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dx.
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Shoulder dislocation
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
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Acute appendicitis
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Anal fissure
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Genitourinary and Reproductive Presentations
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Paraphimosis
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Pyelonephritis
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Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
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Animal bite
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Febrile neutropenia
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Tick-borne illness (Lyme disease)
Tinea infection
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Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Shoulder dislocation
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ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate threats and escalation
Time critical risks
▶
Airway compromise from sedation risk
Hemodynamic instability from polytrauma
Limb threat from vascular injury
Open dislocation
Fracture dislocation
Posterior dislocation after seizure or electrocution
Immediate escalation triggers
▶
If absent distal pulses then emergent reduction attempt and vascular surgery
▶
If pulses not restored after reduction then CT angiography upper extremity
If expanding hematoma then direct pressure and operative pathway
If open injury then antibiotics and orthopedics
▶
If gross contamination then add gram negative coverage
If suspected surgical neck fracture then avoid forceful reduction and orthopedics
▶
If neurovascular deficit then emergent ortho
Analgesia and sedation readiness
▶
Dedicated monitoring personnel during PSA ACEP Level C
Capnography adjunct to detect hypoventilation earlier ACEP Level B
Fasting time not a reason to delay ED PSA ACEP Level B
Pre and post reduction safety checks
Neurovascular baseline
▶
Radial pulse quality
Capillary refill
Hand color and temperature
Sensation lateral deltoid axillary nerve
Deltoid activation if tolerated
Median nerve sensation index fingertip
Ulnar nerve sensation small fingertip
Radial nerve wrist and finger extension
Reduction readiness
▶
Pain control plan
Anticipated dislocation direction
High fracture risk features
▶
Age 40 years or older
First episode dislocation
Humeral ecchymosis
Equipment plan
▶
Sling and swathe
Pulse oximetry and capnography if PSA
Suction and airway equipment if PSA
History
Core history elements
Presentation pattern
▶
Sudden shoulder pain
Loss of contour
Inability to move shoulder
Paresthesias
Mechanism and context
▶
Abduction external rotation injury
Fall on outstretched hand
Direct blow
Seizure
Electrocution
High energy trauma
Prior instability
▶
First time dislocation
Recurrent dislocation history
Prior surgery stabilization
Ability to self reduce
Risk factors and associated injuries
Fracture risk features
▶
Age 40 years or older
First time dislocation
Substantial force mechanism
Rotator cuff injury risk
▶
Age over 40 years
Persistent weakness after reduction
Night pain after reduction
Nerve injury risk
▶
Older age
First time dislocation
Prolonged dislocation time
Posterior dislocation clues
▶
Seizure or electrocution history
Arm held in adduction and internal rotation
Inability to externally rotate
Physical Exam
Focused exam
Inspection and deformity
▶
Loss of deltoid contour
Prominent acromion
Arm position
Skin tenting or open wound
Palpation
▶
Humeral head position
Clavicle tenderness
Proximal humerus tenderness
AC joint tenderness
Range of motion pattern
▶
Guarding
Block to external rotation posterior concern
Luxatio erecta posture inferior concern
Neurovascular and complications
Axillary nerve assessment
▶
Lateral deltoid sensation deficit
Deltoid weakness
Axillary nerve injury described as high as 40 percent in some series
Distal neurovascular assessment
▶
Radial pulse asymmetry
Capillary refill delay
Hand ischemia signs
PITFALLS
▶
