Apollyon

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Had a patient this evening with a recurrent shoulder dislocation, which, this time, was an inferior - came in with the externally rotated, abducted arm flexed at the elbow, just like the classical presentation.

Recalled (honestly!) that about 1/2 of 1% of shoulder dislocations were inferior. Did some quick research, which leaned heavily towards reduction under GA.

Called my ortho on-call, and he said to relocate it just like any other, with traction/countertraction. Well, it worked! (He said that there would be a satisfying "clunk" when it went back in, but I got no such satisfaction.)

So, a few questions...first, have you ever seen one? If you have, did you reduce it, or call ortho? If you called ortho, did they reduce it in the ED, or take it to the OR?
 

WilcoWorld

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I also would skip the lido-only attempt on an inferior dislocation.

I've seen it twice. When I was at a shop without in-house ortho residents I reduced it myself with sedation (though I can't specifically remember which agent(s) I used, I was mostly using etomidate/fentanyl in those days). When I saw it at a shop with in-house Ortho residents they came down & did it in the ED, and I think we used ketofol.
 

tkim

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what about injecting lido into the joint. haven't tried it yet, but i plan on doing it the next time
Had an old school ortho come in to reduce ant shoulder after propofol/fentanyl failed on a semi-pro football player. He did an interartic lido injection then put the arm in a slow abduction, inch at time, talking with the guy all the time. In five minutes, the arm had popped in. One guy, one shot of lido, no nurse, no time out, no conscious sedation, five minutes. Very impressive.
 

Dakota

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I'm a big fan of intraarticular lidocaine (especially because at my residency only anesthesia can give propofol). Unfortunately we have a few chronic dislocators who intentionally dislocate their shoulders to get fun medications in the ER. Predictably for this group the shoulder injections don't work at all.
 

txterp98

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I've had one inferior dislocation and I reduced it myself in the ER with moderate sedation. I called ortho afterwards for routine follow-up.

When I reduced it, I remember 2 clunks. After the 1st clunk, I remember thinking it didn't seem in place. After the 2nd clunk, it seemed to be properly reduced.

In reading about reducing inferior dislocations afterwards, it seems one approach is to first convert the inferior dislocation into an anterior dislocation and then finish the reduction in the standard fashion. I think this is likely what happened with my patient.

Congrats on the reduction....sounds satisfying....and with just Fentanyl/Versed at that!
 
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Apollyon

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In reading about reducing inferior dislocations afterwards, it seems one approach is to first convert the inferior dislocation into an anterior dislocation and then finish the reduction in the standard fashion. I think this is likely what happened with my patient.
I read that as a case report on a peds patient. I wasn't confident that that was the way to go on an adult.
 

roja

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I have only had one of these cases. No propofol where I was. Just used valium, toradol and traction-countertraction (can't use my normal technique on this type of fracture).

I love the intra-articular injection. I also add in 2mg of morphine (its about 1cc and then add in lido or bupivicaine for the remaining 4cc's) and inject. There are mu receptors in the joint and in theory, the morphine will hit those, also. works awesome with a touch of valium. I almost never use propofol for shoulders.
 

southerndoc

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5 mL is all you inject? I inject 10-20 mL (depending if 1% or 2% solution). I frequently inject even if I'm doing a conscious sedation as it requires less sedation when you inject.
 

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I have tried 10cc intraarticular Lido several times without much pain relief/muscles still tight. Ended up having to do sedation for reduction. Any suggestions for better results?
 

lucky_deadman

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I have tried 10cc intraarticular Lido several times without much pain relief/muscles still tight. Ended up having to do sedation for reduction. Any suggestions for better results?
In my experience 10cc is often not enough volume to fill the space and reach the receptors well.

Rather than use 20cc of Lido, I use 10cc of Lido and 10cc sterile saline. I've gotten much better results from this than just the 10cc of Lido.
 

lucky_deadman

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I love the intra-articular injection. I also add in 2mg of morphine (its about 1cc and then add in lido or bupivicaine for the remaining 4cc's) and inject. There are mu receptors in the joint and in theory, the morphine will hit those, also. works awesome with a touch of valium. I almost never use propofol for shoulders.
Good thinking. I'll have to give this a try with my next one.
 

emedpa

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I've seen one of these and reduced it myself with fentanyl/versed. this was about 10 yrs ago. today I would use propofol.
after reduction I called ortho and they wanted him in an external rotation "gunslinger splint" until f/u to keep it from re-dislocating.
 
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Apollyon

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after reduction I called ortho and they wanted him in an external rotation "gunslinger splint" until f/u to keep it from re-dislocating.
Before reduction I asked ortho if the pt needed to be in a "gunslinger" splint, and he told me it wasn't necessary with the swath. Go fig.

As for the gunslinger splint in general, the only place I've ever seen one was when I was a resident. Otherwise, no one had it immediately available.
 
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Apollyon

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Yeah, I think you're right. It wasn't my intended approach!
And I still feel robbed that I didn't get the "clunk"! I was actually short of breath after pulling so hard, waiting for it. The nurse was leaning on the other side, and we were adding to gravity. That was the most tiring 45 seconds I can recall for a long time! It probably popped in almost immediately. I guess I'm lucky I didn't re-dislocate it due to prolonged widening of the joint space from my traction/countertraction. And she wasn't a big lady - if this was a 100kg guy, man...I don't know if I would have been able to do it!
 

VALSALVA

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Amazingly (to me), had two in residency. Each reduced in the ED with propofol/traction-countertraction.
 

diphenyl

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At least we're not having any problems w/ prop at my hospital. Love it.