case 3 (Full Version)

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Dr.Wagner -> case 3 (July 21, 2007 1:42:41 PM)

A 35 year old weekend warrior is playing football with friends.  He is tackled by 3 guys at midfield.  Upon rising, he notes he has severe shoulder pain, so profound it is hard for him to take a deep breath.  He has a large area of ecchymosis on his shoulder.


What would you like to know and what would you like to do? 

(2-3 questions per post)



jma -> RE: case 3 (July 21, 2007 2:00:55 PM)

1. Upon observation, does his shoulder look out of place in the socket (provided that he wasn't wearing pads)?
2. Did he fall on his shoulder with the other guys on top of him?




Dr.Wagner -> RE: case 3 (July 22, 2007 8:40:33 PM)

Shoulder appearance after tackled by 2 guys.



[image]local://2287/293D4AFE44024E66B0EF405B82E312AA.jpg[/image]



jma -> RE: case 3 (July 22, 2007 9:47:57 PM)

1. Were there any x-rays taken and did it show a fracture?
2. Any anterior chest x-rays done, especially in the pec area?



Shill -> RE: case 3 (July 23, 2007 8:26:02 AM)

Gotta be a humeral fx and/or dislocation, to bring about ecchymosis upon rising.  Also, it is nice to see that your ED has an excellent supply of video and music for the viewing and listening pleasure of the patients and staff. 



Dr.Wagner -> RE: case 3 (July 23, 2007 9:10:58 AM)

disclaimer: the picture is not the patient, but similar.



Ok so what is your next move?



FLAOrthoPT -> RE: case 3 (July 23, 2007 11:00:41 AM)

If someone says hard to breath, first thing:
1)Listen to lungs
2)check O2 sats
3)then X-Rays: shoulder, and chest
4)Do clinical eval pending: Check palpation, observation of Clav., AC jt, Glenohumeral functioning if X-ray negative.  If negative check AROM vs PROM to rule in or out joint involvement, MMT of RTC, deltoid and pecs to see if any sig muscle tears, Assess ribs. 



hmgross -> RE: case 3 (July 23, 2007 7:10:35 PM)

1.  Any pain inhaling/exhaling or bruising other than the arm?
2.  How much active motion in the shoulder?
3. Exact mechanism of shoulder injury--was he hit from the back/front/side then fell on his arm?



eam -> RE: case 3 (July 24, 2007 8:59:37 AM)

1. check lungs, x-ray , ribs
2.  Can he move his arm at all?
3.  X-ray -Cervical Spine? Did he fall on his head also?  Was he wearing a helmet? 
Erica



Shill -> RE: case 3 (July 24, 2007 9:14:36 AM)

I would add to the above excellent suggestions to check SC joint for a posterior dislocation.  I have actually seen one of these once, where the man did have pressure with trying to breathe.  He ended up needing a proximal clavicle resection, and did wonderfully.



Dr.Wagner -> RE: case 3 (July 24, 2007 11:19:12 AM)

O2 sat is 95%, patient is acutely tender over the shoulder, there is no clear deformity.  Flexion and abduction is very painful and is limited to 30 degrees each.


[image]local://2287/7246043F4B484DF1BCC7F124136AF8A7.jpg[/image]



Dr.Wagner -> RE: case 3 (July 24, 2007 11:19:51 AM)

film 2


[image]local://2287/E9EE2AFCB9A04EDD9159978906B0F3E0.jpg[/image]



Dr.Wagner -> RE: case 3 (July 24, 2007 11:21:53 AM)

picture 3

do not read any attachments you  dirty cheaters.


[image]local://2287/D70C3558D0A141908FF2CA5C7691B4F1.gif[/image]



Tom Reeves DPT ATC -> RE: case 3 (July 24, 2007 1:53:13 PM)

looks like a dislocation with avulsion off of the coracoid process and deltoid tubercle. or else he has snaps in weird places, maybe a sling or something.  I don't see the white spots in any but the first view.



jma -> RE: case 3 (July 24, 2007 2:07:36 PM)

What kind of view is film 2 please?



Dr.Wagner -> RE: case 3 (July 24, 2007 2:50:15 PM)

Film 2 is a Scapular Y



orthotherapist -> RE: case 3 (July 24, 2007 4:27:24 PM)

posterior dislocation



Chocco -> RE: case 3 (July 24, 2007 6:36:05 PM)

Is there a  high rib fx, maybe 2nd, that could be compromising pulmonary or vascular tissue below it.



SJBird55 -> RE: case 3 (July 24, 2007 7:07:46 PM)

Picture 3 indicates pneumothorax also.



jma -> RE: case 3 (July 24, 2007 8:59:30 PM)

Wow, air in the pleural space on the right side? Are their diminished breath sounds near the involved site? A collapsed lung as well? Perhaps maybe due to a rib fracture? Can't see anything in the flims clearly.



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