CAUSE

• Forced abduction and external rotation of the shoulder

• Common in young adults from sports or road accidents

• Can be recurrent

APPEARANCE

• Slight abduction

• Appears square with prominent ‘ Acromion’

COMPLICATIONS

• Axillary nerve damage- Look for sensory loss over the upper lateral part of upper arm

• Damage to posterior cord of brachial plexus- Assess by testing wrist extension by the radial nerve

• Axillary artery damage- Check by palpating brachial pulse

• Fracture upper humerus- Look for it in the X-ray

MANAGEMENT

• Give morphine in severe pain

• Xray the shoulder always to avoid missing humeral head fracture

X-RAY APPEARANCE

• The humeral head is displaced medially and anteriorly with loss of contact with glenoid fossa in anteroposterior view

• Rule out humeral head fracture- in case of fracture, do not reduce. Discuss with orthopaedic surgeons beforehand

REDUCTION

• Can be done with morphine or under general anaesthesia as required

KOCHER’S MANOEUVRE

• Gentle traction is applied to the arm flexed at the elbow and then external rotation is slowly exerted

• The shoulder should lock back during external rotation. If it does not when 90 degrees is reached adduct the arm across the chest and internally rotate it

• The shoulder is felt to slip back

• If not, repeat the whole process again

• After reduction, place the arm in a sling strapped to the body or enclosed under patients clothes to prevent external rotation

• Always repeat the shoulder X-ray to make sure its back in place.

• Test for neurovascular damage as above

• Follow up this patient with fracture clinic appointment in 2 weeks time.