Anterior Shoulder Dislocation

17 year old basketball player

Diving for basketball with arm outstretched

Players landing on his posterior shoulder while he was gaining control of ball

The resulting pressure from posterior resulted in subcoracoid(anterior) dislocation

90-95% are Subcoracoid(ant) or Subglenoid(ant/inf)

Didn’t see injury

Was in Training Room at time taking care of another athlete

Player presented himself to training room with arm held over stomach area

Player stated arm was numb and couldn’t move

it

The Real Issue

Player- Father in Armed Forces

Legal guardian was grandparents- not at game

Player asked that I reduce shoulder to prevent issues at home

Athletic Director was present at game- agreed

Athlete and AD relationships

Knew of the players issues at home

Very good relationship with AD

Know the family/parents when can

Don’t sit in the Training Room or the corner of the gym in isolation

Typical Protocol

Will place injured athlete in sling or ace wrap arm to side/stomach

Place ice over shirt or wrap

Send to ER for x-rays

Possible issues-- bony injuries or fractures, ligament injuries, neuro damage

What did I do

Check pulse and neuro

Palpate shoulder area- clavicle, scapula for any obvious FX

Palpate humeral head for position/ where is it at?

Check shoulders bilateral

How did I reduce?

Placed athlete prone on stomach/table

Applied 4-5 lbs of manual traction

Shoulder reduced within one minute

Subtle click or visible movement back into glenoid fossa

After Reduction

Check pulse and neuro

Palpate shoulder anatomy to check for symmetry

Placed in sling and applied ice

Sent home athletic instructions of what to look for and call me if any issues

Recheck the athlete daily basis

Asked legal guardians to call me- Never did

Follow-up care

After a few weeks we started ROM

Progressed into shoulder strengthening

Athlete ran track in spring with no complaints

Of course don’t forget to document and sit with AD to fill out paperwork

Know the athletes/AD

Speak with the kids when the come into the training room

Get on the same page with AD and know the school policies

Football Player/Dislocated Shoulder

Athlete was part of a group of players tackling ball carrier

The play ended out of bounds with about 6 players involved

Was about 20 yards away

At the end of the play one player remained on his back

Walking upon the player/injury

Player was in supine position with arm on ground outstretched and elevated- chewing on mouth piece

All UE anatomy looked to be normal

I think my arm fell off!

Was his first words

Stated his arm was numb and hoped it was still on

I reassured that it was still on

Evaluation under shoulder pads

Palpate bilateral shoulder/Cervical

Looking for Scapula FX, Clavicle FX, AC JT, Humeral Head, Cervical Spine

Check elbow, hand and wrist

Check for blood and neuro responses

Trust what you feel

Humeral Head felt like in armpit

After palpation determined dislocated shoulder

And then the wait began

Will usually rotate this back in position, resting arm on stomach and wait for parents to come down from the stands.

No parent at the game

Good relationship with AD- Policy was that players could not be transported/ambulance without parent knowledge

Stuck dislocated shoulder

Attempted to gently rotate arm into resting position on stomach

Arm would not move/ don’t force rotation

Attempted to locate parent at home– No Luck

We waited about 15 minutes with Ice on shoulder

Monitor UE vital signs

AD finally made call

Because of no obvious true emergency we waited approx 20 minutes to call Ambulance

The issue was with parents being very upset with medical bills caused by sports and not being able to pay

The AD was willing to take the responsibility of dealing with the aftermath.

Didn’t remove shoulder pads

Due to the shoulder being stuck in ext rotation and abduction/didn’t want to injury any further.

Ambulance arrived and had to transport with shoulder in that position

Get to know the AD and discuss policies so you are on the same page.

Document

Called AD re injury so we both documented

The ring finger vs logic

Football player- finger stuck in opponent players face mask

Finger will go where the opponents facemask goes

Resulting in loss of continuity between the two joints– aka- dislocated finger

Visible appearance

Usually obvious-- crooked finger, laterally or resting on top on proximal joint

Palpate carpal, metacarpal, phalanges

Once determined that FX is not an issue will reduce. Buddy tape and will play.

How to Reduce

Usually players are sweaty from participation

Gauze works well because of the rough surface, place a gauze pad over proximal, middle phalanx or metacarpal

Place a separate piece of gauze over the dislocated joint

Grasp proximal phalanx or metacarpal firmly

Grasp dislocated phalanx firmly

Lift or pull dislocated finger away from joint– Up/Down or Side

Then pull dislocated finger forward

Finger should slide into place

Check ROM, blood supply, neuro and splint

Fran VS The Ring Finger

After attempting to reduce in this manner the finger would not budge

Then I tried put more force/pull into the effort

Then I put more force/pull into the effort

Finger would not budge

Doctor VS The ring finger

Home team doc arrived upon the scene

Attempted to reduce

Then attempted to reduce again

Then attempted to reduce again

The finger Won. We had to splint in the dislocated position and send to ER with parents

The reason we lost the battle

Because of the violent twisting and pulling of the joint, soft tissue/ligament had gotten caught between the joint

Other Issues with Dislocated Fingers:

Common to have small fractures

Sometimes they when reduced they don’t stay in place. FX

Pseudoarthrosis Clavicle

Original thought to be a matchstick fracture due to pressure from birth canal.

History

Rare Etiology Unknown—Subcalvian Artery saws

through during development? Most are occur on right side. No hx of trauma or tenderness.

Shoulder Deformity

Normal ROM Normal Strength Slight Depression or forward rounding of

shoulder at 9 years old. Very mild lower scapular winging.

Treatment Options?

Surgery? Risk of infection Will bone graft heal/area of poor circulation Is it worth the price? History of surgery plate breaking Other technique is a K wire through bone

Clavicle Pseudoarthrosis Complications

Infection Nonunion Brachial Plexus Injury Rare Complications-- Pain at Site, Shoulder

Asymmetry, Decreased ROM, Thoracic Outlet Syndrome.

What are we doing?

Consulting with Dr Latz Recommend NO SURGERY