Case Study
Shoulder instability: A myriad of decisions for optimal emergency department care

https://doi.org/10.1016/j.ienj.2015.02.005Get rights and content

Highlights

  • Examines recurrent shoulder instability in the emergency department setting.

  • Shoulder instability classification systems assist in making treatment decisions.

  • Shoulder instability confers significant morbidity in the young athletic population.

Section snippets

Initial patient presentation

A 25 year old patient self-presented to the Emergency Department (ED) having sustained a right shoulder injury. Due to his distress at reception, he was streamed directly to the Registered Advanced Nurse Practitioner (RANP) on duty in the ambulatory care area (ACA) within the ED. He was pale and trembling and reported reaching for a newspaper off the back seat of his car and feeling his right shoulder “come out of place”. He denied any falls, sporting injuries or recent trauma. On arrival he

Relevant history

This patient's previous relevant medical history included three previous dislocations to the same shoulder (first at age 17 years), with surgery following his second dislocation to “stabilise his shoulder”. All of his previous dislocations had occurred while playing football or rugby and he was concerned at presentation that this injury would interrupt his football season.

Relevant physical examination findings

Systems review ruled out head, neck, abdominal, spinal, chest, or pelvic injuries and other distracting injury. The patient was alert and orientated to person, place and time. Clothing was carefully removed to adequately expose both shoulders, and he was placed on an examination couch in a semirecumbent position. Physical examination revealed a squaring of the right shoulder vs. the contralateral shoulder that represented an abnormally prominent acromium, with an anterior bulge inferior to the

Case progression and discussion

As the patient's self-reported pain scale was 9/10, analgesia was immediately prescribed: Dexketoprofen trometoprofen 50 mgs IV and patient controlled entonox (nitrous oxide 50% and oxygen 50%) were both administered. Dexketoprofen Trometamol is a non-steroidal anti-inflammatory drug available in Europe and Latin America, which is diluted in 100 ml normal saline and infused intravenously over 10–30 minutes in the acute symptomatic period.

Patient consent was obtained, and the RANP ensured that

Post-reduction case progression

Repeat peripheral nerve assessment (as described in Table 1) following reduction revealed resolution of the “tingling” at the regimental patch, with unremarkable examination of the remaining peripheral nerves. Distal pulses remained symmetrical with the contralateral side.

Post reduction x-rays (Fig. 3, Fig. 4) were requested in this case due to the absence of a validated clinical decision rule. A prospective observational study by Kahn and Mehta (2007) examined whether post-reduction

Teaching points

Recurrent glenohumeral instability is common especially in those patients whose initial dislocation occurred at a young age. The repeated capsular stretch and damage to the active and passive stabilisers are associated with persistent anterior instability. The management of acute shoulder instability by RANPs requires both comprehensive anatomical and biomechanical knowledge and adept clinical skills. Adequate assessment of potential concomitant pathology (especially peripheral nerve

Case outcome

Following successful relocation of the GH joint, this patient was discharged home with a referral to the outpatient orthopaedic trauma clinic within 72 hours. Discharge advice included regular analgesia, icing, and safe positioning options for sleeping, showering and dressing to avoid re-injury. ROM within pain parameters was permitted, with advice to return to the ED in the interim if there were any concerns.

In the months following this ED presentation, this patient experienced a further two

Acknowledgement

The Quebec Shoulder Dislocation Rule was previously published in the Canadian Journal of Emergency Medicine, 11 (1): 36–43 and has been republished with the kind permission of the Canadian Association of Emergency Physicians.

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