A joint is a structure in the body that “joins” two bony parts together. Of all our joints, the shoulder has the greatest amount of mobility and range of motion. Such flexibility comes at the cost of low joint stability.
One common injury is a dislocation. In a dislocation, a bone is pulled out of its joint by some type of trauma. About 50% of all major joint dislocations seen in U.S. emergency rooms involve the shoulder joint, but knees, ankles, and hips may also be affected.
THE SHOULDER JOINT
Unlike the kids’ song, there is no “shoulder bone” connected to the “arm bone”. The shoulder actually consists of three bones: the upper arm bone (known as the “humerus“), the shoulder blade or “scapula“, and the collarbone, also called the “clavicle“. The head of the humerus fits into a socket in the scapula. This socket (called the “glenoid cavity“) is stabilized by ligaments, strong connective tissues that keep the humerus centered in the socket. These connective tissues, along with muscles and tendons, form a capsule that keeps the joint stable.
Significant weakening of the capsule can cause the humerus to be dislocated from its socket. Damage is often incurred in falls, motor vehicle accidents, and sports injuries. In the vast majority of cases, the humerus is pushed forward of the socket, known as an “anterior dislocation.”
SIGNS AND SYMPTOMS OF SHOULDER DISLOCATIONS
In a shoulder dislocation, you’re likely to see:
Inability to use the joint
If the dislocation is momentary and the bone slips back into its joint on its own, it is called a subluxation. Subluxations can be treated the same way that sprains are, using the R.I.C.E.S. method. It should be noted that the traditional medical definition of subluxation is somewhat different from the chiropractic one.
The patient with a shoulder dislocation will present to the medic in obvious discomfort, usually holding their forearm for support. The arm that will appear out of place and swelling is not unusual. You’ll notice that the shoulder appears “lower” than on the uninjured side.
HOW TO REDUCE SHOULDER DISLOCATIONS
Of course, if there is medical care readily available, the patient with a shoulder dislocation should go directly to the local hospital. Indeed, some dislocations may only be reduced surgically under general anesthesia. In an off-grid setting, however, you’re on your own and will probably have to correct the dislocation yourself. This is known as performing a “reduction“.
Reduction is easiest to perform soon after the dislocation, before muscles spasm and the inevitable swelling occurs. Not only does reducing the dislocation decrease the pain experienced by the victim, but it will lessen the damage to the blood vessels and nerves that run along the line of the injury. The faster the reduction is performed, the less likely there will be permanent damage and the faster damaged muscles will recover. Unfortunately, a joint that experienced a dislocation may have a tendency to go out of place again in the future. Injured blood vessels and nerves may be permanently compromised.
If help is not on the way, the family medic must act. Expect significant pain on the part of the patient during the actual reduction procedure. Giving spain relievers like ibuprofen or stronger might be useful before the procedure to decrease discomfort. Prescription muscle relaxers such as Cyclobenzaprine (Flexeril) are also helpful.
The use of traction will greatly aid your attempt to fix the problem. Traction is the act of pulling the dislocated bone away from the joint in such a fashion as to give room for it to slip back into place. This goal can be accomplished in various ways, depending on the type of dislocation.
The following procedures for reducing a shoulder dislocation are just some of the techniques used in this emergency. A video from the Medical College of Georgia follows the description of three separate methods:
Method 1: Have the patient lie face down on a surface high enough that the arm (including the shoulder joint) dangles without hitting the ground. Place the patient’s arm into position slowly for the least discomfort.
Wrap a 15–20-pound weight around the forearm and wrist (again, not hitting the ground). Although they could hold the weight in their hand, this may tense the muscles, and you need them to relax. Once the muscles are relaxed enough (maybe 10 minutes or so), the arm should pop back into place.
Method 2: Have the patient lie on their back. With their elbow at a 90-degree angle, slowly rotate the arm outward with the palm facing the sky. This should be a gradual movement, and pain should be a sign to slow down.
Now, raise the arm so that the hand is behind their head, as if they were scratching the back of their neck. The action is similar to a baseball pitcher about to throw a ball. Once their hand is behind their head, slowly help them reach for the opposite shoulder. This motion should move the arm back into place.
Method 3: If you are alone with your patient, place your foot against the side of the patient’s chest and apply slow traction by pulling the arm while holding the wrist with the palm facing up. This, again, must be done slowly and gradually until the arm pops back into place.
If you’re fortunate enough to have an assistant, wrap a towel or sheet around the upper chest of the patient and have the assistant pull in the opposite direction to provide counter-traction. This avoids having to use your foot for that purpose.
If these procedures are successful, pain and movement should be immediately improved, although it’s normal to have some continued discomfort in the injured shoulder. Your patient may benefit from the placement of ice packs to reduce swelling and a sling to immobilize the joint while it heals. In addition, a length of cloth can be wrapped around the affected arm and chest to further stabilize the joint. This is called a “swathe.”
Full recovery will take about 4-12 weeks, depending on the age and physical condition of the patient. should be noted that the dislocation itself or the reduction procedure could possibly disrupt blood vessels or nerves, leading to circulation issues as well as effects to sensation and motor function.
To help prevent a dislocated shoulder, you should:
Remove obstacles that can lead to falls.
Wear protective gear if playing contact sports.
Avoid situations which could lead to trauma to the area.
Exercise to strengthen muscles in the area for support and maintain flexibility in the joint.
Orthopedic injuries will be common in any austere setting. The medic has to be ready to take the initiative when the ambulance is not on the way if full use of an injured extremity is to be recovered.
Joe Alton MD
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