Accuracy of Landmark-guided Glenohumeral Joint Injections as Assessed by Ultrasound in Anterior Shoulder Dislocations.

INTRODUCTION: To determine the accuracy of landmark-guided shoulder joint injections (LGI) with point-of-care ultrasound for patients with anterior shoulder dislocations. METHODS: Patients with anterior shoulder dislocations who underwent LGI were enrolled at our tertiary-care and trauma center. LGI attempts were recorded by an ultrasound fellowship-trained ED physician who determined if they were placed successfully. Pain and satisfaction scores were recorded. RESULTS: A total of 34 patients with anterior shoulder dislocation and their treating ED physicians were enrolled. 41.1% of all LGI were determined to be misplaced (n=14). Patients with successful LGI had a greater decrease in mean pain scores post-LGI. CONCLUSIONS: LGI had a substantial failure rate in our study. Using ultrasound-guidance to assist intra-articular injections may increase its accuracy and thus reduce pain and the need for subsequent procedural sedation.

Luxación erecta expuesta de hombro en un niño: reporte de un caso / Erect shoulder dislocation in a child: case report / Erecto luxação do ombro em uma criança: relato de caso

La luxación erecta expuesta de hombro es una asociación lesional de muy baja frecuencia en la edad pediátrica. Son más frecuentes las lesiones fisarias y epifisarias que las luxaciones y lesiones ligamentarias. Esto es debido a la presencia de un tejido óseo con gran poder de deformidad elástica y un periostio grueso. Presentamos un caso clínico de un paciente de 11 años de edad que sufrió una luxación erecta expuesta de hombro derecho, producto de una caída de 1 metro y medio de altura. El tratamiento consistió en una limpieza quirúrgica de urgencia, reducción gleno humeral y antibioticoterapia empírica, penicinila 400.000 UI/kg/día fraccionado cada 6 hs y gentamicina 3mg/Kg/día fraccionada cada 8 h por 10 días, inmovilización por 3 semanas con cabestrillo seguido de rehabilitación, y un follow up de 2 años al final del cual el paciente no presento secuelas funcionales en la articulación glenohumeral derecha.

The exposed erect dislocation of the shoulder is a very low frequency lesion association in the pediatric age. The physical and epiphyseal lesions are more frequent than the dislocations and ligament injuries. This is due to the presence of a bone tissue with great elastic deformity power and a thick periosteum. We present a clinical case of an 11-year-old patient who suffered an exposed erect dislocation of the right shoulder, due to a fall of 1 meter and a half high. The treatment consisted of emergency surgical cleaning, humeral gleno reduction and empirical antibiotic therapy, penicinila 400,000 IU/kg/day divided every 6 hours and gentamicin 3mg/Kg/day divided every 8 hours for 10 days, immobilization for 3 weeks with a sling followed by rehabilitation, and a follow-up of 2 years at the end of which the patient did not present functional sequelae in the right glenohumeral joint.

A luxação ereta exposta do ombro é uma associação de lesão de freqüência muito baixa na idade pediátrica. As lesões físicas e epifisárias são mais freqüentes que as luxações e lesões ligamentares. Isto é devido à presença de um tecido ósseo com grande poder de deformidade elástica e um periósteo espesso. Apresentamos um caso clínico de um paciente de 11 anos de idade que sofreu uma luxação ereta exposta do ombro direito, devido a uma queda de 1 metro e meio de altura. O tratamento consistiu em limpeza cirúrgica de emergência, redução de gleno umeral e antibioticoterapia empírica, penicinila 400.000 UI / kg / dia dividida a cada 6 horas e gentamicina 3mg / Kg / dia dividida a cada 8 horas por 10 dias, imobilização por 3 semanas com tipóia seguida de reabilitação e seguimento de 2 anos no final dos quais o paciente não apresentava sequela funcional na articulação glenoumeral direita.

Extra-articular contrast material leaks into locations unrelated to the injection path in shoulder MR arthrography.

OBJECTIVES: To evaluate the localisation, frequency and amount of extravasation in patients with extra-articular contrast material leak into locations unrelated to the injection path in shoulder magnetic resonance (MR) arthrography and associated shoulder disorders. METHODS: The sites of extravasation were determined on the shoulder MR arthrography of 40 patients. The extravasations were measured on three vertical planes of the MR arthrography. Sufficient joint distension was assessed according to the transverse diameters of the axillary recess on coronal MR images. RESULTS: Extravasation of the contrast material occurred through the subscapular recess, the synovium of the biceps, and the axillary recess. In four cases, extravasations were observed in more than one anatomic location. The most common site of extravasation was along the subscapularis muscle. Superior labrum anterior-posterior (SLAP) lesions were found to be most frequently associated with extravasations. The amount of extravasation was significantly higher in patients with adhesive capsulitis compared with the patients with a different diagnosis (p = 0.022). CONCLUSIONS: The extravasations adjacent to the axillary recess do not always indicate glenohumeral ligament pathology. Massive subscapular extravasations were most frequently associated with adhesive capsulitis and SLAP lesions, and might be considered in the MR arthrography report. KEY POINTS: • Contrast material extravasation may reduce the diagnostic value of shoulder MR arthrography. • The extravasations may occur into locations unrelated to the injection path. • The extravasations adjacent to axillary recess can be misleading for HAGL lesion. • Massive subscapular extravasations were frequently associated with adhesive capsulitis and SLAP lesions.

