Point-of-care ultrasound diagnosis and treatment of posterior shoulder dislocation

Woman With Shoulder Pain: Posterior Shoulder Dislocation Diagnosed With Point-of-Care Ultrasound

Posterior shoulder dislocations are relatively rare. When used by emergency medicine physicians, point-of-care ultrasound (POCUS) demonstrates higher sensitivity and specificity for diagnosing shoulder dislocation as compared to two-view plain films. A 49-year-old woman presented to the emergency department (ED) with left shoulder pain following a mechanical fall. Physical examination was remarkable for a gross shoulder deformity and tenderness over the left proximal humerus. POCUS of the left shoulder using a curvilinear probe and a posterior approach was performed and demonstrated posterior displacement of the humeral head relative to the glenoid. Anteroposterior and oblique shoulder X-rays were read as unremarkable by the radiologist; a computed tomography of the shoulder confirmed a posterior shoulder dislocation. Given its efficacy and efficiency as compared to X-ray radiography, POCUS should be strongly considered in the diagnosis and management of posterior shoulder dislocations in the ED setting.

Pragmatic use of ultrasound in plaster room

X-ray represent gold standard to check reduction of fractures and dislocations. Sometimes plaster room is not equipped with C-arm or similar devices. Practical and focused use of ultrasound in plaster room cannot replace X-ray but may be a useful tool especially in tricky situations. We report three emblematic cases and we carry out a review of the literature.

Just the Facts: Point-of-care ultrasound in the management of shoulder dislocations

A 59-year-old man presents with left shoulder pain after falling while playing with his dog at the park. He drove himself to the emergency department (ED). He reports 5/10 pain and has reduced range of motion of the shoulder. His shoulder looks normal on exam and is not squared off. You wonder if he might have a posterior shoulder dislocation.

Accuracy of Ultrasonography in Diagnosis of Shoulder Dislocation: A Systematic Review

Context:

This systematic review of clinical trials was conducted to compare the diagnostic accuracy of ultrasound in comparison to plain radiography in shoulder dislocation.

Evidence acquisition:

MEDLINE, Cochrane Database of Systematic Reviews, clinicaltrials.gov, Google scholar, and Scopus were searched for clinical trials. Diagnosis of shoulder dislocation and confirmation of shoulder reduction were the outcomes of interest. Sensitivity, specificity, positive predictive value and negative predictive value of included clinical trials were calculated.

Results:

Seven studies met our inclusion criteria and were analyzed. All included studies except two had a sensitivity and specificity of 100% for ultrasound (one with a sensitivity of 54% and one with a specificity of 60%).

Conclusion:

It can be suggested that ultrasound can be used as a reliable alternative diagnostic method for detection of both dislocation and reduction in shoulder joint. This may decrease the delay in treatment, cost, radiation exposure, and need for repeated sedation.

Ultrasound Imaging of Orthopedic Injuries

With the high cost and limited availability of gold standard imaging modalities, ultrasound has become an alternative in many musculoskeletal (MSK) injuries. Ultrasound has become increasingly portable and readily available in many acute care settings. Its ability to diagnose MSK injuries and help guide management has the potential to improve patient safety and flow. Ultrasound has been shown to diagnose fractures, dislocations, and tendon and ligament injuries. It helps guide fracture and dislocation reductions and aids in regional anesthesia for pain management. This article reviews the common MSK injuries that can be diagnosed with ultrasound with a focus on point-of-care ultrasound.

Diagnostic Accuracy of Ultrasound for Identifying Shoulder Dislocations and Reductions: A Systematic Review of the Literature

Introduction

Patients with shoulder dislocations commonly present to the emergency department. Ultrasound has the potential to save time, radiation exposure, healthcare costs, and possible need for re-sedation. We conducted this systematic review to compare the diagnostic accuracy of ultrasound compared with plain radiography in the assessment of shoulder dislocations.

Methods

We searched PubMed, Scopus, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials for relevant trials. Primary data and test characteristics were obtained for all included studies. We used QUADAS-2 to assess study quality. Meta-analysis was not performed due to significant heterogeneity.

Results

Four studies met our inclusion criteria, comprising 531 assessments with 202 dislocations. Most studies had a sensitivity of 100% for identifying dislocations. One study demonstrated a sensitivity of 54%, and another had only one dislocation that was misidentified. All studies were 100% specific for detecting dislocation.

Conclusion

Ultrasound may be considered as an alternative diagnostic method for the detection of shoulder dislocation and reduction, but further studies are necessary before routine use.

Accuracy of point-of-care ultrasound using low frequency curvilinear transducer in the diagnosis of shoulder dislocation and confirmation of appropriate reduction

Background

Ultrasound (US) is an effective modality in the evaluation of shoulder dislocation and reduction. In most studies, high frequency US probes have been used.

Objective

To determine the sensitivity and specificity of low frequency US in the diagnosis of shoulder dislocation and its proper reduction in the emergency department (ED).

Methods

In a prospective observational study 84 patients, suspicious of shoulder dislocation, were enrolled in our study. In ED, they all underwent low frequency (curve) probe US examination by the emergency physician at the time of admission. Standard radiographies of their shoulder joints were taken later and then reported by the attending radiologist. As soon as the shoulder dislocation was confirmed, reduction of the joint was done under procedural sedation and analgesia. US and radiography of the relocated joint were taken for the second time. The sensitivity and specificity of low frequency US were compared with radiography by the appropriate statistical analysis.

Results

In comparison to radiography, US had a sensitivity of 100.0%, specificity of 80.0%, positive predictive value of 98.7%, and negative predictive value of 100.0% in diagnosis of shoulder dislocation. The specificity of US in diagnosis of proper reduction of the joint, was estimated to be 98.7% with a negative predictive value of 100.0%. US took a significantly less time than radiography to be performed (p < 0.001).

Conclusions

Low frequency US is highly accurate in diagnosing shoulder dislocation and its proper reduction. Thus it might be a good substitute for radiography in these situations.

Bedside ultrasonography for verification of shoulder reduction: A long way to go

PURPOSE

Shoulder dislocation is a common joint dislocation managed by the emergency physicians in the emergency departments. Pre- and post-reduction radiographic examinations have long been the standard practice to confirm the presence of dislocation and the successful reduction. However, shoulder ultrasonography has recently been proposed as an alternative to the radiographic examination. This study aimed to assess the accuracy of ultrasonography in evaluating proper reduction of the dislocated joint.

METHODS

This was a prospective observational study. All patients with confirmed anterior shoulder dislocation were examined by both ultrasonography and radiography after the attempt for reduction of the dislocated joint. The examiners were blinded to the result of the other imaging modality. Results of the two methods were then compared.

RESULTS

Overall, 108 patients with confirmed anterior shoulder dislocation were enrolled in the study. Ninety-one (84.3%) of the patients were males. Mean age of the participants was (30.11 ± 11.41) years. The majority of the patients had a recurrent dislocation. Bedside ultrasonography showed a sensitivity of 53.8% (95% CI: 29.1%-76.8%) and a specificity of 100% (95% CI: 96.1%-100%) in detecting inadequate reductions. The results of ultrasonography had a statistically significant agreement with the results of radiography (Kappa = 0.672, p < 0.001).

CONCLUSION

The results suggest that the sensitivity of post-reduction ultrasound is not sufficient for it to serve as a substitute for radiography.