Who loves relocating shoulder dislocations as much as I do?
I know you do.
Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.
How can you improve your success rate in injecting into glenohumeral joint injection?
Trick of the trade:
Ultrasound guided shoulder injection
I found a great video on this technique, which is essentially a hematoma block in the joint. This screencasted talk is by Dr. Mike Stone (Highland Hospital) as part of his 2011 ACEP Scientific Assembly lecture on nerve blocks. Coincidentally, I ran into Mike at this week's UCSF Topics in Emergency Medicine course where he gave a talk on the use of ultrasound for the hypotensive patient. When I mentioned that I was going to highlight his shoulder injection trick on this blog, he whipped out his laptop and gave me the 6 minute portion of his ACEP talk. Wow, that was really nice of him.
To view his entire video on nerve blocks, check out the video here.
Things I learned about injecting the shoulder:
1. Use a spinal needle. A traditional needle often will not reach the glenohumeral joint.
2. You almost always get a flash of blood (hemarthrosis) when you are in the joint.
Also check out Dr. Stone's great ultrasound website called Point of Care:
http://pointofcare.blogspot.com/
I'm a fan.
What a coincidence! I just saw my attending doing this last weekend. She used linear probe and traditional needle and it went well; the probe and needle's position varied from this video a little bit.
ReplyDeleteThanks for posting this, Michelle.
Hi Bow: Great to hear from you. Sometimes linear probes work in very thin patients. For shoulder dislocations (95% are anteriorly dislocated), the humerus is too far away from the transducer probe (which sits on the poster shoulder). So an abdominal probe is often better. Glad that it worked for you!
ReplyDeleteHi Michelle. Thanks for sharing the shoulder dislocation tip as well as the http://pointofcare.blogspot.com/ resource. Make that 2 new fans :)
ReplyDeleteHi Benedict: Glad that you liked the shoulder dislocation tip. I'm itching to try it the next time a patient comes. It looks so straight forward and more reliable than traditional blind approach.
ReplyDeleteI can't wait to try this!
ReplyDeleteDitto, Demian.
ReplyDeleteCool technique. I have always wondered whether this would be easy and useful. Looks like it. Maybe we can use this video on our Shoulder site? Another alternative is the analgesic positions for shoulder dislocations (see here: http://shoulderdislocation.net/relocation/positioning) - maybe pop the patient in this position whilst you are getting the lidocaine drawn up.
ReplyDeleteHi Gerard: Just got an email from Dr. Mike Stone (Alameda County Medical Center - Highland General Hospital) who said that it's ok to use on your site. Thanks for checking.
ReplyDeleteAlso thanks for the tip on analgesic positions. I actually read this when mentioned on ACEP News' The Central Line. Still a challenging technique which I clearly have not mastered yet.
I love the Cunningham approach to reductions and have had good success with it, but there are still patients who are uncooperative which is a must with the Cunningham reduction method. This little video may help me with those folks rather than reaching for the ketamine.
ReplyDeleteI too am thankful of the Cunningham videos on ShoulderDislocation.net. Unfortunately I've had horrible success with it. My newest adjunct is the shoulder intraarticular block using ultrasound and a spinal needle.
ReplyDeleteMichelle, when you do the Cunningham method, do you make sure you're constantly telling the patient to arch their shoulders back while your doing the slight traction and massage? I've found that my colleagues that aren't getting success are forgetting this part. By doing that, you get the scapular rotation, then your little bit of downward traction mixed with the massage (which I think is just to get the patient to relax) really seems to work for me.
ReplyDeleteMy shoulder algorithm in a cooperative patient is three methods, all with the patient sitting in a chair. It goes like this:
1. Cunningham method
2. Kocher's method
3. Seated scapular manipulation
I think doing those 3 things, with or without pain meds or shoulder injection, probably could reach a 80-90% reduction rate without sedation. I'm thinking about doing a study on this when I get to my new job with residents this summer, unless someone beats me to the punch.
Yup, keeping telling them to extend/arch their shoulders. They have variable success with that. Interesting that you get such a great success rate with your 3 approaches. Maybe you should give a workshop!
DeleteWell I just came accross these methods on the shoulderdislocation.net site about 6 months ago, so I've got a pretty small sample size to gauge my success, so maybe with the law of averages, my success will run out and I'll have a run of failures. Who knows.
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