rotated bringing the scapular neck and glenoid fossa into correct alignment. Originally described with the patient prone this caused problems positioning uncooperative patients or women with large breasts.23 Variations include: Arm hanging vertically with weights hung from wrist45 Seated patient46 with one physician performing gentle traction in the forward flexion position with counterbalancing in the patient\u2019s midclavicular region. A second physician manipulates the scapula Supine patient47 Boss Holzach matter This technique relies on movement of the scapula with the humerus fixed by axial traction.8 The scapula is rotated by the patient by actively shrugging the shoulders (anteriorly). The patient sits on an examination table, the wrists bound together and placed around the flexed (homolateral) knee. The head of the table is lowered and patient asked to lean back and hyperextend neck exerting anterior axial traction on the humeral head. The patient then shrugs the shoulders anteriorly increasing anteversion of the glenoid cavity. Techniques with the arm in abduction\/forward flexion with external fulcrum Use of an external fulcrum in the axilla as leverage and\/or countertraction has been recommended since Hippocrates.25,41 The choice of fulcrum and direction of traction varies: Nordeen uses the back of a chair in the axilla combined with downward traction48 Manes uses downward traction with the operator\u2019s forearm as an external fulcrum49 Slump reduction technique.50 An assistant supports the axilla from behind while the physician applies longitudinal traction. If unsuccessful external rotation and then scapular manipulation are added White uses the back of a chair as an external fulcrum and abduction with downward traction51 (Emergency Medicine Australasia Volume 17, Issue 5-6, Oct 2005)<\/p>\n Journal of Emergency Medicine Volume 31, Issue 1 , July 2006, Pages 23-28 Validation of rule to limit x-rays<\/p>\n <\/p>\n <\/p>\n FARE MethodThe Journal of Bone and Joint Surgery (American)<\/em>. 2009;91:2775-2782. <\/a><\/p>\n <\/p>\n Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan.<\/p>\n BACKGROUND: An initial anterior dislocation of the shoulder becomes recurrent in 66% to 94% of young patients after immobilization of the shoulder in internal rotation. Magnetic resonance imaging and studies of cadavera have shown that coaptation of the Bankart lesion is better with the arm in external rotation than it is with the arm in internal rotation. Our aim was to determine the benefit of immobilization in external rotation in a randomized controlled trial. METHODS: One hundred and ninety-eight patients with an initial anterior dislocation of the shoulder were randomly assigned to be treated with immobilization in either internal rotation (ninety-four shoulders) or external rotation (104 shoulders) for three weeks. The primary outcome measure was a recurrent dislocation or subluxation. The minimum follow-up period was two years. RESULTS: The follow-up rate was seventy-four (79%) of ninety-four in the internal rotation group and eighty-five (82%) of 104 in the external rotation group. The compliance rate was thirty-nine (53%) of seventy-four in the internal rotation group and sixty-one (72%) of eighty-five in the external rotation group (p = 0.013). The intention-to-treat analysis revealed that the recurrence rate in the external rotation group (twenty-two of eighty-five; 26%) was significantly lower than that in the internal rotation group (thirty-one of seventy-four; 42%) (p = 0.033) with a relative risk reduction of 38.2%. In the subgroup of patients who were thirty years of age or younger, the relative risk reduction was 46.1%. CONCLUSIONS: Immobilization in external rotation after an initial shoulder dislocation reduces the risk of recurrence compared with that associated with the conventional method of immobilization in internal rotation. This treatment method appears to be particularly beneficial for patients who are thirty years of age or younger. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.( J Bone Joint Surg Am. 2007 Oct;89(10):2124-31)<\/p>\n <\/p>\n Scalene block<\/a> vs. procedural sedation by Blaivas (Acad Emerg Med 2011;18:922)<\/p>\n <\/p>\n <\/a><\/p>\n Greg Hendy Method:<\/p>\n \t<\/p>\n \t <\/p>\n <\/a><\/p>\n Bledsoe ARC, also comes in cool version 20 degree internal to 70 external<\/p>\n Arm is held in adduction and internal rotation, can not abduct.<\/p>\n Assoc. c fx of lesser trochanter.<\/p>\n Caused by hyperabduction<\/p>\n Pt presents with arm in the asking a question position.<\/p>\n Assoc c brachial plexus and axillary artery damage<\/p>\n Yerguson\u2019s test with flexed elbow, have pt supinate against resistance, pain is positive<\/p>\n Biceps Tendon Rupture<\/p>\n Peds-sling<\/p>\n Adults-attempt reduction<\/p>\n Middle 1\/3<\/p>\n Reduce by pulling both shoulders backwars. Fracture can injure subclavian as well as CN IV-VIII.