Case Study 1.1: Traumatic Shoulder Dislocation
Scott A. Myrick and Karen M. Myrick
SETTING: URGENT CARE
Definition and Incidence
The estimated incidence of shoulder dislocations in the United States is approximately 24 per 100,000 person-years (Zacchilli & Owens, 2010). Person-years is the product of the number of years times the number of members of a population who have been affected by a certain condition. Furthermore, young age and male sex are risk factors for shoulder dislocation (Zacchilli & Owens, 2010). Athletes who participate in contact and collision sports are at a higher risk.
A 35-year-old male presents with a chief complaint of left shoulder pain and a feeling that his shoulder “went out.” The patient was playing a pick-up game of lacrosse in a local men’s league after work. He reached up high with his stick to catch a pass and was hit from the front and side by another player and landed face down on the turf. After landing on the ground, another player fell on his outstretched arm and he immediately had a feeling of weakness and intense pain in his shoulder. The pain is a 9 out of 10, 10 being most painful, and there is no associated numbness or tingling. Pain is exacerbated when he is not supporting the arm at the elbow, and seems to radiate down to his wrist.
The patient is an active former collegiate lacrosse player. He drives a forklift at a local manufacturing plant full time. His work includes moving heavy boxes and stacking them onto pallets. He does not currently smoke, and drinks a couple nights a week. He is single, and does not have any children.
The most prudent course of treatment for a first time traumatic dislocation is surgical repair to stabilize the joint and repair any damage to assure best patient outcomes. When suspecting a shoulder dislocation, three radiographic views should be obtained, an anterior–posterior view, axillary view, and transscapular lateral view (also referred to as a “Y” view) (see Figure 1.1). These allow for the visualization of a Hill-Sachs lesion and may suggest the presence of a Bankart lesion (tear of the anterior labrum) (see Figure 1.2). Bankart lesions are the most common type of complication with anterior shoulder dislocations (Kim, Cho, Son, & Moon, 2014).
He stands 6′2″, 185 lb, with an athletic build. He is in great distress due to the shoulder pain. He is neurologically intact. Capillary refill as measured is brisk. On palpation, there is a marked step off, distal to the acromion. Additional palpation reveals diffuse pain and spasm in the musculature surrounding the shoulder joint. When asked to perform active range of motion (ROM), the patient attempts forward flexion but is unable to move the arm due to pain. Passively he allows his arm to reach approximately 50 degrees of forward flexion. In light of the significant limitations in his ROM and high level of pain, strength testing is not performed, nor are any special tests.
A radiograph was obtained to look for the presence of any fracture, and to evaluate the position of the humeral head. There is no visible evidence of any fracture but a Hill-Sachs lesion is clearly shown. The views also demonstrate an anterior dislocation, and a positive “empty glenoid”sign, as demonstrated in Figure 1.3.
Left anterior shoulder dislocation with Hill-Sachs lesion.
Dislocations are frightening to the patient, and reassurance is the first course of treatment. Explaining in plain terms that you will be attempting to reduce the shoulder quickly, it is important for the patient to understand and cooperate as best he can. After explaining this route to him, he elects, signs consent, and is placed prone without his shirt on a treatment table. A nerve block is performed with 6 mL of Marcaine and 2 mL of lidocaine injected with a posterior approach distal to the acromion. This is met with some pain relief by the patient.
Next, the patient assumes a supine position with a therapy belt under his left axilla where a counter force is applied toward the patient’s left ear. Then, a traction force is applied to the patient’s left arm by gripping the distal wrist in a direction directly opposite that of the therapy belt. While an initial small force is applied, the shoulder should slip back into place with the cooperation of a relaxed patient.
Once the reduction is complete, the patient is placed in a sling with pillow attachment, which would allow him a comfortable resting position. He is instructed on a regimen of nonsteroidal anti-inflammatory drugs (NSAIDs) and icing four to six times daily. Lastly, follow-up with an orthopedist is advised within the next 1 to 3 days. Postreduction radiographs are obtained.
It is important to educate the patient that first-time anterior shoulder dislocations are best treated with surgical stabilization. Given this, it’s important the patient understands how preferable the outcomes with surgical treatment are versus nonsurgical treatment.
