So I'm Robbie Bowers. I'm a PM&R sports med doc at Emory in Atlanta. And I'll be moderating to today's session of the, well, if I can go back, of the National Fellow Online Lecture Series. This is the final lecture of the first quarter and we'll transition into the second quarter at the end of this month. And the first lecture of the second quarter is going to be on October 29th at 12 noon Eastern time on asthma and EIB. The speaker will be Jeff Dreher with Nate Nye serving as a moderator. But today in this final lecture of the first quarter, we're gonna be talking about the management of shoulder and elbow dislocations with Dr. Matthew Gammons from Vermont Orthopaedic Clinic and the Killington Medical Clinic in Vermont. And just as a reminder, Dr. Gammons has given us this as some supplemental reading, chapter nine of the textbook, Sports-Related Fractures, Dislocations, and Trauma for any supplemental reading to go along with the lecture today. And just as a reminder, kind of the goals of this lecture series is to serve as an adjunct to your individual programs, educational programming. It's not supposed to take the place of any of the education that you're getting in or the fellows are getting in their programs. Also to provide fellows with direct access to educational experiences from experienced AMSSM members, a wide variety of AMSSM members, allows us to kind of interact in a virtual format and also to help assist in CAQ exam preparation. So just as a reminder to everyone, try to mute your device's microphone and turn off the video. You can submit questions through the chat function. If you just put your name and your program or your name and your location, we would appreciate it. I'll ask the questions during the Q&A session at the end of the lecture. So we'll do the entire lecture. Just submit your questions as we go. And then I'll ask the questions to Dr. Gammons at the end. And then if you could, after the program, please complete the evaluation. It'll be a link to it in the chat section as well, if you'll please submit that evaluation. We would appreciate it. So without further ado, Dr. Gammons, you can take it away. All right, well, thank you very much. Welcome to those that are attending tonight and that those may be watching this at a later date. And welcome to the brave new world of medical education in the days of the pandemic. So we're gonna talk tonight about the management of shoulder and elbow dislocations. We certainly want the fellows to get some information that will help them pass the boards. I'm gonna focus probably slightly more clinically as I want you to be able to actually reduce the dislocation rather than answer the question. But we'll certainly be open to some questions afterwards. And at any later date that somebody might have a question, I'm certainly, feel free to reach out to me and you can reach me through either the Vermont Orthopedic Clinic or the Killington Medical Clinic. So one thing about joint dislocations in general is they can really vary from pretty simple to obviously limb threatening when we get into the realm of knee dislocations. Commonly, we see things like fingers, elbow and shoulder with really fingers and shoulders probably being the leading causes of, or the leading amount of dislocations that we see in athletes with elbows followed, you know, somewhat close behind. I will tell you at our ski clinic, we tend to see probably somewhere between 60 to 80 shoulder dislocations a winter. And we probably see somewhere around 10 to 15 elbow dislocations, if that gives you some sense of the ratio that we see them in. That may not be the same for everybody. I think also in these particular lectures, you know, you're gonna get my experience, I'm gonna do my best to throw the evidence in there, but, you know, your attendings experience and your experience may vary a little bit. So I think we'll try to give you some pearls that will help serve you regardless of what level you're at. So we're gonna focus a little bit on pre-hospital reduction, because often in sports, that's when we're gonna see them on the sidelines. And the truth is, there's really not much evidence for that, although it's commonly done. I think most of us that have performed sports medicine for a long time have seen some dislocations on the sideline. Certainly, if you read textbooks, they will often talk very much about getting x-rays and doing certain things before reduction, but in practicality, that's not always the case. And so one of my goals, in addition to what we talked about in terms of the goals and objectives would be to make you comfortable enough to give an attempt at a reduction, even if you've never done it. There's lots and lots of techniques. Certainly, what I talk about tonight are not the only techniques you can use. The purpose here was not to say, hey, here's the best techniques, but we're gonna really focus on our experience with doing lots and lots of dislocations. I think we'll allude to it later, but I personally have probably done close to 500 shoulder dislocations and probably somewhere in the realm of 80 to 100 elbow dislocations. That does not necessarily make me an expert overall, but it certainly gives me a breadth of experience to be able to hopefully speak to you guys in a way that will help you moving forward. So general principles. Obviously, we wanna know our anatomy. I mean, that's an important thing. It's certainly something that the board's focus is on, but the careful assessment of the anatomy often helps us understand whether or not we're dealing with a dislocation or we're dealing with actually a displaced fracture. Now, you can obviously have a fracture dislocation where you combine the two of them. The other thing that's, I think, important to remember is we always wanna document our neurovascular status. Why? Well, certainly there's the medical legal side of things, but it's also because you wanna understand what is the patient like when you see them, what is the patient like after you do a reduction and as you follow them along. But probably the most important thing that I can emphasize to you, and it's something that I was not taught well when I trained, is that really when you look at dislocations, when somebody has a nerve injury or a vascular injury, almost always that occurs at the time the force is applied that causes dislocation. That injury doesn't occur because of the attempts at reduction. Now, there certainly may be a rare case here and there where somebody does something where they use maybe a non-judicious amount of force to try to relocate something, but that's a lot of force. And for anybody who's actually spent any time in the operating room pulling on things like femurs and trying to reduce humerus fractures, there's a lot of force that's applied that does not cause neurovascular damage. So just be sure that you know what's going on ahead of time, but it shouldn't dissuade you from trying a reduction because you're worried that you might hurt something else. Again, one of the other things, this is kind of more of a pearl, but a general principle is when you go to do a reduction, the patient has to cooperate with you. I think this is quite obvious. Even in someone who is not very muscularly developed, for example, with a shoulder dislocation, if they're