A recent study in Annals of Emergency Medicine (found on pubmed too) discusses the use of ultrasound for assessing shoulder dislocation and reduction. Yup, that’s right – no need for that Xray – unless you are concerned about a fracture. But, when you have a patient with a history of shoulder dislocation saying, “it’s out again” then dont get that Xray – before or after your reduction – just use ultrasound. It’s quick and easy and can also be used for joint injections for anestheisa too. Dr. Mike Stone showed a great video of this too – 2 docs competing to see who finishes the assessment, anesthesia and reduction the quickest – guess who won….
Diagnostic Accuracy of Ultrasonographic Examination in the Management of Shoulder Dislocation in the Emergency Department
Emergency physicians frequently encounter shoulder dislocation in their practice. The objective of this study is to assess the diagnostic accuracy of ultrasonography in detecting shoulder dislocation and confirming proper reduction in patients presenting to the emergency department (ED) with possible shoulder dislocation. We hypothesize that ultrasonography could be a reliable alternative for pre- and postradiographic evaluation of shoulder dislocation.
This was a prospective observational study. A convenience sample of patients suspected of having shoulder dislocation was enrolled in the study. Ultrasonography was performed before and after reduction procedure with a 7.5- to 10-MHz linear transducer. Shoulder dislocation was confirmed by taking radiographs in 3 routine views as a criterion standard. The operating characteristics of ultrasonography to detect dislocation in patients with possible shoulder dislocation and to confirm reduction in patients with definitive dislocation were calculated as the primary endpoints.
Seventy-three patients were enrolled. The ultrasonography did not miss any dislocation. The results of ultrasonography and radiography were identical and the sensitivity of ultrasonography in detection of shoulder dislocation was 100% (95% confidence interval 93.4% to 100%). The sensitivity of ultrasonography for assessment of complete reduction of the shoulder joint reached 100% (95% confidence interval 93.2% to 100%) in our study as well.
We suggest that ultrasonography be performed in all patients who present to the ED with a clinical impression of shoulder dislocation on admission time. The results of this study provide promising preliminary support for the ability of ultrasonography to detect shoulder dislocation. However, further investigation is necessary to validate the results and assess the ability of ultrasonography in detecting fractures associated with dislocation.
To view Dr. Mike Stone’s lecture on shoulder dislocation diagnosed by ultrasound, view below:
For another great post of shoulder shrugging – see broomedocs site here!
Quite a few recent studies on bedside ultrasound have focused on the hip, as it should, since it is so darn hard to evaluate it by the physical exam alone. Well, not only could ultrasound be used for diagnosing hip dislocations (as evidenced by the below case report), but it is also great for evaluating septic hip joints by visualizing the effusions and helping in its arthrocentesis needs …..as well as using ultrasound for ultrasound-guided fascia iliaca compartment block for hip fractures (especially in the elderly who you’d rather not give a ton of opiates to). – These are all from the Journal of EM.
The first case report discusses a 51 yr old man who was brought in the ED 20 minutes after a fall on wet grass while playing basketball (I know -good for him for staying active!). The current standard of care is to order an Xray. But, sometimes the Xray will not give you the information you need and you may go to CT, or the radiology tech is busy with traumas or other inpatient needs. In this case, the Ap Pelvis XR was normal. Well, never fear – the ultrasound is here! The diagnosis was made of an anterior hip dislocation by ultrasound. See the image below of his dislocated Right hip and normal Left hip when they used their curvilinear probe in anterior, mid-axial and coronal planes:
Another case report recently published discusses an 18 yr old female c/o 5 days of hip pain radiating down her anterior thigh and worse with weight bearing and hip movement. No fevers or other symptoms… oh, and she is 23 weeks pregnant. Now, the diagnosis of septic hips is a clinical one yet, sometimes, it can fool the best of us. I know Ive seen a patient with a septic hip walk…yes, with a limp, but still walk… saying “I think I just twisted it.” She was a bounce back to the (different) ED for persistent hip pain after an US was negative for DVT. She had mild leukocytosis (but what pregnant patient doesn’t!?!). The ED docs took a look with their ultrasound machine and saw an effusion (top picture below) (compared it to the opposite a-symptomatic hip (bottom picture below)) and then performed an ultrasound-guided arthrocentesis of purulent fluid: arrow and closed arrow is the femoral head and neck, respectively.
For a great podcast, the only way they know how to make it even more enjoyable – check out UltrasoundPodcast insert for hip ultrasund, aspiration and injection.
Now, the last study I will highlight, is one that is a more common concept/indication for hip issues – the fascia iliaca block for hip fractures. “”Hip fracture (HFx) is a painful injury that is commonly seen in the emergency department (ED). Patients who experience pain from HFx are often treated with intravenous opiates, which may cause deleterious side effects, particularly in elderly patients. An alternative to systemic opioid analgesia involves peripheral nerve blockade” - word! A small study showing a decrease in pain scale in over 75% of the patients:
In a prior post we discussed the concept of what is now one of the post popular phrases that have come to be used as a Sono-term: ‘pus-stalsis’. Yup, that’s right - the movement of pus seen with compression over the area of hypoechogenicity when using the linear probe to evaluate for fluid filled pocket that’s concerning for abscess. It can fool you! Instead of doing a needle aspiration – take a look! push down on it and see if there is pus-stalsis! It’s easy. Continue reading
A patient comes into your emergency department or outpatient clinic that has a painful red area on their skin:
-from Medicineo blog
…and you wonder whether its a superficial cellulitis, or if it’s a pus-filled abscess – and if it is an abscess, then how deep is it? how long is it? how loculated is it? Continue reading