01Approach to the Critical Patient/attcp31

Immediate priorities

›First look priorities

›Airway and breathing compromise

›Hemodynamic instability

›Altered mental status

›Polytrauma triggers

›Limb threat screen

›Distal pulses

›Capillary refill

›Skin temperature and color

›Motor and sensory distal to shoulder

›If hard signs of vascular injury, immediate surgical consultation

›Pre-reduction safety

›Procedural sedation readiness if needed

›NPO status when feasible

›Allergies and prior sedation complications

›IV access and monitoring plan

Neurovascular documentation

›Baseline neurovascular exam

›Axillary nerve

›Deltoid contraction

›Lateral deltoid sensation

›Brachial plexus screen

›Median nerve motor and sensation

›Ulnar nerve motor and sensation

›Radial nerve motor and sensation

›Vascular status

›Radial pulse

02History/hx29

Core history

›Key history elements

›Time since injury

›Mechanism

›Abduction and external rotation mechanism

›Direct posterior force mechanism

›Axial load on abducted arm mechanism

›Prior dislocation episodes

›Prior shoulder surgery or instability diagnosis

›Clues to dislocation type

›Anterior pattern clues

›Arm held abducted and externally rotated

›Sense of shoulder coming out anteriorly

›Posterior pattern clues

›Seizure or syncope

›Electrical injury

›Inability to externally rotate

›Inferior pattern clues

›Arm fixed overhead

›Axial load with hyperabduction

Associated injury risk history

›High risk associated injuries

›Elderly

›Proximal humerus fracture risk

›Rotator cuff tear risk

›Anticoagulation or bleeding diathesis

›High energy trauma

›Neurovascular symptom history

03Physical Exam/exam25

Shoulder focused exam

›Inspection and posture

›Shoulder contour loss

›Arm position at rest

›Skin tenting or threatened skin

›Palpation

›Humeral head position

›Clavicle and AC joint tenderness

›Proximal humerus tenderness

›Range of motion limitations

›External rotation block

›Abduction limitation

›Pseudoparalysis concern

Neurovascular and functional exam

›Neurovascular exam

›Axillary nerve function

›Brachial plexus screen

›Radial and ulnar pulses

›Rotator cuff screening after reduction if tolerated

›Supraspinatus strength

›External rotation strength

›Subscapularis strength

PITFALLS

›Posterior dislocation miss risk

›Normal appearing AP radiograph risk

›Axillary or scapular Y view requirement

›Greater tuberosity fracture with anterior dislocation risk

›Persistent pain or weakness after reduction trigger

04Differential Diagnosis/ddx21

Traumatic shoulder pain differential

›Major joint and bone injury differential

›Glenohumeral dislocation

›Anterior

›Posterior

›Inferior

›Proximal humerus fracture

›Greater tuberosity fracture

›Glenoid rim fracture

›Clavicle fracture

›AC separation

›Soft tissue and neurovascular differential

›Rotator cuff tear

›Labral injury

›Brachial plexus injury

›Axillary artery injury

›Non-traumatic mimics when unclear history

›Septic arthritis

›Hemarthrosis

Coding alignment

›Coding and terminology

›ICD-10-CM S43.0 dislocation of shoulder joint

›SNOMED CT concept: Shoulder joint dislocation

05Laboratory Tests/lt10

Labs when clinically indicated

›Targeted labs

›Pregnancy test when pregnancy possible and imaging planned

›Blood glucose when altered mental status or seizure

›Creatine kinase when prolonged seizure or crush concern

›Procedural sedation pathway labs when needed

›Electrolytes if significant comorbidity or arrhythmia risk

›Hemoglobin if major bleeding concern

PITFALLS

›Lab limitations

›Normal labs do not exclude vascular injury

›Normal labs do not exclude compartment level ischemia distal to shoulder

06Diagnostic Tests/dt43

Scoring Systems

›Imaging decision support

›Quebec Decision Rule for radiography in shoulder dislocation

›Older age and high risk mechanism factors

›Post-reduction radiographs when fracture concern

›Sedation risk stratification

›ASA physical status classification

›Airway assessment elements

Radiographs

›Radiograph strategy

›Pre-reduction radiographs when safe and no limb threat

›AP glenohumeral view

›Scapular Y view

›Axillary view

›Velpeau axillary view if unable to abduct

›Immediate reduction without pre-reduction radiographs

›Neurovascular compromise

›Threatened skin

›Post-reduction radiographs

›Confirm concentric reduction

›Screen for associated fractures

›Key radiographic findings

›Anterior dislocation findings

›Subcoracoid humeral head position

›Hill-Sachs lesion possibility

›Posterior dislocation findings

›Lightbulb sign on AP view

›Rim sign

07Disposition/dispo19

Disposition pathways

›Discharge criteria

›Successful reduction

›Pain controlled with oral regimen

›Neurovascularly intact

›Reliable follow-up

›Admission criteria

›Irreducible dislocation