resisting you, it can be quite difficult to apply enough traction and enough force to get the joint reduced. So you want somebody to be calm. You want to use gentle, slow movements. You always want to support the joint, no matter what joint you're trying to reduce. And in general, you want to use gradual amount of force rather than one big force to try to reduce a reduction, I mean, to try to affect reduction. So here's one of the pearls, and we'll try to point out a few of them. And this goes to a lot of experience, but it also goes to the fact that, again, even if you're not experienced with reductions, it's certainly reasonable if you think something's dislocated to attempt it. And that's that inline traction will reduce a lot of them. You don't always need a lot of special techniques. Many of these things, particularly if done early on before there's muscle spasm and we get to them quickly, inline traction will reduce a joint without difficulty. Now, as everything, there's always an exception to a rule. The exception tends to be the metacarpophalangeal joint dislocations, where instead of pulling on a joint, you really want to push the joint over the top. I know we're not talking about that specifically tonight. Doesn't mean that those joints aren't occasionally reduced well with inline traction, but we want to be thoughtful about just understanding that there's always an exception. Here's the other thing, and if there's anything, again, I can emphasize beyond what we talked about with the neurovascular, it's this, is that in general, if you look at somebody and they have a big swollen joint, that's fractured. If somebody has a deformity, so if you look at the guy with his shoulder down and would be my left of the screen looking at the computer, that's a dislocation. If we look at the pictures on the right side where you kind of have a sort of oblique view and then the side view, you can see that's very swollen. So when you see a joint that's swollen, in general, that's going to be a broken joint or there's going to be a broken bone that's displaced. Doesn't mean at some point it's going to not need reduction, but it may not be something that we want to attempt right away. And here we can see in this particular patient, this is a displaced fracture rather than a dislocated shoulder. Here's the other exam pearl when you're looking at somebody acutely with a shoulder is, and we see this a lot in the wintertime at Killington because you're reaching up under a lot of layers of clothing because it's cold, or certainly on the football field or lacrosse field or hockey where they're wearing pads, is when you reach up underneath, the step off of a grade three AC separation and the step off of an anterior shoulder dislocation are going to feel relatively similar and they're sometimes difficult to assess. One of the things we've learned over the years, and I would call this level of evidence M, level of evidence, Matt, because it's certainly not been studied, but that if you have an AC separation, if you support the athlete's elbow, they will let you internally and externally rotate the shoulder without creating much pain. If you either have a dislocation or certainly a fracture associated with the glenohumeral joint, they're not going to let you do that. So that's one of the ways sometimes you can tell the difference between the two. Now let's go back to fractures. Certainly, we're always concerned that there may be a fracture associated with a dislocation, but that should not necessarily dissuade us from attempting reduction. We need to understand that it may be a more painful attempt at reduction, that based on our level of experience and how often we've reduced these and how sure we are this is a fracture versus a dislocation, that we may not make many attempts, but it certainly is okay to attempt. I mean, if you make a mistake, and I've done this before, and I've actually done it live with a similar type of humeral fracture that I just showed, where I actually pulled on it and reduced it on the hill, not thinking it was a dislocation when it was actually a fracture. But again, the risk there is really causing pain, and maybe we don't want to cause athletes or patients that much pain, but the risk of causing more damage is incredibly low. So just be thoughtful about it, but it's okay. We don't have to worry that there's something else broken in there that we're going to cause a big problem with. And when you have fracture dislocations, again, it doesn't mean we shouldn't try to reduce them. This is an example of a anterior shoulder dislocation with sort of a metaphyseal diaphyseal humeral shaft fracture. This particular patient, we were able to do reduce without actually anesthesia. And you can see here that sometimes just pulling on it works particularly again, if you get there early. Here's another example where there's almost a split between the sort of end of the ball and the greater tuberosity going down. But this is another one that didn't require anything additional than the normal techniques we use for shoulder reduction. So let's go, we can move a little bit into elbows and I'll see if I can get this video to play. I'm going to try to mute it here for us. So some of you may recall this in the NBA from many years ago, where there was an elbow dislocation, but you know, it's a relatively common sports injury. It's certainly not as common as we see other dislocations. And remember, usually the mechanism is a fall on an outstretched arm. And in general, the olecranon is going to go either to the posterior medial or posterior lateral direction. Certainly anterior dislocations of the elbow can occur. These are almost always open. And they're almost always involved with multi-trauma and a lot more force than your typical elbow dislocation. Why is it important to understand where they go in terms of posterior medial, posterior lateral? We'll talk about it. But one of the ways in which we judge the reduction is we need to get the olecranon into the center of sort of the alignment prior to trying reduction, and that makes it much easier. So here's a couple of x-rays just showing a sort of complete dislocation versus a perch dislocation. Just like shoulders, elbows in particular can be almost subluxed rather than truly dislocated and gentle inline traction. And sometimes even just stabilization and examination will reduce some of these, which is why I think it's very reasonable for someone to attempt these, even if they're not entirely sure what the best technique is. So we don't have a lot of evidence to suggest that it's safe to reduce elbows without x-rays. I will tell you that in practicality, if you talk to people like me or other providers that have done this, it's done on a regular basis, and we do feel it's relatively safe. Like most reductions, if you can get to it quickly and you reduce it, you will help the athlete feel much better faster. If you don't know if there's a fracture there, and the truth is, as the rule that I said before with fractures, swell and elbows, I mean, dislocations tend to just look deformed. Sometimes elbows can be a little more swollen based on some of the factors in terms of what ligaments have been torn and some of the other things. So if you're really not sure, it certainly is very reasonable