A 50 year-old woman fell and injured her right shoulder. There is a visible deformity and palpable dislocation. She reports a history of prior shoulder dislocations and confirms that this feels the same.
What is the most appropriate next course of action?
A) Administer pain medication/sedation and reduce the shoulder
B) X-ray of the shoulder
C) CT of the shoulder
D) Sling and close follow-up with orthopedics
An x-ray is performed:
Diagnosis: anterior dislocation with fracture of the coracoid
In the olden days, it was important to justify every test you ordered. Cost, time, and resources were considered. The paradigm has shifted now to one of ensuring that nothing has been missed. It amazes me that in today’s age, the idea of getting a pre-reduction x-ray on an obviously dislocated shoulder is still an issue of debate.
There are few absolutes in medicine, but in the absence of neurovascular compromise, always obtain pre-reduction imaging studies. Sometimes fractures will present similar to dislocations. Sometimes fractures will present with dislocations. If the post-reduction film shows a fracture and there’s no pre-film to compare it to, the assumption will be that you caused the fracture. For anyone working in the ER, getting an x-ray in someone with bony pain is like the “A” in “ABCs”…