›Recurrent immediate instability after reduction

›Persistent neurovascular deficit

›Associated fracture requiring inpatient management

›High risk medical comorbidity requiring monitoring after sedation

›Transfer criteria

›Vascular injury concern

›Open fracture or open joint injury

›Complex fracture-dislocation

Follow-up timing

›Follow-up plan

›Orthopedics or sports medicine follow-up within 1 week

›Earlier follow-up within 72 hours if fracture, elderly, or persistent weakness

›Physical therapy referral timing after immobilization period

08Treatment/t78

Immediate life-saving interventions

›Time-critical interventions

›If pulseless limb, immediate reduction attempt and vascular surgery activation

›If threatened skin, urgent reduction

›If severe pain with evolving neurologic deficit, escalation to resuscitation setting

Immobilization and Splinting

›Immobilization approach

›Sling and swathe in internal rotation for most anterior dislocations

›External rotation brace consideration for selected anterior instability patterns

›Posterior dislocation immobilization in external rotation as tolerated

›Inferior dislocation immobilization in adduction after reduction

›Immobilization principles

›Comfort positioning

›Neurovascular recheck after immobilization

›Avoid circumferential casting in acute swelling phase

Reduction

›Reduction indications

›Neurovascular compromise

›Threatened skin or severe deformity

›Pain refractory to analgesia

›Reduction technique principles

›Traction and countertraction

›Gentle sustained force

›Avoid repeated forceful attempts

›Post-reduction stability assessment

›Anterior dislocation techniques

›Scapular manipulation

›Prone or seated positioning

09Special Populations/sp19

Pregnancy

›Pregnancy considerations

›Shielding for radiographs when feasible

›Analgesic selection

›Acetaminophen preferred

›NSAID avoidance in later pregnancy

›Sedation considerations

›Airway edema risk awareness

›Obstetrics consultation when viable gestation and sedation planned

Geriatric

›Geriatric considerations

›Higher fracture-dislocation rate

›Greater tuberosity fracture screening

›Rotator cuff tear screening

›Lower threshold for CT with equivocal radiographs

›Early mobilization planning to reduce deconditioning

Pediatrics

›Pediatric considerations

›Proximal humerus physeal injury mimic consideration

›Imaging and gentle reduction technique

›Nonaccidental trauma consideration when history inconsistent

›Orthopedics follow-up for recurrent instability risk

10Background/b30

Epidemiology

›Epidemiology facts

›Anterior dislocation as most common subtype

›Posterior dislocation as uncommon subtype

›Inferior dislocation as rare subtype

›Higher recurrence risk in adolescents and young adults

Pathophysiology

›Mechanism and lesions

›Anterior dislocation injury patterns

›Bankart lesion risk

›Hill-Sachs lesion risk

›Posterior dislocation injury patterns

›Reverse Hill-Sachs lesion risk

›Posterior labral injury risk

›Inferior dislocation injury patterns

›Capsuloligamentous disruption risk

›Neurovascular stretch injury risk

Therapeutic Considerations

›Therapeutic rationale

›Early reduction benefit

›Pain relief

›Skin protection

›Neurovascular decompression

›Immobilization tradeoffs

›Comfort and short-term stability benefit

›Stiffness risk with prolonged immobilization

›Rehabilitation goals

›Restore range of motion

11Patient Discharge Instructions/pdi24

Copy discharge instructions

›Discharge instructions

›Sling use

›Wear continuously except hygiene and exercises as instructed

›Sleep with sling if painful without it

›Pain control plan

›Acetaminophen dosing per label

›NSAID dosing per label if allowed

›Opioid short course only if required

›Ice and elevation

›Ice 15 to 20 minutes at a time

›Keep arm supported on pillows when resting

›Activity restrictions

›No lifting with injured arm

›Avoid abduction and external rotation until cleared

›Follow-up

›Orthopedics or sports medicine appointment within 1 week

›Earlier follow-up if fracture, elderly, or persistent weakness

›Return to ED now

›Increasing pain despite medication

›New numbness or weakness

›Cool, pale, or blue hand

›Increasing swelling or tightness

›Recurrent dislocation sensation

›Fever or redness with severe joint pain

12References/r6

Clinical guidelines and evidence sources

›Reference list

›AAOS patient and clinician education resources on shoulder instability

›American Shoulder and Elbow Surgeons resources on shoulder instability and recurrent dislocation

›ACEP clinical policy and guideline resources for procedural sedation and analgesia in the ED

›Quebec Decision Rule publications and summaries for shoulder dislocation radiography

›Orthopedic and sports medicine reviews on Bankart and Hill-Sachs lesion management

Evidence & Review

Evidence & Review