to try to obtain a radiograph before you try. But again, understanding that even if there's a supracondylar fracture there, it's unlikely that you're gonna cause severe damage. You certainly can cause pain. Make sure you know your bony anatomic landmarks, right? So if the olecranon and the condyles are remaining in the same anatomic orientation as the non-affected limb, then that's probably a supracondylar fracture that's displaced. What you really wanna feel is that the olecranon is posterior or in posterior medial or lateral to those epicondyles, and that will help us understand that, well, this really is out of place rather than just fractured. Here's a CT scan picture of it. Think about it in the sense that this one, the radial head is slightly out of place, which is not always the case in these. Many times the radial head stays located. But if you think about the condyles as uprights and the olecranon is something that's going side to side, what we really wanna do is we wanna make sure the olecranon comes to the middle before we try to pull it through into reduction. If somebody is sedated, you can almost apply enough force as needed to actually pull it over the condyle with sort of a grind. And if they're not in a lot of pain, you can do it. But when you're doing this in a non-sedated setting, getting the olecranon to the middle really helps aid that reduction. And I would say the biggest mistake I see most of our fellows make or people make is they apply too much traction and too much force in the longitudinal direction, sort of down the wrist and down the forearm before they get that olecranon to the middle. So sideline reduction. If you come upon somebody right on the field, you can certainly attempt reduction to see whether or not this is something that you can easily reduce. A brief attempt on the field, I think is almost always indicated. There are certainly circumstances where it's not indicated where you may wanna get the athlete sort of out of the way of fans. I tell an infamous story about with a professional team, it was not an elbow, but a reduction we were gonna attempt on the field. And we looked up and we were on the jumbotron. And certainly that's not a circumstance when you necessarily wanna try to affect reduction on an athlete. But in many cases, particularly with elbows, the reduction can be done without anybody really knowing that you're actually attempting reduction. So in this picture, you can see with the elbow that one hand is stabilizing the wrist. The other hand is stabilizing the humerus while the thumb is placed on the olecranon. We can use our thumb to push the olecranon towards the middle. And as we feel it go towards the middle, we can pull the elbow into place. This is relatively effective, particularly with those perch dislocations. But it's certainly a reasonable thing to try when you get out on the field, because sometimes it'll just slide back in and it saves you a whole lot of trouble. Obviously, if you're struggling at all with it, and this is true for any dislocation that you see on the field, we wanna get onto the sidelines. We wanna be able to reevaluate and decide what the best plan is from there. This is sort of the more traditional way to reduce an elbow. Gives you a little bit more control as the patient is, of course, in the prone position. The elbow is off the side of the table. This allows the sort of the upper arm to rest on the table, which gives us control of the lower arm, stabilizing the lower arm. And in general, we would say slightly pronated position, but I will tell you that in practicality, it's whatever position the forearm is comfortable in is the one you wanna stabilize it in. Once we're in this position and we can determine which way the olecranon needs to move, whether it needs to go from medial to the middle or lateral to the middle, we can then affect pressure on the olecranon. Once we feel it going to the middle, we can either then simultaneously pull it through or we can get it centered and then pull it through. Generally, a little bit of extension is helpful with this. Certainly 90 degrees can be a little bit more difficult. So as you feel it go to the middle, we're gonna generally gently extend the elbow into that position around 30 degrees. Again, remember, like I said before, there are other techniques. And if you look in the literature, there's techniques that involve a lot of brutane. These can often be effective in the pre-hospital setting, but I will tell you in practicality, many of them require sedation. So those of you that are saying, well, I do it this way or I do it that way. That's great. And I'm not telling anybody that their way is wrong. I'm just giving you sort of the way that we have found over the years is tends to be the simplest way to get these back into place. I'm going to try to show you a couple videos here real quickly. So in this video, we'll see that the thumb is going to be placed onto the olecranon. We're going to move it. That's my Steven Spielberg terrible iPhone video, but we're going to see the thumb go towards the middle. And as we feel it go, we're going to pull and you can see it kind of pop into place there. It's not very dramatic. It seems like it'd be dramatic. In the second video is I think it's a little bit more observable. This is my partner, Jim Russell. I'm going to shout out to him. He's the one that trained me and he's done probably twice as many of these as I have done, but you're going to see him in a second. He's going to move the olecranon again towards the middle. Once he feels that it's comfortably there, he's just going to pull the elbow into place. Again, it seems like it'd be more dramatic than it is, but generally we don't see them being more difficult. I would say on average, we have more trouble with shoulders than we do with elbows, particularly once you understand the basic principles. So post-reduction, obviously we always want to repeat the neurovascular examination to see if there's any changes. Just remember, like I stated before, or at least was in the slides before, the treatment of a pulseless dislocation or dislocation with nerve injury is to put the dislocation back. There, of course, I'm sure, and I have never come across any, there's going to be rare cases where somebody had a pulse and you put the joint back and there may not be a pulse and it's important to document, but you're not going to know that ahead of time anyways, so you really just want to make sure you understand what it was like before and what it was like after. Most dislocations of the elbow that are comfortable can be placed in just a sling. If you read sort of many of the textbooks associated with this, they'll talk about short-term splinting. A simple posterior splint is certainly adequate. If I do splint people because they are uncomfortable, I will allow them to take the splint off to bathe or change and they can certainly wrap it back on, but we know that short-term splinting only, if you're going to, if you're going to splint somebody who really wants to only be, you know, 24 to 72 hours at the most, you want to get them moving as quickly as possible. We're going to obtain an x-ray after the reduction. Now, certainly if we've had an x-ray before the reduction, you can compare. If you didn't have an x-ray