A few questions to ask yourself before trying to relocate a shoulder dislocation.
Following a recent course (The Advanced Shoulder Course) in Reading it made me challenge my views on pitch side relocation/reduction of shoulder dislocations. One thing I learnt from the course is that even when you have clinical experts in a room they disagree and have different approaches to often the same clinical case (like us physios). The following article is by no means to sway your own clinical judgement but to highlight some areas I had not considered before. I have also under gone the pitch side RFU ICIS course which advise to use your own judgement. Physiowizz continues to provide information from both sides of the coin and it is up to you to develop your clinical reasoning skills and apply this to your practice as you wish.
I asked top shoulder/bone surgeons from various locations around the world “What are your feelings on reducing shoulders pitch side” and of I course was greeted with an awkward polite smile.
“Well of course this is different for every individual but how do you know there is no fracture?”
The general consensus from a surgeons point of view was that a force with large enough impact to dislocate how can you clinically rule out fracture and more importantly if you try to reduce it without a pre XRay what if you complicate the fracture?
Are your qualified to do the procedure?
By this I mean do you have adequate skill to relocate a fracture? This, like any competency should be taught, practiced, ideally supervised by a senior and updated regularly which is not ideal in a pitch side role where these are relatively rare.
How far is the nearest hospital?
Most hospitals are within 30 minutes. When I questioned the surgeons about axillary nerve palsy their feelings were that the majority of damage would come from the initial impact and that if you watched shoulder surgery the joint was dislocated for long periods of time and dislocated repeated to change view (of course anaesthetic affects muscle spasm/pain). They felt that an extra 30 minutes would be unlikely to cause the nerve palsy although I have not found any evidence to suggest either way. If anyone knows any specific evidence for this area could you please add to forum discussion.
Are they a secondary offender?
If the patients have dislocated before (and have not had a repair) they are more likely to dislocate again due to the soft tissue damage of previous dislocations. This could be intepretated that they may be more likely to dislocated with a lesser force however how you judge the force is difficult. Remember 30-50% of adult dislocations have associated fracture (check out ref below for population group).
What is the age of the patient?
Reid et al (2013) describe that there is a lower risk of associated fracture in paediatric patients and questioned whether pre reduction radiographs were required. If the patient is elderly and at risk of osteoporosis this again is going to increase your index of suspicion that there may be a fracture and treat conservatively. Rugby/ contact sport players tend to be young fit and healthy however it it very difficult to assess force of impact and A and E would certainly routinely take pre and post reduction radiographs.
Is the limb vascularly compromised?
If the limb is vascularly compromise (ie no distal pulses) it is potentially a limb threatening injury unless treated immediately.
Do you have sufficient pain relief should there be a problem with reduction?
Top clubs have entonox and team doctors however if you are treating club level and are on your own do you have the resources if things don’t go to plan?
What does the patient want?
This is a discussion to have with players prior to any injury/re offenders and explain pros/cons of both. They could have the option to give written consent once understanding the risks. This is something you would need to ask the CSP for advice on. Remember the player will thank you for reduction if it all goes ok but if it doesn’t you will have to prove you were working within your scope of practice and make a good clinical decision.
Have your say!
What is your opinion on this controversial subject? What is your experience and view on this? Do you already have a system, care pathway in place? Please take the time to share your experience and help others. Click here to go to our forum now and have your say.
- Wilson SR et al;(2009) Dislocation, Shoulder, eMedicine,
- Reid et al (2013) Anterior shoulder dislocations in pediatric patients: are routine prereduction radiographs necessary? Pediatr Emerg Care. 2013 Jan;29(1):39-42.