Ep 135 Commonly Missed or Mismanaged Shoulder Injuries – Approach and Glenohumeral Dislocations

In this EM Cases main episode podcast Commonly Missed or Mismanaged Shoulder Injuries - Approach and Glenohumeral Dislocations with Dr. Arun Sayal and Dr. Dale Dantzer we answer questions such as: why do we miss orthopedic injuries in general? Where do we go wrong when it comes to ordering and interpreting extremity x-rays? How do we know we have adequate shoulder x-ray views? How can we best remember the differential diagnosis of an orthopedic emergency with a normal x-ray? What is the quickest and best way to test neurologic status of patients with shoulder injuries? Why is axillary view of the shoulder so valuable? What is the biggest myth when it comes to the mechanism of injury for posterior glenohumeral shoulder dislocations? Why do we miss posterior shoulder dislocations so often? What physical exam maneuvers increase suspicion for posterior shoulder dislocation? What are the subtle findings on x-ray we should look for in patients with suspected posterior shoulder dislocation? What is the preferred first line reduction technique for posterior shoulder dislocation? What are the most common and consequential pitfalls in the management of anterior shoulder dislocations? and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Saswata Deb, edited by Anton Helman February, 2020 Cite this podcast as: Helman, A. Sayal, A. Dantzer, D. Episode 135 - Commonly Missed or Mismanaged Shoulder Injuries - Approach and Glenohumeral Dislocations. Emergency Medicine Cases. February, 2020. https://emergencymedicinecases.com/shoulder-injuries-glenohumeral-dislocations/. Accessed [date] Go to part 2 of this 2-part podcast on shoulder injuries Why do we miss orthopedic extremity injuries so often? * Under-relying or rushing through a history and physical * Not considering a wide differential diagnosis * Not ordering X-rays in the first place (13% of fractures missed [1]) * Over-relying on X-rays * Failure to order the correct test (58% of cases in a malpractice cases study [5]) * Not ordering the most specific X-rays for the associated injury (for example, ordering a hand X-ray for a finger injury); a hand X-ray will include the finger with the rest of the hand, but a dedicated finger X-ray will focus on the finger with more detail to help identify any finger pathology * Inadequate or improper X-ray views * Misinterpretation of X-rays (37% of cases in a malpractice cases [5]) * Presence of occult fractures * Presence of multiple fractures with premature closure after identifying one fracture   Dr. Arun Sayal's 'SCARED OF' mnemonic for orthopedic extremity emergencies in a patient with a normal appearing x-ray We are not ‘SCARED OF’ this scenario! Septic Compartment Syndrome Abuse RE Radiology report wrong, REferred Pain Dislocation/Subluxation that has reduced Operative Soft Tissue Injury Fracture (Occult) 3 aspects of shoulder mechanics we should be aware of in our approach to shoulder injuries - shoulder dislocations and fractures * The rotator cuff is a unique set of muscles and tendons that tends to get injured along with many other shoulder injuries and contributes to the sometimes very prolonged recovery for some patients compared to other joints in the body. * The shoulder gets stiff with immobilization of >1-3 weeks and so for most fractures, early mobilization is important to prevent adhesive capsulitis (“frozen shoulder”) and chronic stiffness. * On the other end of the spectrum, the shoulder is the most unstable joint in the b...