before the reduction, it allows us to look for alignment and make sure that everything's okay. Now, the question of whether or not that needs to be done urgently is one that comes up when the fellows rotate with us a lot. I would say this, that in my experience, having done a lot of them, if I'm at a football game and I reduce an elbow on the sideline, the book answer is I'm going to send them for an x-ray. My reality answer is if the elbow is stable and they're comfortable and they move it well. If it's a Saturday, I'm probably just going to give them my number and if they have any problems, but otherwise I'm going to bring them to the office on Monday to get the x-ray because I don't think it tends to be that urgent if they're doing well. I will try to test them, certainly testing them at somewhere between 15 and 30 degrees will give you some sense of how stable the elbow is. Most of these are relatively stable and so they don't tend to really want to fall back out of place, but certainly if they do, you're going to want to split them in such a position that so if they're stable at 60 degrees but they're unstable at 30 degrees, we're going to want to split them at 60 degrees and allow them to work in that range but not extend too much. You want to get them started with early range of motion as quick as possible. There's good evidence to suggest again that the best thing you can do is get these moving because loss of extension is the most common sort of joint complication associated with these and if it's really unstable again and we'll talk a little bit about some things that can associate with that, we're going to want to, you know, protect them but we're probably going to want to get some more information. This algorithm is a little tough to see but it's in your references at the end of this talk. We talk about the terrible triad for the knee, well there's a terrible triad for the elbow. This is associated with elbow dislocation, a coronoid fracture and a radial head fracture and why are these associated together? Well, because it generally is going to be an unstable injury. So when we say refer, that's not necessarily refer urgently to the emergency room because they have to have surgery that night, but this is something we have to keep a close eye on. I will, in my experience in the last oh 20 years or so of doing this, I would say it's about 50-50. You see this combination sometimes where it actually is relatively stable and we don't feel like we need to go on to do surgical reconstruction of these injuries, but you always want to keep that in mind and that's certainly something that may come up on the boards. Obviously, if they have a neurovascular compromise or certainly if they have significant fractures, we're going to want to send those athletes. If you have a fracture that's blocking reduction, which occasionally happens, so where you feel like you get it part of the way, but then the athlete can't move the arm well afterwards because most of these, if you reduce it, even though it's sore, they're going to have some motion in the joint. You didn't do anything wrong. Sometimes the radial head or another piece will be in the way, but you're going to want to potentially refer that for an x-ray sooner than you would if they're moving the joint well and they're comfortable. So return to play. Nobody has a sort of a good evidence-based answer for this. I will tell you in practicality, we generally use the, you have at least reasonable range of motion. I say full range of motion there, but I think you have to be close. I think you have to have reasonable strength and then the question is, can we protect it? We will generally use a brace like the one pictured here, which limits the athlete from extension based on their sport. If they can participate effectively with that, we'll let them back as soon as they're comfortable while continuing to work on the range of motion, but that'll vary person to person and sport to sport. All right, shoulder dislocations. So if you're going to see a dislocation on the sideline other than a finger, this is the most common one you're going to see. We do have some evidence, at least in the emergency room literature, that would suggest that reducing the fracture early is helpful and one of the fellows that rotated through our clinic a few years ago presented a paper at AMSSM that showed the faster we got to the reduction, the easier it was. I would say it was probably moderate quality evidence, but at least it showed that, hey, look, if we get to a quickly, they tend to be easier. And we also know that if you're pretty confident that the shoulder is dislocated, that a pre-reduction radiograph is not necessary. As a matter of fact, there's actually some studies that would show you either you need an x-ray before or after, but that you don't really necessarily need them before and after. And there are occasions where you will see things in x-rays after the reduction that you can't see pre-reduction because of the anatomy. So if we're going to get x-rays on them, I certainly prefer the post-reduction x-ray. Rather than the pre-reduction x-rays. So there's several different ways to reduce the shoulder. We kind of talk about it as the Furness versus Brutane. I think it depends on the actual person. And as I spoke to before, you know, we've done, boy, I guess at least I have 500 myself and greater than a thousand between at least my Dr. Russell, who's my current partner, and Dr. Jordan, who has passed away, my former mentor, you're probably getting close to 2000 of these. That doesn't mean that there's not different ways to do it. And again, we're going to kind of go through the basic principles. I think these principles apply to no matter what reduction technique you use, but they mostly apply to those when we're not using sedation, or at a minimum, we're using interarticular lidocaine to help with the reduction. So you want to know again, where does the shoulder rest? Is it resting anteriorly, posteriorly, or inferiorly? The inferior ones are relatively rare, even in the circumstance where the person kind of comes in with their arm over their head. Most of the time, those are really more anterior than they are inferior. But if you get a sense of where the ball is, it certainly is greatly helpful in terms of how we're going to approach the reduction. For the boards, and again, I told you I wasn't going to try to teach the boards too much. I think in your fellowships, they're going to cover most of what you need. But remember, the axillary nerve is the most commonly injured nerve. So you always want to check that sensation. But you can see other brachial sort of plexus type injuries. So you always want to check that distal function as well. And just remember, if you're less than 35, generally, the risk of re-dislocation is going to be much higher in terms of moving forward. And if you're over 35, the risk of re-dislocation goes down, but the risk of rotator cuff tear goes up. So there are several different ways to approach this. Again, we try to approach it at our clinic or on the sideline sort of in a systematic fashion of, can we do it in a sort of seated position? Do we need to lie them down? Do we need to turn them over? I think if you look at the literature that's in most of the ER, but in some