Normal frontal radiograph does not exclude posterior dislocation
Missed posterior dislocation reported as high as 79 percent in some studies
Persistent pain after reduction suggests fracture or cuff tear
Differential Diagnosis
Traumatic shoulder pain and deformity
Shoulder dislocation ICD 10 S43.0
▶
Anterior glenohumeral dislocation
Posterior glenohumeral dislocation
Inferior dislocation luxatio erecta
Fractures
▶
Proximal humerus fracture
Greater tuberosity fracture
Surgical neck fracture
Glenoid rim fracture bony Bankart
Clavicle fracture
Scapular fracture
Soft tissue injuries
▶
Rotator cuff tear
Labral tear Bankart
AC separation
Neurovascular injuries
▶
Axillary nerve neuropraxia
Brachial plexus injury
Axillary artery injury
Mimics
▶
Cervical radiculopathy with shoulder pain
Septic arthritis if atraumatic fever
Calcific tendinitis
Laboratory Tests
Reduction and sedation safety labs
PSA related tests when indicated
▶
Pregnancy test for patients with pregnancy potential
▶
Imaging and sedation medication risk mitigation
Point of care glucose if seizure or altered mental status
▶
Hypoglycemia as seizure trigger
Electrolytes if seizure evaluation planned
▶
Sodium abnormalities as seizure trigger
Coagulation and bleeding risk when indicated
▶
INR if anticoagulant use
▶
Hematoma risk and procedural planning
Platelets if thrombocytopenia concern
▶
Procedure bleeding risk
Trauma associated labs
Multisystem trauma labs when indicated
▶
CBC for suspected hemorrhage
▶
Anemia baseline if major trauma
Type and screen if high energy trauma
▶
Operative pathway readiness
Creatinine for CT angiography planning
▶
Contrast safety context
Diagnostic Tests
Scoring Systems
Quebec shoulder dislocation decision rule for radiography
▶
Purpose
▶
Reduce unnecessary prereduction and postreduction radiographs
Prereduction radiography indications
▶
Age 40 years or older and humeral ecchymosis
Age 40 years or older and first episode dislocation
Younger than 40 years and mechanism other than fall from standing height or atraumatic injury
Derived rule performance
▶
Sensitivity 100 percent for clinically important fracture dislocation
Specificity 34.2 percent
Negative likelihood ratio 0.04
Postreduction radiography indications in refined approach
▶
Clinically significant fracture on initial radiography
Uncertain reduction
MRI
MRI shoulder
▶
Indications
▶
Suspected labral tear in recurrent instability
Suspected rotator cuff tear with persistent weakness
Persistent pain despite normal radiographs
Technique considerations
▶
MR arthrogram for labral pathology
Standard MRI for rotator cuff evaluation
Limitations
▶
Not required for acute ED reduction success
Availability and timing constraints
CT
CT shoulder
▶
Indications
▶
Suspected glenoid fracture
Suspected humeral head impaction defect evaluation
Preoperative planning for recurrent instability
CT angiography upper extremity
▶
Indications
▶
Persistent pulse deficit after reduction
Expanding hematoma
Interpretation focus
▶
Axillary artery injury
Distal runoff compromise
Ultrasound
Point of care ultrasound applications
▶
Dislocation confirmation when radiography delayed
▶
Humeral head position relative to glenoid
Post reduction confirmation adjunct
▶
Rapid confirmation prior to post reduction radiographs in select settings
Rotator cuff screening
▶
Full thickness tear concern in older patients
Limitations
▶
Operator dependence
Glenoid rim fractures not reliably excluded
Plain radiography
Radiograph views
▶
AP shoulder
Scapular Y view
Axillary view or Velpeau axillary if pain limits abduction
Radiographic clues
▶
Anterior dislocation subcoracoid position
Posterior dislocation lightbulb sign
Hill Sachs defect on humeral head
Bony Bankart glenoid rim fragment
Timing
▶
Prereduction imaging when fracture risk high
Postreduction imaging for alignment and associated fractures
Disposition
Discharge criteria and follow up
Copy
Discharge after successful reduction
▶
Pain controlled with oral medications
Neurovascular exam normal or baseline unchanged
Stable postreduction imaging or clear clinical confirmation pathway
Follow up planning
▶
Orthopedics or sports medicine within 1 week for first time dislocation
Earlier follow up for high risk recurrence
