UNLOCKING SHOULDER DISLOCATIONS

A patient presents with a recurrent anterior shoulder dislocation. Milch fails but Spaso works. The next month she is back and the procedure feels different, with more resistance. This time Spaso fails and Milch works. Same shoulder, so what is different? Why did the efficacy reverse?

 

Milch’s 1938 article started with a question: why do some reductions seem impossible and then under general anesthesia they become very easy, almost going in spontaneously? It was the muscle and tendon opposition, he concluded, so his technique focused on putting the patient in the muscle neutral position overhead (hanging from a limb position). The various shoulder muscles would share equal stress and equal angles.

 

Milch’s idea has probably not yet been fully fulfilled – it was the idea that shoulder reduction is not about overcoming force but about untangling the humeral head from the adjacent muscles, tendons, and soft-tissues. That was the same idea that inspired Kocher.

 

We have all had the tough shoulder that would not go in with technique A, but after trying technique B, a second attempt with A yielded an effortless reduction. There seems to be an unlocking of the soft structures that occurs.

 

Now as to the unlocking. I suspect there is advantage in the difficult shoulder to running through a variety of techniques. Ideally we would know which soft structures are causing the locking, but the literature lacks consensus and I do not know to resolve that. So I run though a variety of techniques.

 

This is reductionistic but you can think of all techniques as the application of external rotation in different positions.

 

Kocher is external rotation in the adducted humerus, as are all the derivative techniques.

 

Milch is external rotation in the abducted elevated humerus (technically he advocated doing the external rotation on the way up).

 

Spaso is external rotation in the forward flexed shoulder.

 

Back to the bedside. Its your next shoulder attempt. The shoulder is locked in internal rotation. Your goal is to get it into external rotation. You try Kocher but there is too much resistance to external rotation. You laterally abduct to Milch and you came close but did not fully reduce the shoulder. Finally, you perform forward flexion (Spaso) which also does not work. You then go back to Kocher, which this time was successful.

 

Take Home Points:

-The obstruction to shoulder reduction is not bone position but soft structures

-The obstruction can apparently be unlocked through applying external rotation in various positions through the range of motion

-If your favorite technique does not work, range the shoulder, externally rotate, and try it again.


Check out medicalclassics.com for more on Milch. If the link does not work, here is the location.  https://medicalclassics.com/2016/09/05/1938-milchs-shoulder-reduction-techniqueabduction-external-rotation-and-pulsion/

 

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KOCHER INTENDED FOR SUBCORACOID DISLOCATIONS, NOT SUBGLENOID

The Kocher technique, one of the oldest and most popular techniques, was developed for the subcoracoid anterior dislocation. Review Neil Cunningham’s resources at shoulderdislocation.net for insight on this, as well as his translation of the original Kocher article.

 

The goal of Kocher’s method, which was worked out on cadavers in 1870, is to roll the greater trochanter of the humeral head on the glenoid rim. It might have been named the “shoulder rim roll.” Here are the steps:

 

1) Adduct the elbow all the way to get the greater trochanter right next to the glenoid rim.

2) Externally rotate to roll the greater trochanter on the glenoid rim.

3) Forward flex the shoulder (sagittal plane) to tip the humeral head back toward the socket.

4) Internally rotate to complete the reduction.

 

Kocher’s words:

“Pressing the arm bent at the elbow towards the body, turning outward until resistance is felt, lifting of the outwardly rotated upper arm in the sagittal plane as far as possible, and finally slowly turning it inward” (translation by Cunningham)

 

DON’T USE THE SHOULDER RIM ROLL IF YOU AREN’T ROLLING ON THE RIM

The subglenoid dislocation will not be resolved with the Kocher technique because the external rotation phase will not latch onto anything. Kocher himself in his article specified that this was for subcoracoid dislocations, and said “the more therefore the head has departed from the coracoid process toward the interior … the less can be expected from the method.”

 

PITFALLS

-Make sure you fully adduct the elbow first.

-Avoid traction, which is what creates the need for sedation(Chitgopar Injury 2005).

-Avoid sedation. This is the best way to avoid too much force. Kocher’s method excluded the use of force. Perpendicular forces of opposing muscles can lead to fracture. If you get resistance, use another technique.

 

TAKE HOME POINTS:

-Kocher’s shoulder reduction was originally intended for subcoracoid dislocations, not for subglenoid.

-Do not use force with Kocher’s method.