Pain relief for reduction of acute anterior shoulder dislocations: a prospective randomized study comparing intravenous sedation with intra-articular lidocaine.

OBJECTIVES: The aim was to compare the effectiveness of intra-articular lidocaine (IAL) versus intravenous Demerol and Diazepam (IVS) in reduction of acute anterior shoulder dislocation. DESIGN: This is a prospective randomized study. SETTING: Emergency room setting. PATIENTS: Thirty-one dislocations reduced with IVS, whereas 32 patients were reduced using IAL. MAIN OUTCOME MEASUREMENTS: The visual analog pain scale was used before analgesic administration and during the closed manipulative reduction. Length of time since dislocation, frequency of dislocation, ease of reduction, patient satisfaction, adverse effects, and duration of hospitalization were recorded. RESULTS: The IVS group had a 100% success rate, whereas the IAL group had a 19% (six of 32) failure rate (P = 0.024). However, there was no significant difference in terms of pain relief (P = 0.23) or patient satisfaction (P = 0.085) between both groups. In addition, patients in the IAL group had a shorter duration of hospitalization and no reported complications, whereas the intravenous group had a longer hospital stay and a 29% complication rate. The cost of IAL was 32% less than the cost for IVS. CONCLUSION: IAL was more cost effective than the IVS method. IAL provided adequate pain relief and fewer complications and is a viable option for analgesia during reduction of acute shoulder dislocation.

Onabotulinum toxinA injection as an adjunct in the treatment of posterior shoulder subluxation in neonatal brachial plexus palsy.

BACKGROUND: Botulinum toxin A is used to treat contractures in children with spasticity by temporarily interfering with neural transmission at the motor end plate. In infants with brachial plexus palsy, posterior shoulder subluxation and dislocation are the result of muscle imbalance, in which neurologic recovery is evolving, and spasticity is not a deforming force. We postulated that temporary weakening of the shoulder internal rotator muscles with botulinum toxin A would facilitate reduction of the glenohumeral joint in such infants with early posterior shoulder subluxation or dislocation. METHODS: Thirty-five infants with posterior subluxation or dislocation of the shoulder due to brachial plexus palsy were treated with botulinum toxin A between January 1999 and December 2006, and were followed for a minimum period of one year. Records were reviewed for the severity of the palsy, age at time of treatment, recurrence of subluxation or dislocation, and the subsequent need for further treatment to reduce the glenohumeral joint. RESULTS: The average age at the time of shoulder reduction and botulinum toxin-A injection was 5.7 months. Six patients had a second injection. Reduction of the shoulder was maintained in twenty-four (69%) of the thirty-five patients. There were no complications related to the use of botulinum toxin A. CONCLUSIONS: Although there may be specific risks associated with its use, botulinum toxin-A injection into the internal rotator muscles is a useful adjunct to the treatment of early posterior subluxation or dislocation of the shoulder in infants with neonatal brachial plexus palsy, and may help to avoid the need for open surgical procedures to restore or maintain shoulder reduction.

Shoulder pain and external rotation in spastic hemiplegia do not improve by injection of botulinum toxin A into the subscapular muscle.

OBJECTIVE: To study the effect of botulinum toxin A in the subscapular muscle on shoulder pain and humerus external rotation. METHODS: 22 stroke patients with spastic hemiplegia, substantial shoulder pain and reduced external rotation of the humerus participated in a randomised, double blind, placebo controlled effect study. Injections of either botulinum toxin A (Botox, 2x50 units) or placebo were applied to the subscapular muscle at two locations. Pain was scored on a 100 mm vertical Visual Analogue Scale; external rotation was recorded by means of electronic goniometry. Assessments were carried out at 0 (baseline), 6 and 12 weeks. RESULTS: 21 patients completed the study. We observed no significant changes in pain or external rotation as a result of administration of botulinum toxin A. External rotation improved significantly (p = 0.001) for both the treatment group (20.4 degrees (16.6) to 32.1 degrees (14.0)) and the control group (10.3 degrees (19.5) to 23.7 degrees (20.7)) as a function of time. CONCLUSIONS: Application of botulinum toxin A into the subscapular muscle for reduction of shoulder pain and improvement of humeral external rotation in spastic hemiplegia does not appear to be clinically efficacious.