Physical therapy referral timing after immobilization period
Activity restrictions
▶
Sling and swathe use
Avoid abduction external rotation until cleared
Admission or transfer indications
Admission considerations
▶
Irreducible dislocation in ED
Vascular injury concern
Significant fracture dislocation
Uncontrolled pain
Unsafe discharge environment after sedation
Transfer considerations
▶
Need for emergent orthopedic surgery capability
Suspected axillary artery injury
Treatment
Analgesia and anesthesia options
Multimodal pain control
▶
Acetaminophen PO 1000 mg once
▶
Maximum 4000 mg per 24 hours typical adult
Ibuprofen PO 600 mg once
▶
Avoid in pregnancy third trimester
Ketorolac IV 15 mg once
▶
Avoid if renal impairment or bleeding risk
Fentanyl IV 0.5 mcg per kg
▶
Repeat 0.5 mcg per kg every 5 minutes as needed
Morphine IV 0.05 mg per kg
▶
Repeat 0.05 mg per kg every 10 minutes as needed
Intra articular lidocaine option
▶
Lidocaine 1 percent 20 mL intra articular
▶
Aspirate joint fluid first if possible
Onset 5 to 10 minutes
Similar effectiveness to IV sedation with fewer adverse events in meta analysis
Procedural sedation and analgesia
PSA safety framework
▶
ASA classification and airway risk assessment
▶
High risk comorbidities cardiopulmonary disease
OSA history
Monitoring
▶
Pulse oximetry continuous
Blood pressure cycling
ECG monitoring
Capnography adjunct ACEP Level B
Fasting
▶
Do not delay ED PSA based on fasting time ACEP Level B
Propofol ACEP Level A
▶
Propofol IV 0.5 mg per kg bolus
▶
Repeat 0.25 mg per kg every 1 to 3 minutes
Hypotension monitoring
Propofol IV infusion 25 mcgg per kg per minute
▶
Titrate 10 to 20 mcg per kg per minute to effect
Ketamine ACEP Level A children
▶
Ketamine IV 1 mg per kg
▶
Repeat 0.5 mg per kg every 5 to 10 minutes
Emergence reaction risk in adolescents
Ketamine IM 4 mg per kg
▶
Repeat 2 mg per kg after 10 minutes if needed
Etomidate ACEP Level B adults
▶
Etomidate IV 0.1 mg per kg
▶
Repeat 0.05 mg per kg once if needed
Myoclonus consideration
Ketamine propofol combination ACEP Level B
▶
Ketamine IV 0.5 mg per kg
▶
Pair with propofol IV 0.5 mg per kg
Repeat small propofol boluses to effect
Reduction techniques
General reduction principles
▶
Gentle technique with muscle relaxation
Stop if mechanical block or severe pain
Repeat neurovascular exam after each attempt
Anterior dislocation options
▶
Scapular manipulation
▶
Prone or seated position
Downward medial pressure on scapular tip
External rotation method
▶
Elbow flexed 90 degrees
Slow external rotation without traction
Milch technique
▶
Abduction with gentle external rotation
Humeral head guidance if needed
Stimson technique
▶
Prone with arm hanging
Gradual traction with weights
Traction countertraction
▶
Sheet countertraction
Steady longitudinal traction
Posterior dislocation reduction
▶
Gentle traction in line with humerus
▶
Gradual external rotation to neutral
Anterior pressure on humeral head as needed
Avoid forceful rotation
▶
Risk of iatrogenic fracture
Inferior dislocation luxatio erecta
▶
Traction and gradual adduction
▶
Convert to anterior then reduce
High neurovascular injury risk pathway
Post reduction care
Immobilization
▶
Sling and swathe internal rotation
▶
Typical immobilization 1 to 3 weeks for simple reduction
Early pendulum exercises when cleared
Post reduction reassessment
▶
Pain relief improvement
Full neurovascular recheck
Post reduction imaging when indicated
Recurrence counseling
▶
High recurrence in young patients
▶
Under 20 years recurrence 72 to 100 percent
Age 20 to 30 years recurrence 70 to 82 percent
Over 50 years recurrence 14 to 22 percent
Special Populations
Pregnancy
Pregnancy specific considerations
▶
Radiation minimization
▶
Shielding and lowest necessary views
Ultrasound adjunct when feasible
Analgesia choices
▶
Acetaminophen preferred
Avoid NSAIDs in third trimester
PSA considerations
▶
Aspiration risk awareness
Left lateral tilt in late pregnancy
Geriatric
Older adult considerations
▶
Higher fracture dislocation risk
▶
Low energy falls still high risk
Prereduction radiography threshold lower
Higher rotator cuff tear risk
▶
Persistent weakness prompts early imaging and referral
Sedation risk
▶
Lower dosing
