What is the diagnosis and management for a patient with an anterior inferior shoulder dislocation, Hill-Sachs deformity of the greater tuberosity, possible displaced greater tuberosity fracture, and suspected bony Bankart fracture?

From the Guidelines

The patient with an anterior inferior shoulder dislocation and associated injuries should undergo immediate reduction in the emergency department under appropriate sedation and analgesia, followed by immobilization and further evaluation with advanced imaging as needed, prioritizing orthopedic consultation for potential surgical intervention. The presence of a Hill-Sachs deformity, possible greater tuberosity fracture, and potential bony Bankart lesion indicates significant trauma and instability, increasing the risk of recurrent dislocations 1.

Initial Management

• Immediate reduction of the dislocation in the emergency department is crucial to prevent further injury and alleviate pain.
• Sedation and analgesia should be used as necessary to facilitate a comfortable and successful reduction.
• After reduction, the shoulder should be immobilized in a sling for a period that depends on the stability achieved, typically ranging from 1 to 3 weeks.

Further Evaluation and Management

• Given the complexity of the injuries, including the possibility of a displaced greater tuberosity fracture and a bony Bankart lesion, advanced imaging such as CT without IV contrast may be necessary to characterize the fractures more clearly, especially for preoperative planning 1.
• Orthopedic consultation is essential for assessing the need for surgical intervention, as the management of these associated injuries often requires operative fixation to restore anatomy and prevent recurrent instability.
• Physical therapy will be a critical component of the rehabilitation process after the initial immobilization period, aiming to restore range of motion, strength, and function while preventing further instability.

Imaging Considerations

• The initial use of radiography is appropriate for the assessment of shoulder trauma, as it provides a quick and inexpensive evaluation for fracture and dislocation 1.
• For further evaluation of labroligamentous injuries, such as those suspected with Bankart or Hill-Sachs lesions, MRI of the shoulder without IV contrast or MR arthrography are appropriate studies 1.

Conclusion of Management Approach

The management approach should prioritize reducing morbidity, mortality, and improving the quality of life for the patient, which in this case involves prompt reduction, appropriate immobilization, advanced imaging as necessary, and orthopedic consultation for potential surgical intervention to address the complex injuries associated with the anterior inferior shoulder dislocation.

From the Research

Management of Anterior Shoulder Dislocation

The management of anterior shoulder dislocation in the emergency department involves adequate procedural sedation and analgesia. The goal is to reduce the dislocation with minimal pain and discomfort to the patient.

Sedation and Analgesia Options

Several sedation and analgesia options are available for the reduction of anterior shoulder dislocation, including:

• Diazepam plus fentanyl 2
• Midazolam plus fentanyl 2, 3, 4
• Remifentanil 3
• Dexmedetomidine 4
• Propofol 5
• Intraarticular anesthetic injection (IAA) 6
• Peripheral nerve block (PNB) 6

Comparison of Sedation and Analgesia Options

Studies have compared the efficacy and safety of these sedation and analgesia options, including:

• A randomized clinical trial comparing diazepam plus fentanyl with midazolam plus fentanyl found that diazepam plus fentanyl was superior in terms of onset of muscle relaxation, patient and physician satisfaction, and time taken to reduction 2
• A randomized clinical trial comparing remifentanil with fentanyl/midazolam found that remifentanil resulted in lower procedural time, lower failure rate, and lower pain during procedure, as well as higher patient satisfaction 3
• A randomized clinical trial comparing dexmedetomidine with midazolam-fentanyl found that dexmedetomidine provided a higher level of analgesia and quicker procedural sedation 4
• A randomized clinical trial comparing propofol with midazolam/fentanyl found that propofol was as effective as midazolam/fentanyl for reduction of anterior shoulder dislocation, but had a shorter recovery time and easier reduction 5
• A systematic review and network meta-analysis comparing IAA, PNB, and intravenous sedation (IVS) found that the three methods resulted in little to no difference in the immediate success rate of reduction and patient satisfaction, but IAA had a shorter emergency department length of stay and lower pain score 6

Key Findings

Key findings from these studies include:

• The importance of adequate procedural sedation and analgesia for the reduction of anterior shoulder dislocation
• The efficacy and safety of various sedation and analgesia options, including diazepam plus fentanyl, midazolam plus fentanyl, remifentanil, dexmedetomidine, propofol, IAA, and PNB
• The need for further research to determine the optimal sedation and analgesia strategy for the reduction of anterior shoulder dislocation.