other trauma things, they use a variety of these techniques based on sort of the timing of when the patient comes in, how long it's been out, and sort of whether or not the provider has a preferred method. So I think in the end, the calmer you can get the patient and the quicker you get to it, the better off you're going to be. So the seated, or what I would call sort of the position that you would use on the sideline, or most easily if someone's sitting down, is really, really good for those dislocations that we get too early. It's certainly really good for those that are perched. All these types of techniques really involve a measure of traction and counter traction and some stabilization of the shoulder. So you can see in this position, we've got a hand on the elbow, we've got the forearm resting on the arm, and we're using the other arm to provide counter traction. One of the mistakes we see the fellows make the most of the times is they're not really controlling the forearm very well. So you really want to pay special attention to controlling that forearm, making sure they're very relaxed and resting on your arm while you're doing this. And if you do that, then you will gain control of the shoulder much better. As you apply traction, you should be able to move the arm from an internally rotated position to a neutral position. If somebody is stuck and they're not allowing you to go to a neutral position, what it's really telling you is that I haven't gotten enough traction yet, and so you need to either reposition or I'm going to have to apply more force until I can get to that position. Sort of the recreation of the injury, which is the sort of old milch technique, would bring them up into external rotation or significant external rotation, you know, that certainly can work. It tends to be more painful and tends to be more effective if there's pain medicine on board. But they really, if they get, if you get them to neutral most of the time, you know you have enough traction applied, then we have to just figure out does it need to come a little bit into forward flexion or a little bit into abduction. So again, you can see here you can have the athlete help you. There are some techniques to talk about the athlete retracting the scapulas themselves to help you. You always want to increase force gradually, so it's not a sort of a jerky motion increasing force. You want to slowly change positions. Try not to grip and re-grip. One of the other things that happens with fellows is their hands get tired. If it's a little more difficult and then as the shoulder kind of relaxes, it'll cause more pain. The more pain you cause, the more spasm you're going to have, the harder it's going to be to do the reduction. So you really want to move, you know, not, I see we say slowly, but I think you just want to move flawlessly, but you want to gradually apply force. If you have to let go for a minute, you want to gradually reduce that force you're applying as well so that you're not creating more pain. I'm going to show you a couple of examples here. Actually, I'm going to actually hold off. I'm going to show this one. This is one where you show very quickly. This is my partner. He's going to pull relatively quickly on the elbow, and you're going to see a little pop here in a second, and then the shoulder's back in place. So that's sort of a simple one. This is one of our fellow, former fellows that I like to make fun of, and I put this in because there's a couple of mistakes here, even though it eventually affects reduction well. One of the mistakes is you can see the position of the patient is totally different than the position of the patient we showed before. So you want to try to get the patient in an upright position, but even if they're not retracting their shoulder blades, you want to make sure that they're upright and back because it allows you to work better. The other thing you can see here, initially he wasn't controlling the forearm very well. He was able to get it back in, so we'll give him an A for the reduction, and we'll give him a C- for the technique, but it gives you some sense of we want those shoulders level. We want the patient to relax. In this case, we use a weight bench, but even if you don't have anything behind you, they can lean back away from you. The second position we use if we're not successful there, or maybe if the shoulder has been out quite a bit and the patient's not comfortable, is the prone position. This is well described in the literature where you're able to then use the table to sort of help the patient relax, apply some traction at the shoulder, and then actually rotate the scapula out of the way. By rotating the scapula immediately, you're able to open the glenohumeral joint a little bit to allow the ball to slide in easier. I think if you're not experienced with the shoulder reduction, this tends to be one of the easiest ways to get the shoulder back in because, again, with the patient lying on that table, you take out some of those other variables. Scapular manipulation is generally done after you apply traction to the elbow. There are occasions where it's better to actually apply that traction first, I mean apply that rotation first, and then apply traction, but for most people, if you get a little bit of traction on the shoulder by rotating the scapula, that will allow it to go in. Again, those of you that work in the emergency room or have done these in the emergency room, when someone's in spasm for a long time, they will sometimes hang weights off the side, and I certainly think that's a reasonable thing, but we're really focusing on the athlete or the patient where the shoulder hasn't been out too long. Again, when in doubt, pull harder, that's sort of the rule, but if the patient is fighting you, pulling harder is not going to work very well, but the more you can rotate that scapula, and here's the other little pearl that I didn't put in here, is that if I'm pushing on the scapula and my assistant can feel that the shoulder wants to go with them, that really tells us that we've not disengaged the ball from the socket, so in general, if I've got enough traction, that scapula should rotate relatively easily towards the medial aspect of the body. I'm going to show you this one. This is a how not to, one of our former fellows, so one of the things to think about is as you're getting somebody from the position of either sitting, and we want to get them into that position, you're going to see here the mistake that's made, and I as the attending, I suppose, should take credit for some of the mistake, but I'm going to blame it completely on the fellow, is that you can see the arm is not off the table, so that's kind of, I'm looking down, I'm helping the patient get up, I didn't see it, you can see the arm stuck, so here as we actually get the arm off the table, the shoulder reduces, and so again, it's really how not to reduce the shoulder, it actually worked very well, but you want to make sure if you're going to lay somebody down, that that arm comes off the side, and then this is sort of the more traditional technique, it's sort of glamorized in movies and on tv, which is sort of the towel around one side, and we're applying traction, this allows us to use kind of body weight and maximal