Shoulder Dislocations, Separations-Lessons Learned in Hospital Emergency Room.

April 27, 2013, (I Am,Forever Grateful to Jesse and Corin) while on a fishing trip on the Chilliwack, (Vedder) River, I suffered a fall, causing a dislocation and minor fracture (probably the Hill-Sach’s Lesion) of the left shoulder.

 I am not complaining about the doctors or nurses who finally treated me; they were very professional; and that treatment was excellent. I am complaining, however, about my reception at Emergency; I never was actually admitted to the Chilliwack Hospital.

One of the admitting/reception personnel; who apparently could not accept,  comprehend, or even consider, the fact that I might be in extreme pain; unable to easily reach into a back pants pocket to retrieve a wallet; virtually unable to use either arm (my injury was somewhat unusual in that I was unable to bring my left arm in toward my body, as people usually will do after suffering a dislocation, meaning that in order to be able to tolerate the pain at all, I had to support it with my right hand)was extremely obnoxious and accused me of being uncooperative. When I told her that I was presently unable to sign any papers she spoke out loudly enough for several other prospective patients to hear “I can’t get anything out of this guy, maybe one of the nurses can but he’s low priority anyway.” It took seven or eight hours, before I was examined or received treatment of any kind. The thing that is comical about all this: nothing in that wallet was later required and I never did sign any papers  all information was already on their computer system. 
What is not comical or funny-the outside of my upper arm and shoulder still feels numbed, a symptom of probable (unnecessary, had I been treated in an expedient manner) nerve damage.My clothing was all soaking wet from the rain, I mention this only because while I told hospital staff that I had suffered either a broken arm or shoulder injury due to a fall, so had obviously suffered severe trauma, was in severe pain, could quite possibly have suffered a compound fracture, could quite possibly have had severe internal or external bleeding, other unnoticed or unmentioned injuries; I was not given even a quick, cursory physical examination--nothing at all--except "observation"-- for seven or eight hours.

The most common, and probable, ways of a separated, or a dislocated, shoulder injury occurrence are through: falling onto your shoulder, especially on a hard surface, being hit in the shoulder, and  by trying to break a fall with your hand.

The two injuries are easy to confuse; but a dislocated shoulder and a separated shoulder are two separate and distinctly different injuries.
Here's the run-down.  To diagnose a separated  or dislocated shoulder, your doctor will give you a thorough exam. You may need X-rays to rule out broken bones and other conditions.

What's the Treatment for Dislocated Shoulder or Separated Shoulder?

If you strongly suspect you or someone you know has a shoulder dislocation, seek emergency care, IMMEDIATELY. There will generally be a short SHOCK PERIOD-this phenomenon occurs even in sudden death- before your body fully realizes that it has been injured. THIS SHOCK PERIOD IS THE TIME YOU MUST USE, BEFORE YOU ARE FULLY INCAPACITATED, IN ORDER TO SEEK HELP.
Further, waiting several hours before seeking treatment could result in unnecessary suffering, and further, damage, to tendons, muscles, blood vessels, and nerves.
Dislocated shoulders need to be treated right away. Your doctor will need to move the arm bone back into the shoulder socket. Since there will be internal bleeding, and bruising, the joint will get more swollen, and more painful, by the minute, the sooner the better.In my case, there was actually two types of pain. First, an over powering-what is often described as dull numbing-except that there was nothing dull about it; and then with any slight movement-a scorching, searing, flame; threatening to consume my entire body. Once the arm bone is back in the socket, some of the pain will go away- it did in my case; but then, I had also been given six milligrams of morphine during the procedure. 
After the shoulder bone is repositioned, you can use conservative treatment to reduce pain and swelling. The same treatment would also be used for a separated shoulder. The patient should see an orthopaedic doctor for a follow-up examination within a few days. Pain relieving medications may be modified and the joint examined to see that relocation has been maintained. The doctor may re-examine for injury to structures damaged by the original trauma.

People with either of these two injuries appear in the ER in an extreme amount of pain, and pain control is the first priority. The usual sequence of events begins with drugs to help with the pain, a quick exam (first responders or first-aid type)  by the doctor, followed by x-rays to make sure no bones are broken. Only then can the dislocated shoulder can be reduced. Most people prefer to be aggressively sedated for the procedure. After the shoulder is back in place and another x-ray confirms this, the patient is allowed to wake up and go home using a sling or shoulder immobilizer.

