Read the case below and attempt to answer the questions. 
Steven, a 19 year old professional basketball player, presents to the ED  with right shoulder pain and deformity after his arm was pulled backwards when he was defending another player in a basketball game 2 hours ago.

1. From the photo of Steven to the left, describe what you see?
There is obvious asymmetry between Steven’s shoulders, his right acromion and humeral head are prominent, his right arm is slightly abducted and internally rotated, and is being supported by his left hand.

2. Describe the likely mechanism of injury?
The shoulder is abducted and externally rotated when an anterior force is applied to the arm.

3. What focused physical examination would you undertake?
ALWAYS – check neurovascular status, rule out concurrent injuries (brachial plexus, vascular and cervicle)
5% of anterior dislocations are associated with axillary neuropraxia- should resolve within weeks. It will be difficult to assess deltoid function, therefore check dermatomal innervation (skin over distal deltoid) AND remember the entire brachial plexus is also at risk, not just the axillary nerve.

Apprehension Sign: patient is supine with shoulder off side of bed, abduct shoulder to 90 degrees and elbow to 90 degrees then externally rotate shoulder, positive test is facial expression of ‘apprehension’

Relocation Sign: decreased apprehension with anterior force applied on shoulder, when conducted apprehension maneuver descrived above.

Sulcus Sign: arm adducted by side, place inferior traction on elbow, if a depression occurs just below the acromion, then sulcus sign is positive.


4. What imaging would you order?
1. Xray – AP, lateral (scapular Y), axillary (if possible)
            Other views: stryker view (shows Hill-Sacks lesion), west point view (shows glenoid bone loss)

2. CT if delayed presentation, complex fracture dislocation, osteoperotic patient


5. An AP Xray was taken of Steven's right shoulder, describe it and the diagnosis.

Always start with: Patient details, date, any previous Xrays to compare to, any additional views.
AP view: Head of humerus is anterior to the glenoid and inferior to the coracoid.
Always remember to ask for lateral/other views?
Diagnosis: subcoracoid anterior dislocation.

6. What closed reduction methods could you use to relocate Steven's shoulder?
Closed Reduction manoeuvres
Ensure adequate analgesia, ideally anaesthetic involvement.
1.   Cunninghams Method: Ensure patient sits up straight during the entire maneuver. Have patients arm adducted, elbow at 90 degrees and arm in neutral position. Begin by firmly massaging trapezius muscle on affected side, beginning proximally and working towards shoulder, then deltoid and finally massage biceps muscle
2.   Kocher’s tractionless manoeuvre: Humerus adducted, elbow flexed at 90 degrees and arm in neutral position. Then externally rotate arm and humerus (keeping humerus adducted to body) then move humerus anteriorly (keeping body still) and finally internally rotate arm.

7. You have successfully reduced Steven's shoulder, what is the next step?
1.     Place in neutral brace
2.     Recheck neurovascular status
3.     Repeat Xrays
4.     Refer to fracture clinic within 1/52

8. What injuries are associated with anterior dislocations?

1.     Labral and cartilage injuries:

1. Bankart Lesion: avulsion of the anterior labrum and anterior band of the IGHL – present in 80% of patients with anterior dislocations
   
2. Humeral avulsion of the glenohumeral ligament
   
3. Glenoid labral articular defect
   
4. Anterior labral periosteal sleeve avulsion
   

2.     Fractures:

1. Hill-Sachs deformity: a compression fracture of the posterosuperior aspect of the humeral head 
   
2. Bony Bankart lesion: fracture of the anterior inferior glenoid
   
3. Greater tuberosity fracture
   
4. Lesser tuberosity fracture
   

References:
[1] Cunningham, N., Fennessey, G. (2012) Shoulderdislocation.net. Retrieved on 6 June 2015 from http://shoulderdislocation.net/anatomy/dislocated-anatomy
[2] Matthew, S., Stevenson, H. Physio-pedia. Retrieved on 6 June 2014 from http://www.physio-pedia.com/Shoulder_Dislocation#References

A classic paediatric injury which can have catastrophic consequences.

A 5 year old boy falls off a trampoline and presents with the injury shown below. What must be assessed and what are the principles of management?

Do you know any guidelines that help in decision making?

Immediate assessment and management
Is the injury open or closed? 
It is crucial to examine the motor and sensory components of the radial, ulna and median (including the anterior interosseous) nerves. In young children it is often easier to ask them to give you the thumbs up and the "OK" sign. 
Distal perfusion needs to be assessed including the presences of pulses, warmth and capillary refill
Early surgical treatment is needed for displaced fractures
Emergency surgery is necessary if the limb perfusion is impaired or skin viability is threatened. The vascular team should be informed if the limb is pulseless or cold, and reduction needs to be performed as soon as possible. Perfusion normally recovers once the fracture is reduced.
Immobilise the arm in a backslab for comfort until surgery.

Gartland classification:
Type I - Nondisplaced - anterior humeral line intersects the capitellum, an intact olecranon fossa, no medial or lateral displacement.

Type II - Partially displaced - usually fragment is extended but not completely translated with some cortical contact. The anterior humeral line does not intersect the capitellum. Some rotational displacement and tilt into varus may be present. Subdivision: 
IIa - minimally displaced, no rotation
IIb - rotational deformity

Type III - Displaced - circumferential break in the cortex with displacement of the fracture fragments. The distal fragment is generally displaced posteriorly with the metaphyseal fragment impaled into the brachialis muscle and anterior soft tissues.


Types IIb and III nearly always need reduction and fixation with K-wires.

Further Reading / Guidelines
The British Orthopaedic Association have recently brought out BOAST number 11 describing the standards of care for paediatric supracondylar fractures.

This is a 73 year old lady who fell over onto her dominant outstretched left hand. Her radiographs are shown below:

What do you assess for when reviewing the radiographs of a Colles fracture? 
What are the treatment options and what would influence your decision?

Radiographic assessment should include:
- Fracture location, displacement and angulation
- Radial height. Normal = 11mm
- Radial inclination. Normal = 22 degrees
- Articular step off. The joint surface should be congruous.
- Volar tilt. Normal = 11 degrees

Options are numerous and arguments can be made for each. There still remains little evidence of one modality over another.
1. A simple plaster of Paris can be used if the fracture is in an adequate position. This example is not and needs better reduction.
2. An attempt should always be made to reduce an acute fracture under a local block eg. haematoma block. A backslab should then be applied followed by a plaster of Paris at a later date.
3. Manipulation under anaesthesia is an option if the fracture is significantly displaced. It then needs to be held with a plaster of Paris. Often the distal fragment(s) are held in place onto the proximal bone with K-wires to prevent displacement. The wires can also be used to joystick the fragments back in to position. The wires are usually pulled out in clinic 4-6 weeks later.
4. Open reduction and internal fixation. Volar plating has become increasingly common. It allows accurate reduction of the fracture, rigid internal fixation and early mobilisation (AO principles). There are however higher risks with the surgery and metalwork.
5. External fixation is an option if the fracture is severely comminuted. It may be spanning (across the joint) or bridging (across the fracture only, which has the advantage of allowing joint mobilisation). Again K-wires can help augment the fixation.