 

References:

shoulderdislocation.net (see the lectures and translation of the original Kocher article)

Chitgopkar SD, Khan M. Painless reduction of anterior shoulder dislocation by Kocher’s method. Injury. 2005;36:1182-4.

LISFRANC JOINT INJURIES: PALPATE AND TWIST

We think of the foot as a simple thing but it actually comprises one fourth of all the bones of the body, with 26 overall. Although some stability comes from the arch structure (the Roman arches did not require mortar) most of the stability of the foot is ligamentous.

It therefore should not be surprising that diagnosing foot injury and predicting complications is difficult. Ligaments are essentially invisible on xray. Weight-bearing radiographs, recommended by the American College of Radiology, are difficult to order on emergency department patients in acute pain and MRI is usually not available. Thus, some of these patients will not be diagnosable by us but we can protect these patients through clinical suspicion and follow-up.

After negative xrays. acute traumatic midfoot pain is usually a ligament injury of one sort or another. If stable, it will likely heal. If it is a third degree injury and unstable, it may require surgery.

The Lisfranc joint is eponymous for Jacques Lisfranc who treated a Napoleonic soldier who had fallen off his horse with his foot caught in the stirrup. Ultimately the patient developed gangrene and required amputation at what became known as the Lisfranc joint complex (tarsometatarsal joints).

Today we hear about injuries in the news if you watch football, especially in defensive linemen who pivot on the toes, stressing the tarsometatarsal joints. As they twist in this equinus position to get around the offensive tackle, the Lisfranc joint can rupture.

There are not sufficient studies on physical diagnosis of the Lisfranc joint but the review articles tend to recommend stressing the midfoot with lateral and medial stress, abduction and pronation, etc. If you have trouble remembering all the Latin words, just do what you do with stress testing of any orthopedic limb – check it in the x, y, and z axes.

Take Home Points:

Recognize midfoot pain as a potentially ligamentous injury

Palpate the tarsometarsal joints

Stress the tarsoemetarsal joints in the X, Y, and Z planes, if the patient allows

PHYSICAL DIAGNOSIS OF OCCULT HIP FRACTURES

An elderly female presents after a fall. You were concerned about hip fracture but the x-rays were negative. You go back to examine her and she is able bear weight but she has a very slow and antalgic gait. You order a CT scan of the hip and this also comes back normal. You go back to examine her wondering whether you can use physical diagnosis to exclude a fracture.

LIMITATIONS OF ADJUNCTIVE TESTING

X-rays are only 90% sensitive for fractures, and CT has well-known limitations, though its sensitivity is not as well-described (Cannon J JEM 2009).  MRI is currently considered the gold standard, but is less available in the ED for this condition.

PHYSICAL DIAGNOSIS OF HIP FRACTURE

Physical examination techniques for discovering an occult hip fracture include slow and gentle palpation to isolate the area of maximal tenderness. Internal and external rotation isolate hip joint movement. Ambulation is essentially a stress test of the hip, performed when the patient does well on the other tests. These tests have not been studied in an undifferentiated ED population with hip pain after a fall.

In any limb I suspect of having a fracture I try to hold the limb at non-painful areas above and below and then apply stresses in the X, Y, and Z planes (twisting, back and forth, and side to side). Exacerbation of pain suggests a fracture.

LIMITATIONS OF PHYSICAL DIAGNOSIS

Being good at physical diagnosis doesn’t mean using it to get the answer. Sometimes it means knowing it isn’t capable of giving you the answer.

If an elderly patient has persistent hip pain after a fall and negative x-rays, it might be a fracture. Period. This does not mean they all need admission to the hospital, but whatever plan is arranged must take this fact into account.

Can the patient still bear weight? So could 7/26 patients found to have an occult hip fracture in a retrospective study (Hossain Injury 2007). Does the patient have no pain with passive rotation of the hip? This is true of 10/26 patients with occult hip fracture. Can the patient perform a straight leg raise? So could 13/26. How about axial loading? 7/26 had no pain with this.

The patient with hip pain who is unable to walk usually is admitted for MRI the next day. But even the patient who CAN walk might still have a fracture. If discharge is chosen, the patient should be informed of this possibility, given crutches, and told to follow-up within a few days with the primary physician for reevaluation. If the patient is better, no MRI is needed. If the patient is still having significant pain, MRI is indicated.