Reduction of acute anterior shoulder dislocations: comparing intraarticular lignocaine with intravenous anesthesia.

Anterior shoulder dislocation is the most common dislocation in the body. Various methods of anesthesia are available for reduction. The objective of this study was to compare the application of intra-articular anesthesia with intravenous anesthesia for reduction of acute anterior shoulder dislocation. This study was conducted at Kathmandu Medical College Teaching Hospital (KMCTH) and Kathmandu Hospital and comprised of patients coming with anterior dislocation of shoulder from July 2001 to June 2005. Forty-five patients aged 17-55 years with no associated fractures of adjoining bones were included in the study. In twenty-three patients, reduction was done using intra-articular anesthesia and in 22 patients intravenous anesthesia was given. In five patients (three in intra-articular group and two in intravenous group) the reduction technique had to be changed to the Hippocratic method. In these three patients intravenous anesthesia had to be given after intra-articular anesthesia failed to relieve pain and spasm. In the intravenous group two patients had to be admitted overnight while in the intra-articular group none had to be admitted to the hospital. However, in the intra-articular group the average time taken from injection to reduction was significantly longer (<.001). The use of intra-articular lignocaine for reduction of shoulder dislocation is safe and effective especially when patients present early. In patients presenting late (more than 5 hours) intravenous anesthesia should be primarily considered as the method for shoulder reduction.

Bilateral, spontaneous, anterior subluxation of the sternoclavicular joint: a case report and literature review.

A case of atraumatic, spontaneous, bilateral, sternoclavicular joint subluxation in a 20-year-old man on combat duty in Iraq is reported. There was no history of an underlying pathologic condition and no history of injury to the area. The patient demonstrated recurrent, mildly painful, subluxation whenever either arm was abducted past 80 degrees to 90 degrees. Computed tomographic scans of the joints in both reduction and subluxation were obtained, and pseudodislocation was excluded. The patient was reassured that the subluxation would not affect his upper extremity strength, was treated with conservative measures, and returned to duty. The literature was reviewed for comparison of surgical and nonsurgical options. Surgical stabilization of sternoclavicular joint dislocations is associated with a high incidence of serious complications. Spontaneous sternoclavicular joint subluxations have a benign course and do not fare well after surgical repair. It is recommended that all grade I and II sternoclavicular joint sprains be treated conservatively.

Treatment of recurrent posterior dislocation of the shoulder in cerebral palsy by injection with botulinum toxin A into the M. subscapularis.

SUBJECTS: A 20-year-old woman, known to have cerebral palsy and a spastic hemiparesis, suffered from frequent (up to 20 times a day) and painful posterior dislocation of the affected shoulder. INTERVENTIONS: For the last two years we have treated her with injections with botulinum toxin A (100 U Botox) in the M. subscapularis. RESULTS: Pain and dislocation rate have improved substantially.

Etomidate and midazolam for reduction of anterior shoulder dislocation: a randomized, controlled trial.

STUDY OBJECTIVE: We determine whether patients with acute, anterior shoulder dislocation undergoing emergency department procedural sedation and analgesia (PSA) with intravenous etomidate would experience a reduced time of impaired consciousness when compared with a group of patients receiving intravenous midazolam. METHODS: This study was a prospective, double-blinded, randomized, institutional review board-approved trial of ED patients with anterior shoulder dislocation. Patients were randomized to receive intravenous boluses of etomidate (0.1 mg/kg) or midazolam (0.033 mg/kg) during PSA. The primary outcome for comparison was PSA duration. RESULTS: Forty-six patients with anterior shoulder dislocation were enrolled: 22 in the etomidate group and 24 in the midazolam group. Three patients sustained reduction without physician or sedative intervention. Two patients were excluded from protocol because of unavailable study drug or fracture dislocation. The median lowest modified postanesthetic recovery score observed during PSA was 5 (95% confidence interval [CI] 4 to 7) in the etomidate group and 6 (95% CI 6 to 7) in the midazolam group. The median time of PSA for patients receiving etomidate was 10 minutes (95% CI 8 to 15) compared with 23 minutes (95% CI 16 to 30) for patients receiving midazolam, with a difference between the group medians of 13 minutes (95% CI 5 to 22). Reduction success was achieved in 37 (90%) of 41 patients: 2 did not experience reduction with etomidate and 2 did not experience reduction with midazolam. There were 15 PSA complications reported. CONCLUSION: Etomidate provides effective PSA for reduction of ED patients with anterior shoulder dislocation. When compared with midazolam, etomidate use confers a significantly shorter period of PSA.