force, this is often necessary when the ball is really stuck on the glenoid, or if there's a fracture associated with the dislocation, where it's very difficult to get enough force to pull that off of there, one of the tricks here that we see, is that when you apply traction, the forces need to be going opposite, because otherwise you're going to start to pull the shoulder off the table, unfortunately some of these don't want to go in straight abduction, they actually want to come a little bit into forward flexion, so the trick we've learned over the years, that you'll see in this video, is that it's a three-person technique, where you've got traction, counter traction, and then I'm actually going to use my hand, so my right hand is actually pushing down on the acromion, such that as my partner tries to lift up, I'm still stabilizing so that we can get traction, and that allows the shoulder to be reduced, it looked a little bit choppy on my end, hopefully it worked a little better on your end, but just remember, if I'm coming up this way, and traction is applying the other way, the whole shoulder is going to come up off the bed, and I'm not able to apply a counter traction, traction force to disengage the ball from the socket, so here we can see in that particular patient, there was a greater tuberosity fracture associated with it, and those tend to be on average, the more difficult ones that we see, these are the cases, and I didn't put it in here, and I probably should have, where sometimes you want to use interarticular lidocaine, so the approach to the joint is the same, it's that posterior approach, if you're going to use interarticular lidocaine, the volume of injection is around 15 to 20 mls of lidocaine, you need at least that much, you can't use less than that, or you're not going to really get adequate anesthesia to be able to help with the reduction. So the finishing move, one of the things that we see sometimes, and we saw previously from my partner, and if you were paying attention, that once the shoulder is in place, you're going to see him place his hand in the axilla, and kind of lift up while he brings the shoulder down, we have sort of coined this the finishing move, the reason we do that is because sometimes when you think the ball's back in, it's not quite all the way in, but if you put your hand in the axilla, and as you're bringing the elbow down, and you're lifting, you're going to push the ball back into the socket, and you're not going to let it come back out of place, which can happen on occasion. Here's an example of when I made a mistake, yes I know those of you that know me know that I'm fairly perfect, but I'm not completely perfect, in this particular circumstance we felt that, I felt personally that the shoulder was back in, my partner rightly felt that it was not, but as I brought the elbow back down, we're going to see it actually slide out of place, rather than back into place. So here I think I've affected reduction, but it's just perched. And I didn't really use the finishing technique. I kind of just had my hand halfway up in the axilla. Again, this is a technique that's not been reported, but I will tell you, having done so many of these, it will save you a lot of trouble if you use it. And it will also actually help with reduction sometimes with those that are perched. You can do it that way. But we can see here as I come back down, the ball is going to pop. There it is. It pops back out because I didn't use the finishing move. And that's enough of me not doing a good job. Here's the other thing is you want to take dislocations in the direction they want to go. So in this particular circumstance, this is not an inferior dislocation. This is an anterior where the arm was just stuck over the head. And you just want to apply traction along the plane of the shoulder and the elbow. If you do that, then often you will affect reduction. Sometimes you have to bring it back down. You'll see here that I'm going to kind of hold the humeral head while I lower the elbow down. But if they're stuck in a position, whether it be out to the side or whether it be above, that's the first direction you want to go. Some of the literature talks about bringing it straight down into the sort of more traditional position of the shoulder dislocation where it's internally rotated. But that's unnecessary and generally going to be more painful for the patient. Here's another example where the shoulder is sort of stuck out to the side. Again, we're just going to apply traction in that plane. And once we apply traction in that plane and we get it out far enough, we're able to just relocate the humeral head. In this case, I'm just going to lift up a little bit and it goes back in. So comparison of techniques, you can look at this. But in general, if you need lots of force, sometimes you have to put them on your back. If you need less force, the seated technique works. All of these are very reasonable along with the multitude of other that are described in the literature. So I'm okay with you picking your favorite technique. Let's just understand the basic principles of what we're trying to do. So post-reduction management, I think it's relatively straightforward. We just use a sling for comfort. We know that generally just using a sling and keeping them in internal rotation does not reduce the risk of re-dislocation. There were some initial studies that looked at using a gun sling or external rotation sling that showed maybe some promise in helping that labrum position in a better position, in a better anatomic area to heal. It turns out it probably doesn't work that well in practical terms, even when we thought it might help. I had a hard time keeping patients in that position for six weeks to allow the labrum to heal. So I've kind of gone away from doing that. Just know there's some literature out there that talks about it. But in general, you're going to sling for comfort. You're going to progress them through range of motion. We will often tell patients early, keep your hand where you can see it. So if you're in this plane, you're going to be okay. If you're reaching back here, that's an at-risk place for the shoulder to dislocate until the muscles work a little bit better. So return to play. This is, there's lots and lots of papers on this. Almost all of them show that if you send an athlete back in season after they dislocate their shoulder, that there's pretty high risk of it happening again. There was a few more recent studies that showed it was maybe not as, quite as high as we thought it would be. Some of the studies were somewhere in the range of 70 to 80%. And a few of the more recent studies looked at 30 to 40%. Just know that braces are not very effective for keeping sort of this from happening. Unless you're using the type of brace that doesn't allow the shoulder to get out into an abducted and externally rotated position. So in football players, those Lyman braces can be somewhat effective at keeping the shoulder out of an at-risk position. Any brace that allows the athlete to get up into this position is not likely to be very effective. And sort of those soft type of braces may be helpful for comfort. They may be helpful to remind the athlete. But they're certainly not going to help sort of the ball not come