The patient was discharged home. The hospitalist felt that she did not require admission for MRI because she was able to walk and had negative xrays and CT. The MRI was not done. A week after discharge from the ED she took a normal step and her femoral neck gave way to a displaced fracture.

Take home points:

-Even if the patient with hip pain can walk, he or she may have a fracture. Close follow-up is needed for elderly patients with persistent hip pain after a fall. Non-weight bearing status should be considered in selected patients.

LUMBAR SPINE NEUROLOGICAL EXAMINATION TEMPLATE

The neurological examination is relative to the pathology you are investigating. This should not be used in a cut and paste fashion but rather for reference.

 

MOTOR

Hip flexion “pull your knee to your chest” (L2/3) 5/5

Hip adduction “pull your knees into each other” (L2/3) 5/5

Hip abduction “pull your knees apart” (L4/5/S1) 5/5

Hip extension “pull your thigh back” (L4/5) 5/5

Knee extension “hold your knee straight” (L3/4) 5/5

Knee flexion “pull your heel to your bottom” (L5/S1) 5/5

Ankle dorsiflexion “pull your foot up” (L4/5) 5/5

Ankle plantarflexion “step on the gas” (S1/S2) 5/5

Great toe dorsiflexion “pull your big toe up” (L5) 5/5

Great toe plantarflexion “squeeze your big tow down” (S1,S2) 5/5

Anal tone – (S2/3/4) 5/5

 

SENSORY

Light touch (pinprick vs ice vs proprioception vs vibration if evidence of pathology found)

L1 – inguinal ligament

L2 – medial thigh

L3 – distal thigh

L4 – medial leg and dorsal foot

L5 – 1st web space, lateral foot

S1 – plantar foot

S2 – popliteal fossa, posterior thigh

S3/4/5 – perianal area

 

REFLEXES

 

Patellar – L3/4

Medial hamstring reflex L5

Ankle – S1

TWIST AND SHOUT – DIAGNOSING OCCULT TODDLER’S FRACTURE

A 2 year old presents with leg pain and a limp after slipping on a “slip and slide” water toy slide. X-rays are negative. The child will step when asked but will not walk on his own. Is this an occult fracture?

This is a situation where the reference standard, radiography, has limitations in sensitivity. Studies show that using alternative tests reveal evidence of fracture, such as hematoma elevation on ultrasound (Lewis J Clin Ultrasound 2006) or MRI or delayed radiographs.

You go back and examine the leg, placing “bowing” stress on the leg. Sometimes it elicits pain and sometimes it does not. You press on different parts of the leg and it is difficult to localize but there does seem to be the most pain on the distal tibia.

You then twist the leg and foot spirally and the child shouts in pain. You make a clinical diagnosis of Toddler’s fracture. On follow-up, the mother reports that the child reverted to crawling for about 4 weeks before gingerly walking and then returning to normal use of the leg in about 6 weeks. Repeat xrays in the primary physician’s office remained negative. This was an occult tibial fracture.

Take Home Points

Negative x-rays do not rule out fracture

Twisting a long-bone can elicit pain from an occult fracture, especially one in a spiral pattern

HAND LACERATION: TEST RESISTED RANGE OF MOTION

A patient presents with a laceration to the flexor side of her left forefinger. The student tells you function was normal.

“How did you determine that?” you ask.

“Range of motion.”

You ask the patient to repeat the range of motion test, but this time you apply active resistance and simultaneously check the opposite side for comparison. There is significant weakness on the left compared to the right. You just discovered a partial tendon laceration and prevented an easy misdiagnosis.

Range of motion is not sufficient to rule out a partial tendon laceration. Strength testing picks up partial lacerations because some of the muscle fibers were connected to the part of the tendon that was lacerated. You can’t always visualize the laceration so this strength testing a useful part of the examination.

There are some interesting articles about this that indicate range of motion can not even be used to rule out a complete tendon laceration. A patient had complete transection of the FDS and FDP yet intact range of motion via the vincula (connections between tendons). Resisted range of motion made the diagnosis (Sasaki J Hand Surg Br 1987)

Take Home Points:

-For suspected tendon laceration, don’t just test range of motion, test resisted range of motion

GAIT ASSESSMENT: WALK THE WALK  

A mother brings her 2 year old child in for a limp. The student believes the patient has ankle pain because she cried when she grabbed the ankle. After that she cried with everything. After calming the child down you watch her walk and it is abnormal but you wonder how to interpret this.