Delirium risk with benzodiazepines
Pediatrics
Pediatric considerations
▶
Physeal injury mimic
▶
Proximal humerus epiphyseal injury consideration
Recurrence risk high in adolescents
▶
Early sports medicine referral
PSA options
▶
Ketamine safe for children ACEP Level A
Weight based dosing strict
Background
Epidemiology
Epidemiology basics
▶
Traumatic anterior dislocation common
▶
Incidence near 24 per 100000 person years
Male predominance 2 to 5 times
Nearly half occur before age 30
Direction distribution
▶
Anterior dislocations about 90 percent of cases
Posterior dislocations less than 4 percent of cases
Miss rate and diagnostic difficulty
▶
Missed posterior dislocation reported as high as 79 percent
Pathophysiology
Mechanism and lesion patterns
▶
Anterior dislocation mechanism
▶
Abduction and external rotation lever out of glenoid
Associated bony lesions in anterior instability
▶
Bony lesions reported in 96 percent in pooled studies of recurrent instability
Hill Sachs lesion prevalence 69 percent in pooled sample
Bony Bankart lesion prevalence 13 percent in pooled sample
Neurovascular injury mechanisms
▶
Axillary nerve stretch across humeral head
Axillary artery tethering in older patients
Therapeutic Considerations
Reduction timing and outcomes
▶
Earlier reduction improves pain control and muscle spasm
Prolonged dislocation increases difficulty and complications
Analgesia strategy evidence
▶
Intra articular lidocaine similar success to IV sedation in RCT meta analysis
Intra articular lidocaine associated with fewer adverse events and shorter ED length of stay
Immobilization strategy
▶
Internal rotation sling commonly recommended
Immobilization duration commonly 1 to 3 weeks after simple reduction
Surgical consultation rationale
▶
High recurrence in young active patients
Large bony defects increase instability recurrence
Patient Discharge Instructions
Copy discharge instructions
Copy
Discharge care after shoulder reduction
▶
Sling and swathe continuously except hygiene
Ice 15 minutes up to 4 times daily for 48 hours
Acetaminophen as directed on label
NSAID use only if safe for kidneys stomach and pregnancy status
Keep elbow wrist and hand moving several times daily
No lifting pushing pulling with injured arm
Avoid shoulder abduction and external rotation
Follow up
▶
Orthopedics or sports medicine within 1 week
Earlier follow up for first time dislocation age under 30 or athlete
Physical therapy referral after immobilization period
Return to ED immediately
▶
New numbness or weakness in arm or hand
Fingers cold blue or very swollen
Severe increasing pain not controlled with medication
Shoulder looks out of place again
Fever or redness around any wound
Chest pain or shortness of breath after sedation
References
Clinical guidelines and policies
ACEP Clinical Policy Procedural Sedation and Analgesia in the ED 2014
▶
Fasting time should not delay ED sedation ACEP Level B
Capnography may be used as adjunct to detect apnea earlier ACEP Level B
Propofol can be safely administered for ED PSA ACEP Level A
Ketamine can be safely administered to children for ED PSA ACEP Level A
Etomidate can be safely administered to adults for ED PSA ACEP Level B
Quebec decision rule refinement for radiography in anterior shoulder dislocation CJEM 2009
▶
Sensitivity 100 percent for clinically important fracture dislocation
Negative likelihood ratio 0.04
AAOS OrthoInfo Dislocated Shoulder patient guidance
▶
Immediate goal return to normal alignment
Evidence based sources
Systematic review and meta analysis intra articular lidocaine vs IV sedation 2022
▶
Similar reduction success
Fewer adverse events
Shorter ED length of stay
Review traumatic first time anterior dislocation recurrence by age 2016
▶
Under 20 years recurrence 72 to 100 percent
Age 20 to 30 years recurrence 70 to 82 percent
Over 50 years recurrence 14 to 22 percent
Systematic review bony lesion prevalence in traumatic anterior dislocation 2022
▶
Hill Sachs lesion prevalence 69 percent
Bony Bankart lesion prevalence 13 percent
Review posterior shoulder dislocation missed diagnosis 2018
▶
Missed initial diagnosis reported as high as 79 percent
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Shoulder dislocation