out again. The question always becomes, should we move right to surgery in these athletes? There were a few studies that looked at the risk of arthritis after, you know, after doing surgery, after initial dislocation versus subsequent. I will tell you that I don't think the difference between coming out one times and two times is probably a big deal. Certainly the difference between coming out one time and 10 times is a big deal when it comes to both how well the repair might work, the type of repair that you need, and the risk of arthritis down the road. So you really got to talk to your athlete about, hey, here's the risk. Here's what we know. And here's what we don't know. I think in practicality, most of us will give an athlete a chance to go through a season or at least try to finish a season as long as we feel like they're aware of the risk. But I think that the best thing we can do is kind of educate them to know that, hey, they may not do as well as we would like them to do trying to get through. And hopefully, they'll make a choice that they're comfortable with. So posterior dislocations, they're relatively rare. You know, the ratio in our clinic is, again, 60 to 70 anterior dislocations, maybe up to 80, somewhere between two to five posterior dislocations. They are traditionally associated in literature with things like seizures, but we certainly see them in sports, generally falling on the arm out in front, which pushes the ball out the back, and you get things like reverse heel sacks, and you can certainly get rotator cuff tears. There are some tricks with posterior dislocations because they tend to not look as dramatic. So it's actually one of the things that we see that's most litigated in the ER literature in terms of musculoskeletal injuries is missed posterior joint dislocations. One of the signs on x-ray is what we call the light bulb sign. So at least as I'm facing my screen, the right-hand side shows a normal view of the shoulder, the left-hand side with the outline shows what we call the light bulb sign. And that's what happens is the ball goes out the back, it basically rotates posteriorly. So you're really looking at the posterior aspect of the shoulder in that view, and it should give you some hint that something's not right. You also have the overlap sign, which means that you're sort of looking at the AP, and it looks like the ball's in place, but there's no gap between them, and that gap does not even look like the typical bone on bone arthritis type of gap. There's actually an overlap between the humeral head and the glenoid there. So these are relatively difficult to detect sometimes, particularly in bigger athletes and bigger people, they do not look anywhere near as dramatic as the anteriors. You can see in the picture above that that's somewhat sort of obvious to say something is wrong. Here's what I would say, and here's another one of those pearls, is that if somebody comes in, and they've fallen on their arm, and they will not either actively internally, externally rotate, or they will not actively allow you, or excuse me, passively allow you to internally and externally rotate, you need to be suspicious of this injury. Because if you cannot passively either externally rotate them or internally rotate them, that tells you it's either out of place, or something's fractured there. So think about those sort of views. If you're not sure with the x-ray views that you've got ahead of time, think about an axillary view, because that really gives you the best look. You can look with ultrasound. There are some studies that are mounting with this. I didn't have any good ultrasound pictures of a posterior or anterior dislocation, but certainly you may want to consider some imaging. But, you know, in general, unless something is out of place or broken, a patient should really let you move that shoulder passively pretty easily, as long as you're supporting it well. So how do we reduce this? Well, either in the prone position all the way in their back, or you could do it actually with the athlete or patient sitting up like either in a chair. But the arm's going to go out to the side more. So we've got to get that ball sort of out from behind. Occasionally we have to bring them up into forward flexion a little bit, but almost never do we need to do that. Usually just once we get them out to the side, it's going to reduce itself. And I would say, again, in my experience, which is a dangerous word, these are way easier overall to reduce than some of the more difficult anterior ones. So we're going to show you a little video here. You'll see the patient they present in the same position. That position is that internally rotated position. We want to get that arm out to the side. Once the arm, we get out into that somewhat abducted position, then we're able to apply traction to reduce the shoulder. In this particular case, we're not using a blanket or a towel to apply countertraction. You'll see my partner, Dr. Russell, has his hand on the acromion. We're very, very fond of using that as a fulcrum point to be able to push countertraction. And you'll see here as soon as he applies enough traction in that line with countertraction, the shoulder's going to easily reduce. Here's my Steven Spielberg work again, moving up a little closer. And a little more force, and there's the shoulder back in place. So most of these are relatively stable. How do you tell if they're stable? Well, you can certainly take them through range of motion. If they come into internal rotation, it seems like it wants to pop out the back. You can certainly put them in the gunslinger position. If you look at the literature, and there's an algorithm I'll show you in a second, most of these, most of these are stable. They talk about a lot of them being unstable with large amounts of either bony injury. I think that comes from the non-sports literature than the sports literature. Again, in my experience, I think I've seen one of these in the last 20 years that was unstable compared to the anterior ones. But just keep in mind that these can be unstable just as well as the anterior ones. But as a general rule, they're not going to be that way. And this is in your references. It's an algorithm just looking at whether or not the shoulder feels unstable, you know, how much bony damage there may be either to the posterior glenoid or to the humeral head and that reverse heel sax. And, you know, some of these may require more treatment. So, there's some references, certainly not a complete list of references, but some ones that I thought would be worth your time in terms of breeding. I really hope this was helpful. Certainly, again, it's very different than doing this live. If there's any questions, I'm certainly happy to take them now or at a later date, you're welcome to reach out with me at any time. So, thank you very much. Thanks so much, Dr. Gammons. We appreciate it. Looking at the chat, everyone's saying thank you. That was great. You know, at the very early on, we had a question asking about the, you know, best techniques on the sideline for shoulder and elbow dislocation. I feel like you kind of went through that and we have those. I would say, let me comment. So, you know, there's a couple, you know, any technique early on can be pretty