Author Credentials and Financial Disclosure: Dr. Lovato is an Assistant Clinical Professor at the UCLA School of Medicine, the Director of Critical Care for the Department of Emergency Medicine at Olive View-UCLA Medical Center, and the LLSA Workshop Co-Director for the Olive View-UCLA National Conference on Advances in Emergency Medicine.
All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.
Learning Objectives: After reading this article, the physician should be able to:
1. Describe the presentation of a patient with an anterior shoulder dislocation and different methods for proper reduction.
2. Summarize the classification scheme for AC joint injury and the appropriate management strategy for each.
3. Differentiate the direct and indirect ways a physician can be influenced by the pharmaceutical industry.
Release Date: May 2008
Management of Common Dislocations
Ufberg J, McNamara R
Clinical Procedures in Emergency Medicine
This excerpt from a chapter in Clinical Procedures in Emergency Medicine focuses on glenohumeral dislocations and acromioclavicular injuries, two traumatic conditions commonly seen in the emergency department.
Patient preparation including the judicious use of analgesia and verbal reassurance are keys to successful reduction of any dislocation. Procedural sedation is often required, but intra-articular anesthesia always should be considered an alternative. Because of the risk of neurovascular injury with any dislocation, a detailed neurovascular exam should be completed and repeated after any reduction attempt, whether or not it is successful. Judicious use of radiographs is especially recommended after a reduction, although many would not consider x-rays mandatory in straightforward cases. In all cases of reduction, gradual and gentle application of force is recommended over excessive and abrupt motion to minimize potential for iatrogenic injury.
Anterior shoulder dislocations are usually the result of indirect force applied to the glenohumeral joint, usually by a combination of abduction, extension, and external rotations to the arm. After the appropriate mechanism, the presentation is usually quite obvious, with an exam showing loss of the normal rounded shoulder contour and a fullness under the subcoracoid area. The arm is usually supported and held in abduction. The axillary nerve, which carries sensation over the deltoid area, is the most commonly involved neurological lesion associated with an anterior dislocation, but the brachial plexus is also at risk. Vascular injuries are much rarer. Both types of injuries can usually be caught clinically with a complete neurovascular exam of the extremity.
Anterior dislocations are usually radiographically obvious with the humeral head most commonly found either subcoracoid (more than 75% of the time) or subglenoid. On the lateral or scapular “Y” view, the humeral head is displaced toward the ribs from its normal alignment over the intersecting scapular axes. The Hill-Sachs deformity is a groove in the posterolateral humeral head due to repeated anterior dislocations of the shoulder. A Bankart lesion is a disruption of the inferior glenoid labrum often implicated as a cause of recurrent dislocations, although it is not visible on plain films unless accompanied by bony involvement.
It is important to be familiar with several different reduction techniques for an anterior dislocation because no single method is 100 percent successful.
With the Stimson maneuver, successful up to 96 percent of the time, the patient is placed prone on the edge of the gurney, with the affected arm dangling off the bed. Between five to 10 pounds of weight is attached to the wrist for traction, and the patient is left in this position for up to 20 to 30 minutes. If it does not self-reduce, gentle external and internal rotation of the arm along with manual traction or scapular manipulation can assist in the reduction.
Scapular manipulation focuses on manipulating the glenoid fossa instead of the humeral head. The patient may be seated, supine, or prone (as with the Stimson maneuver), and the arm is supported at 90° of forward flexion. Traction is applied by another operator or by gravity (Stimson). One hand stabilizes the superior and lateral edge of the scapula, while the other hand applies medial and posterior pressure to the inferior scapular tip.
With the external rotation method, the patient lies supine with the arm fully adducted and internally rotated. With slow, gradual motion over several minutes, the arm is externally rotated, as tolerated, with motion temporarily halted when the patient feels pain. If reduction has not occurred, once full external rotation is achieved, then slow traction can be applied to the arm. External rotation is successful about 80 percent of the time.
The traction-countertraction method uses up to three operators and bed sheets to assist in applying the force. Traction is applied by wrapping a sheet around the proximal forearm of the affected side with the elbow flexed at 90°. The other side of the sheet is tied around the primary operator's body, in such a way that his body weight can be used to supplement the traction force. Countertraction is applied by a second operator using a sheet wrapped around the affected axilla. If necessary, a third operator can use a sheet to apply lateral force to the midhumerus.
