Case vignette
50yo F presents with L shoulder pain after fall. She received 200 mcg IV fentanyl with EMS.
RR 12, SpO2 92%. Pt weights 166kg.
She is sleepy appearing. She has squared off appearance of L shoulder with poor ROM. Neurovascularly intact. She develops severe pain with your attempts to move shoulder and does not tolerate trans-scapular Y XR views.
She is ASA class III. You are single provider coverage.
What do you do next?
The patient is sleepy but will not tolerate attempts at reduction without further sedation. You attempt intra-articular joint injection but cannot palpate landmarks and are unable to inject into the shoulder joint.
What do you do next?
You use US to identify the joint space and use dynamic needle visualization to perform joint injection.
What do you see?
Picture: Using curvilinear probe, a long axis view of humeral head identifies the joint space (superiorly). The probe is rotated until the joint space is in view. Normally, the glenoid is seen; with this dislocation, you cannot see it.
MSK1 US1: fluid is injected into joint space, showing a more anechoic appearance.
Procedure (description): "Using a curvilinear probe set to higher frequency range and lower depth, the left shoulder region was interrogated, and the humerus was tracked to the humoral head. The humoral head was found not to be adjacent to glenoid fossa (absent golf ball on tee sign), consistent with shoulder dislocation. There was an anechoic to hypoechoic fluid collection in this space, consistent with fluid/blood in the distorted joint space. Next, the skin was prepped with chlorhexidine, and 10cc 0.5% bupivicaine and 10cc of 1% lidocaine with epinephrine were mixed in a 20cc syringe. Next, the skin was penetrated using a 22G 3.5inch spinal needle, a wheal was made, and then under dynamic ultrasound guidance the needle was guided into the joint space in long axis. Blood tinged joint fluid was aspirated confirming placement in the joint, then 20cc of anesthetic was injected. After minutes, the patient had good anesthesia of the shoulder. Repeat neurologic exam after procedure showed intact sensation and strength in the hand and arm."
Teaching points. POCUS can be used to help identify shoulder dislocations and for dynamic guidance of any procedure involving needles. Consider it for procedures you usually perform using landmarks when that method is unsuccessful. When performing any nerve blocks, ensure to use and document pre- and post-procedure neurovascular exams, appropriate anesthetic doses (see MDCalc Local Anesthetic Dosing), availability of intralipid, sterile technique, aspiration before injection, protection of nerves (lack of excessive pressure on injecting, injecting around but not into nerve), and saving clips!
Residents/staff: Dr. Joshua Johnson
Shoulder Dislocation Injection