effective. And, that's where that inline traction comes in. And, Dr. Bergfeld, who's a long time Cleveland Browns physician who was one of the original orthopedic surgeons who helped start the Primary Care Sports Fellowships, will talk about taking the NFL guys off the sideline. And, as he's walking them off, he'll just pull down on their arm as they're walking off. So, you know, there is a lot of different techniques. And, again, I tried to cover them. I think, you know, early on, just that inline traction often is enough to reduce both either an elbow or a shoulder. Yeah, I would, I agree. I think I've had two shoulder dislocations with football this year. And, both of them have gone back in very, very easily. And, those kids are still playing. They're seniors and wanted to finish their year. So, we put them in a Sawa or a Sully brace and they're finishing. You know, they can't get into that position like you were talking about. And, they've been fine. They're just both, you know, one's a defensive back. And, they just realized they're not going to be intercepting any passes unless the quarterback throws it into their belly because they can't get up here. And, just another comment based on some things that you had talked about. I've had several where people have come to clinic and their shoulder's been out for 24, 48 hours and they're all spasmed up. And, yeah, 20 cc's of lidocaine in the joint and just let them kind of lay on the table with their arm kind of hanging off the side. And, that has been pretty good. That technique, I feel like I've had good success with a technique that you were talking about that's helpful where they lay prone and you just provide some traction while they lay there and kind of relax a little bit. But, that's just my two cents as someone who's done much, much less of this than you have. So, I have one question here. I'm not sure who it's from asking about same day return to play with a shoulder dislocation. So, say it's football or something like that on the sidelines. They dislocate. You put it back in. What are your thoughts on same day return to play? Well, I mean, you know, I think the basics are they have to have good motion and good strength, right, in order to do that. So, I think that's not unreasonable depending on the level and the athlete. I think you have to warn them that there's fairly high risk of that re-dislocating. And, we will certainly see that at the clinic a fair amount where somebody comes in. They fell early skiing. They dislocated their shoulder. I put it back. They ask if they can go back out. We go through the sort of the, okay, here's the risk and benefits. And, then they fall again. And, the shoulder comes back out. And, we see them again. So, it's not super common because I think a lot of people aren't going back out. I think you can argue that their ability to protect themselves probably isn't as great, you know, right in that acute setting because the muscles aren't going to work as well. But, I think there are people where whether it be because they're relatively ligamentously lax that the ball came out easier. And, the rotator cuff is strong and firing well where they might be able to protect themselves in such a way that it's not significantly in higher risk than sort of the typical risk. But, you know, so I'm okay with it. I think you just have to have a good discussion with the patient. I'm probably going to not let the 12-year-old go back into Pop Warner, the NFL guy. You're going to have a different conversation with. Right. I had one question asking if you wouldn't mind going back to the screen with the references on it. Sure. Let's see if I can do that. Yep. So, some people can just, I think they're wanting to jot those down. Yep. And, let's see a couple of the questions. And, I apologize, you know, the book chapter seems probably highly self-serving since I'm on the conference. I will tell you, Dr. Cody from the University of Colorado who also works a lot in the ski clinic, he was the workhorse on this book. If you're looking for a sports drama book, though, I would say that there's a lot of really, really good information. We tried super hard to not only search through the evidence, but to try to provide some practical information for the stocks that maybe don't see it as much as we might see it in sort of the ski clinic or snowboard clinic setting. Yeah. And, it just came out this year, right? Yeah. It just came out, yeah, just last, really in the springtime. Okay. So, yeah, very up to date. Yeah. Let's see. If one person had a question about with skiing mechanism of injury for, they don't say what, whether shoulder dislocations or elbow, but just what's the general mechanism of injury for some of these dislocations? In skiing, and both in actually snowboarding, it's fairly similar to sort of other, sort of fall on the outstretched arm where they get it up into this position. The one difference that we do see occasionally with skiing with a pole plant, somebody will get, they'll plant their pole. And, if it's really kind of sticky snow, it'll get kind of jerked behind them. So, it's actually, they're sort of stuck. And, if they're strapped in and they don't let go, it'll jerk it out. But, in both with elbows, you know, elbows are almost always, you know, it's a fall on that extended arm. That's why those braces that we showed can be effective in getting an athlete back earlier because if they can't get into full extension, the likelihood that they're going to dislocate is extremely low with the elbow. So, that brace that kind of blocks that last 15 degrees of extension works pretty well in athletes where that, you know, that lets them be functional. Yeah. Hold on. There's a couple more. Yeah, they were talking specifically about skiing shoulders. So, you covered that. Let's see. I would say in skiing, occasionally recurrent dislocations will come in our freestyles just by throwing their arms over their head. So, the guys that are going inverted and upside down, you'll occasionally see them where they just do that and the ball will pop back out. But, that's in somebody who's previously dislocated. That's, rarely is that in somebody who, you know, a native shoulder dislocation. Right. It doesn't look like we have any other questions here. So, if those that are still hanging on, if you want to jot down these references, also the sports trauma book that we referenced, where Dr. Gammons is one of the authors from earlier this year that came out, that'd be a good reference for sports trauma as well. Also, don't forget the next lecture for the Fellows Online Lecture Series is October 29th at 12 Eastern on asthma and EIB. Otherwise, unless there are any more questions, please, if you don't mind, go in the chat right now and click on the link to fill out the survey for some comments for after the talk. That would be helpful. Otherwise, we will let everyone go and enjoy their night. Thanks so much, Dr. Gammons. We appreciate it. Yeah. Thank you very much, everybody. Have a wonderful evening. Be well. Yeah. Thanks, everyone.

3rd Edition, CASE 16

3rd Edition

Elbow and Forearm

shoulder dislocations

elbow dislocations

sports medicine

AMSSM

anatomical landmarks

reduction techniques

neurovascular status

CAQ exam preparation

National Fellows Online Lecture Series