 

The last time I tried really hard to analyze gait and make recommendations, it was so complicated that no one could remember it. I now have a more simple approach. An abnormal gait is either neurologic or orthopedic. If there is pain, it tends to be orthopedic. No pain suggests neurologic.

 

Next, don’t just watch the gait. Imitate it. Follow the child. This allows your proprioceptive neurons to do the thinking for you.

 

When you do that on this child you see she is splinting her hip. You examine the calmed child and get good range of motion of the ankle and knee. Internal and external rotation of the hip seems to cause discomfort. Now your differential is transient synovitis vs septic arthritis and you proceed from there.

 

Take Home Points:

Painful gait abnormalities are usually orthopedic. Painless are usually neurologic.

Walk the walk: imitate the gait so you can feel what they are doing with their gait

SCAPHOID FRACTURE: CHECK BOTH SIDES, LOCALIZE IT

A patient presents with wrist pain after a fall. X-rays are negative. You palpate the snuffbox and there is mild tenderness.  One dominant current practice is to apply a thumb spica splint in all such cases but you suspect this causes too many patients to be immobilized. Can the physical examination help?

 

There actually have been a large number of studies on this, with one study reviewing 18 separate clinical signs and keeping 7.(Steenvorde 2006) For the sake of consistency though, the examination of this bone for a fracture can be thought of in the same way we examine any other bone for a fracture.

 

First, have the patient point to the area of maximal pain. Are they pointing at the scaphoid?

 

Second, remember that this bone has multiple sides. Don’t just palpate the snuffbox. You can feel the scaphoid tubercle on the volar side at the base of the thumb metacarpal. Palpation is 87% sensitive and 57% specific for a fracture, which generates a better likelihood ratio than snuffbox tenderness, which is only 40% specific.(Steenvorde 2006)

 

Because this bone is superficial, feel for any swelling. If you find snuffbox swelling with a “fall on outstretched hand” mechanism, fracture is the only pathology that plausibly accounts for the finding, if it is isolated. Swelling is found in 61% of scaphoid fractures.

 

Finally, stress testing can be helpful in the fracture examination. Axial compression, resisted supination, and ulnar deviation can all be signs of a fracture if they isolate pain to the area of the scaphoid. False positive will occur with other injuries so we are not just looking for pain, but localizing scaphoid pain.

 

Take Home Points:

-Have the patient point to the maximally painful area

-Palpate the scaphoid tubercle in addition to the snuffbox for suspected scaphoid fractures

-Check for swelling in the snuffbox

-Provide axial, supination, and ulnar deviation stress tests

HIP REDUCTION: LATERAL APPROACH USES GRAVITY TO HELP

[Although technically not physical diagnosis, some bedside procedures rely on discerning anatomical and physiological clues at the bedside, and thus are bedside skills]

A patient presents after a hip injury with a right lower extremity that is flexed, adducted, and internally rotated. You suspect hip dislocation and confirm it quickly with x-rays. You attempt reduction with the traditional Allis technique and this is not successful, nor was the Captain Morgan and Whistler techniques.

You want to use gravity to help you and considered the Stimson technique of placing the patient prone and placing your knee behind the patient’s knee for force. But the patient is morbidly obese and you are concerned about sedating a high risk patient in a prone position. Are there any other techniques that recruit gravity to assist in reduction?

One of the problems with hip reduction is that most of the current techniques involve pulling longitudinally on the femur, but the joint is oriented almost perpendicularly to that. Thus, one must generate considerably more force in order to effect reduction. The femoral head often catches behind the rim of the acetabulum and can not make it over. I suspect that one day we will have many “finesse” procedures for the hip as we do for the shoulder.

Another option is the lateral technique. It does not have the good marketing name of the “Captain Morgan” technique, and its eponymous name would have been Skoff (Orthopedic Review 1986). It does not get a lot of attention but it seems to deserve more study. Lay the patient on the side, flex the affected hip, gravity will adduct it, and you internally rotate it. Somewhat like the Kocher technique for the shoulder, you are trying to roll that joint head over the rim.

You try this technique with success. We wait for emergency medicine literature to answer remaining questions about the comparative efficacy of current techniques.

Take Home Points:

-Hip reduction is difficult because the muscles are strong and traditional techniques apply forces at an almost perpendicular angle (as well as against gravity).

-In the absence of good emergency medicine studies, do consider prone or lateral positioning for the reasons stated above.