<\/p>\n Need ortho only if neurovascular injury, skin tenting, or open fracture<\/p>\n Distal 1\/3<\/p>\n Sling and refer<\/p>\n Medial 1\/3<\/p>\n Assoc. c intrathoracic injury<\/p>\n X-Rays AP\/LAT<\/p>\n May need CT Chest for Pneumo and pulm. Injuries<\/p>\n Get axillary view of shoulder<\/p>\n Treat c Sling<\/p>\n <\/p>\n As discussed after the shoulder talk, scapulothoracic dissociation is a cool diagnosis that most of us don\u2019t know too much about. Attached is the first case report and a couple more recent reviews. Here\u2019s the abstract from the first case report:<\/p>\n <\/a><\/p>\n <\/a><\/p>\n as manifested by lateral displacement of the scapula and acromioclavicular separation, is a previously unreported injury in which there is a complete disruption of the scapulothoracic articulation without an overlying partial or complete amputation through the soft tissue. Associated with the disruption of the scapulothoracic articulation are injuries to the brachial plexus and the subclavian artery and vein; multiple open and closed fractures of the ipsilateral upper extremity are often present also. In the patient with severe multiple injuries, scapulothoracic dissociation may not be recognized immediately, with potentially fatal consequences. In this paper we present the cases of three patients with radiographic and pathological evidence of scapulothoracic dissociation and review the literature on related injuries.<\/p>\n<\/dd>\n<\/dl>\n <\/p>\n Legg Reduction Maneuver (JAOA 2008;108(10):571)<\/p>\n seat patient with back against something firm at 45-90 degree angle<\/p>\n assitant pushes down on oppsoite shoulder<\/p>\n abduct arm straight out to 90<\/p>\n face their palm forward<\/p>\n flex elbow to 90<\/p>\n pull arm back so it is behind the coronal plane of the occipit<\/p>\n adduct arm fully flexing the elbow<\/p>\n internally rotate and adduct arm so it crosses the patients chest<\/p>\n<\/p>\n https:\/\/vimeo.com\/178808271<\/p>\n <\/p>\n From Trevor Jackson\u2019s TJDogman<\/strong>:<\/p>\n This condition is \u201cBrachial neuritis<\/strong>\u201d or \u201cParsonage-Turner syndrome<\/strong>\u201d an acute idiopathic neuropathy with predominantly motor rather than sensory findings. It presents initially with severe pain in the shoulder followed by weakness affecting various branches of the brachial plexus, with the upper trunk most commonly affected. (anatomy reminder<\/a>) The condition can be bilateral, and 80% of patients will recover function although this may take two years.<\/p>\n I hadn\u2019t heard of this condition before and a search of the standard EM texts wasn\u2019t so helpful with only Tintinalli including it. I suspect this might be because many of these patients would be referred direct to neurologists rather than ED. I\u2019ve posted this case mainly to share my illumination of something completely new, particularly given the puzzling nature of the presentation (use of dogma no. 3<\/a> didn\u2019t help me this time) And the supraspinatus tear? Just an incidental finding that succeeded in throwing us off the scent!<\/p>\n References <\/p>\n","protected":false},"excerpt":{"rendered":" Array<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[17],"tags":[],"yoast_head":"\n60)<\/strong>Adhesive capsulitis (\u201cfrozen shoulder\u201d) and true glenohumeral arthritis are often preceded by a history of non-adhesive capsulitissymptoms, are characterised by deep joint pain, and restrictactivities such as putting on a jacket (impaired external rotation).Adhesive capsulitis is more common in people with diabetes andmay also occur after prolonged immobilisation. On examinationglobal pain is present, along with restriction of all movements,both active and passive.<\/p>\n<\/span>AC Joint<\/span><\/h3>\n
<\/a><\/p>\n<\/span>Sternoclav Joint<\/span><\/h3>\n
<\/span>Dislocation<\/span><\/h2>\n
<\/span>Anterior Shoulder Dislocation<\/span><\/h3>\n
<\/span>Cunningham Technique<\/a><\/span><\/h2>\n
<\/a><\/p>\nFractures<\/h4>\n
X-Rays<\/h4>\n
<\/a><\/p>\n<\/a><\/p>\n<\/a><\/p>\n<\/a><\/a><\/a> Younger patients should be immobilized for about 3 weeks. Those > age 60 should have early follow-up (5-7 days) to allow for early immobilization to avoid joint stiffness (Roberts: Clinical Procedures in Emergency Medicine, ed. 4, pg. 957)<\/p>\n<\/span>Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial.<\/span><\/h2>\n
<\/span>Scapular Manipulation<\/span><\/h2>\n
<\/a><\/p>\n<\/span>Shoulder Brace<\/span><\/h2>\n
<\/span>Posterior Shoulder Dislocation<\/span><\/h3>\n
<\/span>Inferior Dislocation (Luxatio Erecta)<\/span><\/h3>\n
<\/a><\/p>\n<\/span>Soft Tissue<\/span><\/h3>\n
Rotator Cuff Tears<\/h4>\n
\n
Biceps Tendonitis<\/h4>\n
<\/span>Clavicular Fractures<\/span><\/h3>\n
<\/span>Scapula Fractures<\/span><\/h3>\n
\n
<\/span>Scapulothoracic dissociation<\/span><\/h2>\n
<\/span>closed forequarter amputation<\/span><\/h2>\n
<\/h3>\n
<\/span>Self Reduction of a Shoulder<\/span><\/h2>\n
\n
\nEmedicine<\/a>
\nWheeless\u2019 textbook of Orthopaedics<\/a><\/p>\n<\/blockquote>\n