ULTRASOUND ZOOM
POCUS For Shoulder Dislocations: Another Weapon in Your Clinical Arsenal By Naomi P. Newton, MD, PGY-2
University of Miami / Jackson Health System
Introduction I have always been an “in the trenches” kind of person. While the acuity, adrenaline rush, and hands-on aspects of emergency medicine certainly hold their appeal, I love this field because it so beautifully straddles both the most dramatic and the most humbling aspects of the medical profession. Emergency medicine is messy, both literally and figuratively. We see everything, and we see it before anyone else in the hospital. We often meet patients when they are in their most vulnerable states, and we wade daily through a sea of trauma, injustice, poverty, substance use, homelessness, mental health disorders, and other complex medical and societal issues. We are constantly investigating, teaching, advocating, stabilizing and treating—all while seeking the best and most efficient disposition for our patients. However, life “on the front lines” of the healthcare system can also be physically, mentally, emotionally and even spiritually grueling, especially given the unique time constraints under which we work. Successful physicians navigate these challenges by charging toward the battlefield, armed with every weapon at their disposal. Point-of-care ultrasound, or POCUS, is one of the most versatile and advantageous tools in the emergency medicine armamentarium.
Shoulder Dislocations: The Clinical Problem I have heard some seasoned attending physicians remark that they have grown increasingly weary of the procedural aspects of emergency medicine over the course of their 42
Edited by Leila Posaw, MD, MPH
Emergency Ultrasound Faculty, Jackson Memorial Hospital
careers. They view procedures, such as shoulder reductions, as time and resource-heavy endeavors that add to the existing burden of life “in the trenches.” From a purely clinical perspective, shoulder dislocations are quite straightforward; they usually present with an obvious shoulder deformity, and they are treated with joint reduction techniques. However, in practice, the diagnosis and treatment of shoulder dislocations can be tedious and can send the emergency room workflow to a screeching halt. When a patient’s presentation is suspicious for a shoulder dislocation, one generally begins by obtaining x-rays to confirm the diagnosis and rule out concomitant fractures. After each reduction attempt, one must then obtain more films to determine whether the procedure was successful. In my bustling and often chaotic urban, public hospital, where my colleagues and I work with limited staff and resources, we often encounter delays in obtaining timely imaging—even for portable films. Delays in obtaining the initial diagnostic x-rays can worsen the patients’ muscle spasms, making any attempted reductions more difficult. Additionally, obtaining multiple x-rays for shoulder dislocations–especially if several reduction attempts are required—further consumes time, staff and medical supplies, and increases the costs associated with the emergency room visit. It also exposes patients to more radiation, which can be particularly problematic if they are pregnant, if they are children, or if they have other contraindications to irradiation. Furthermore, many shoulder reductions are performed EMpulse Fall 2021
under procedural sedation, which requires additional staff and supplies at the bedside before, during and after the procedure.
The POCUS Advantage POCUS is a wonderful weapon for more efficiently managing shoulder dislocations, even during the most tumultuous of shifts. POCUS spares the patient from radiation and provides real-time information about the success of a procedure at the bedside.
Shoulder POCUS or Traditional Radiograph? How does shoulder POCUS compare with traditional radiographs, in terms of diagnostic accuracy? Can shoulder POCUS completely replace x-rays in the diagnosis and management of shoulder dislocations, or will it miss clinically relevant, concomitant fractures, which are known to occur in about a quarter of all shoulder dislocations? Only a few small, prospective, observational studies have compared the diagnostic accuracy of POCUS and x-rays in the setting of shoulder dislocations & reductions. Although the sensitivities and specificities for diagnosing dislocations with POCUS ranged from the high 80s to 100% in nearly all the studies, the data cannot be generalized, due to both the heterogeneity of the study designs, and the level of ultrasound training among clinicians participating in the studies (ranging from POCUS-trained physicians to college students, who had completed a shoulder POCUS crash course). However, other studies