As this injury will most likely require surgical consultation, the nurse practitioner may not follow the patient through his entire continuum of care. If the nurse practitioner is in a setting where nurses work collaboratively with an orthopedic surgeon, the nurse may refer the patient if there is no initial progress being made or simply collaborate on the most effective course of treatment. For the primary care nurse practitioner, it is likely the patient would return after rehabilitation has been completed in order to gauge the athlete’s readiness to return to his sport. This may be done in conjunction and collaboration with the physical therapist and/or athletic trainer. In the case of surgery, the surgeon may oversee the follow-up.
Kim, Y., Cho, S., Son, W., & Moon, S. (2014). Arthroscopic repair of small and medium-sized Bony Bankart lesions. American Journal of Sports Medicine, 42(1), 86–94.
Zacchilli, M. A., & Owens, B. D. (2010). Epidemiology of shoulder dislocations presenting to emergency departments in the United States. Journal of Bone & Joint Surgery, 92(3), 542–549. doi:10.2106/JBJS.1.00450
Case Study 1.2: Acute Acromioclavicular Separation
Karen M. Myrick
SETTING: URGENT CARE
Definition and Incidence
Acromioclavicular (AC) separations are commonly known as “shoulder separations.” As a common injury, AC separation affects patients at all age groups across the life span (Wright, MacLeod, & Talwalker, 2011).
Patient presents with the chief complaint of left shoulder pain. There was an acute onset of pain when the patient slipped on ice, landing directly onto the left shoulder and left side this morning. Pain is rated as 6 out of 10, aching in quality, relieved slightly with ibuprofen 800 mg and keeping his arm supported at the elbow. Pain is not associated with any numbness or tingling or other symptoms.
This 37-year-old male is an accountant and father of three young children ages 6, 7, and 9. He is active with running and martial arts training.
Depending on the degree of the AC separation, surgical intervention might be indicated (Felder & Mair, 2015). AC separations are graded I to VI, with I being the least degree of damage and displacement, and VI being complete disruption of the acromioclavicular and coracoclavicular ligaments (see Table 1.1).
The patient is a 37-year-old male who is in no acute distress, but demonstrates hesitancy and some discomfort throughout the physical examination. He is 5′10″ and weighs 186 lb. He has an obvious step off at the AC joint to inspection, and tenderness over the AC joint with palpation. He has an intact shoulder shrug with examination, clavicle rising on both the left and the right sides. Shoulder range of motion is full, but uncomfortable throughout motion. There are no focal neurological deficits in the left upper extremity.
A radiograph was obtained, and demonstrates widening of the AC joint consistent with a type II AC separation (see Figure 1.4).
If the shoulder shrug is intact with equal rising on both sides, this indicates that the deltoid and trapezius muscles are intact.
I. Acromioclavicular ligament sprain
II. Acromioclavicular ligament disrupted
III. Acromioclavicular and coracoclavicular ligaments disrupted
IV. Acromioclavicular and coracoclavicular ligaments disrupted and distal (lateral) clavicle displaced posteriorly
V. Acromioclavicular and coracoclavicular ligaments disrupted, attachments of deltoid and trapezious murcleson clavicle disrupted, clavicle displaces superiorly
VI. Acromioclavicular and coracoclavicular ligaments disrupted, clavicle displaces inferiorly
Type II AC separation.
The patient was placed into a sling for comfort, and a 2-week follow-up visit was recommended. Modalities for decreasing inflammation such as a NSAIDs, ice 20 minutes three times a day, and rest were recommended.
The elbow is one of the joints in the body that may become stiff very quickly. Although recommending a sling and using it for comfort is good practice, it is important to recommend that the patient also take the arm out of the sling five to seven times a day and perform full elbow range of motion.
At the 2-week follow-up visit, the patient was relating the decreased use of the sling on most occasions, as his discomfort was significantly less at this point. The step off was decreased on evaluation, and shoulder range of motion was full, but now without discomfort except for the extremes of motion. Six-week course of physical therapy was recommended, and follow-up on an as-needed basis after that.
Felder, J. J., & Mair, S. D. (2015). Acromioclavicular joint injuries. Current Orthopaedic Practice, 26(2), 113–118.
Wright, A., MacLeod, I., & Talwalker, S. (2011). Disorders of the acromioclavicular joint and distal clavicle. Orthopaedics & Trauma, 25(1), 30–36. doi:10.1016/.jmporth.2010.10.011