Once reduction is confirmed radiographically, the patient is immobilized with a sling. Orthopedic follow-up is warranted to ensure that full function returns. Younger, active patients can be immobilized for up to three weeks after reduction to promote stabilization and healing, while older patients should begin mobilizing sooner to prevent debilitating joint stiffness.
The classic mechanisms for posterior shoulder dislocations are seizures, electrical shocks, and falls. The patient presents with the arm adducted and internally rotated and resistant to movement, and the humeral head may be palpated posteriorly, but the presentation can be subtle, especially when combined with more pressing clinical concerns. The anteroposterior (AP) x-ray can be falsely reassuring, but the scapular “Y” view usually shows displacement away from the ribs. An axillary view allows for easy confirmation in cases that are not obvious. Usually traction-countertraction reduction is used for posterior dislocations with the third operator applying direct pressure to the humeral head.
Acromioclavicular (AC) injury generally results from direct trauma to the shoulder, often from a fall, with the arm in adduction. The force is transmitted along the scapula to the AC and coracoclavicular (CC) ligaments. Patients typically present with tenderness directly over the AC joint along with increasing pain depending on the grade of injury. Orthopedic referral is routinely recommended for all injuries grade II and above.
Doctors and Drug Companies
N Engl J Med
As you read this article, take a quick survey of your surroundings (don't forget your pockets), and ask yourself how much pharma has spent on you. As of 2003, it was estimated that pharmaceutical companies spend between $8,000 and $15,000 yearly per physician on marketing expenses. The net effect of this often convoluted relationship between physicians and pharma is on the table for discussion.
Future physicians and the pharmaceutical industry often meet on the first day of medical school, but this relationship matures over time. In training, gifts from pharma are often of relatively little value (i.e., pens, lunches, stethoscopes, books), but as a physician begins practice, there is a tendency for the gifts to become more lavish (i.e., honoraria, grants, travel).
Physicians who accept gifts tend to believe they are not vulnerable to bias from the pharmaceutical industry, especially if the gifts are modest or related to professional activities. Physicians in general express more concern if gifts are considered more generous or recreational, but these delineations are not always clear. “Self-serving bias” refers to the increased difficulty an individual may have in identifying bias when that bias serves his own interests. The opposing viewpoint comes from social science research, which indicates that feelings of obligation are not necessarily related to the monetary size of a gift, but more to whether more fundamental human needs such as hunger, friendship, or flattery are satisfied.
Patients are more inclined to think that physician gifts from pharma are inappropriate, and may influence prescribing behavior. The American College of Physicians has expressed concern that this perception not only affects a patient's confidence in an individual physician, but can undermine patients' collective trust of our profession.
Marketing and advertising can have an even greater impact when it is done indirectly. Many continuing medical education (CME) events for physicians are sponsored by for-profit medical education companies, which are often subsidiaries of pharmaceutical companies. Drug companies can indirectly alter physician's prescribing practice by promoting organizational changes, such as to a system's formulary. Pharma also frequently sponsors the activities, publications, and practice guidelines of major physician organizations, which can have rapid and far-reaching effects in changing physician's behavior.
Few would disagree that the system is in need of reform, but there is little consensus on how to elicit change. Some feel that the interaction between doctors and drug companies is unavoidable and necessary to promote advancement, and that these relationships can be overseen within mutually acceptable boundaries. Others feel the only way to protect patients, the system, and the public good from market interests of the pharmaceutical industry is to reject all gifts regardless of perceived value. According to the article, the American Medical Student Association is the only major professional group that advocates severing all ties to pharma.
About the LLSA
As part of its continuous certification program, the American Board of Emergency Medicine has developed the Lifelong Learning and Self-Assessment (LLSA) program to promote continuous education of diplomates. Each year, beginning in 2004, 16 to 20 articles are chosen based on the Emergency Medicine Model. A list of these articles can be found on the ABEM web site, www.abem.org.
ABEM is not authorized to confer CME credit for the successful completion of the LLSA test, but it has no objection to physicians participating in such activities. EMN's CME activity, Living with the LLSA, is not affiliated with ABEM's LLSA program, and reading this article and completing the quiz does not count toward ABEM certification. Rather, participants may earn 1 CME credit from the Lippincott Continuing Medical Education Institute, Inc., for each completed EMN quiz.