Dislocated shoulder: in this injury, a fall or blow causes the top of your arm bone to pop out of the shoulder socket. Unlike a lot of joints in your body-your elbow, for instance-the shoulder is incredibly mobile. You can twist and move your upper arm in almost any direction. But there's a price for this ease of movement. Dislocated or separated shoulders can result from a sharp twisting of the arm. The shoulder joint is inherently unstable, prone to slipping out of place; consequently, the shoulders are the most common joint in the body to dislocate. The arm is moved away from the body (abducted) and externally rotated (turning the forearm, palm side up). The joint gives way, and the humeral head, or the ball of the joint, is ripped out of the socket. The structures that hold the shoulder together are torn, including the joint capsule, cartilage, and the ligaments of the rotator cuff. Most shoulder dislocations happen at the lower front of the shoulder, because of the particular anatomy of the shoulder joint. The bones of the shoulder are the socket of the shoulder blade (scapula) and the ball at the upper end of the arm bone (humerus). The socket on the shoulder blade is fairly shallow, but a lip or rim of cartilage makes it deeper. The joint is supported on all sides by ligaments called the joint capsule, and the whole thing is covered by the rotator cuff. The rotator cuff is made up of four tendons attached to muscles that start on the scapula and end on the upper humerus. They reinforce the shoulder joint from above, in front, and in back, which makes the weakest point in the rotator cuff in the lower front.

In severe cases of dislocated shoulder, the tissue and nerves around the shoulder joint get damaged. If you keep dislocating your shoulder, you could wind up with chronic instability and weakness.

The Separated shoulder: despite the name, this injury doesn't directly affect the shoulder joint. Instead, a fall, blow, or sharp twisting of the arm; tears one of the ligaments that connects the collarbone to shoulder blade. Since it's no longer anchored, the collarbone may move out of position and push against the skin near the top of your shoulder. Although separated shoulders can cause deformity, people usually recover fully with time.

What Does a Dislocated Shoulder or Separated Shoulder Feel Like?

Symptoms of a dislocated shoulder are:

1.     The main symptoms of a shoulder dislocation are severe pain at the shoulder joint and upper arm that hurts more when the area is moved. The patient will have great difficulty moving the arm; even a little bit.

2.     Deformation of the shoulder-a bump in the front or back of the shoulder, depending on how the bone has been dislocated.

3.     If the shoulder is touched from the side, it feels mushy, as if the underlying bone is gone (usually the humeral head - top of the arm bone - is displaced below and toward the front).The deltoid muscle (the round muscle covering the shoulder joint) may appear to be flatter on the injured side when compared to the healthy side.

4.     Any movement of the arm may cause pain in the shoulder.

5.     The pulse at the wrist, touch sensation, and hand movement are usually normal. (Damage to nerves, blood vessels, ligaments, tendons, and muscles can occur. These injuries can be difficult to diagnose because you are incapacitated by the dislocation.)

6.     A set of shoulder x-rays is usually standard in diagnosing a shoulder dislocation. They are used to determine the presence of a dislocation, and also to check for other injuries (such as a fracture of the upper humerus, or tearing of the ligaments connecting the associated Injuries).

7.     A significant minority of shoulder dislocations involve an associated injury, such as fracture, tendon or ligament tear, or neurovascular injury.

8.     Fractures: occur in about 30% of cases. The most commonly seen fractures are the Hill-Sach’s Lesion (hatchet deformity); seen in 54-76% of cases, this is a compression fracture that results in the formation of a groove in the poster lateral aspect of the humeral head. It is best viewed on x-ray with internal rotation of the arm and should be looked for in all post-reduction x-rays-collarbone to the shoulder blade).

Symptoms of a separated shoulder are:

1.       Intense pain as soon as the injury occurs.

2.       Tenderness of the shoulder and collarbone.

3.       Swelling.

4.       Bruising.

5.       Deformed shoulder

First-Aid and/or home treatment for either injury; you should:

·         Ice your shoulder to reduce pain and swelling. Do it for 20-30 minutes every three to four hours, for two to three days or longer.

·         Use a sling or shoulder immobilizer to prevent further injury until you get medical treatment. Then follow the doctor's advice about whether or not to use a sling.

·         Take anti-inflammatory painkillers. Non-steroidal anti-inflammatory drugs, or NSAIDS, like Advil, Aleve, or Motrin, will help with pain and swelling. However, these drugs may have side effects, like an increased risk of bleeding and ulcers. They should be used only occasionally, unless your doctor specifically says otherwise.

·         Practice stretching and strengthening exercises if your doctor recommends them.

Most of the time, these treatments will do the trick. But in rare cases, you may need surgery. Surgery for severe separated shoulders is sometimes needed to repair the torn ligament. Afterwards, you will probably need to keep your arm in a sling for about six weeks.

For a severely dislocated shoulder, surgery is sometimes needed to correctly position the bones. If you keep dislocating your shoulder, surgery to tighten the tendons surrounding the joint may help.

When Will my Dislocated or Separated Shoulder Feel Better?

How quickly you recover depends on how serious your shoulder injury is:

·         Separated shoulders may resolve after six to eight weeks.

·          Dislocated shoulders may take longer- more like three to 12 weeks. But these are just rough estimates. Everyone heals at a different rate.

·          Some symptoms, like stiffness, may linger for a time. A separated shoulder can sometimes leave a permanent, but painless, bump on your shoulder.

·          Once the acute symptoms are gone, your doctor will probably want you to start rehabilitation. This will make your shoulder muscles stronger and more limber. It will both help you recover and reduce the chances of future shoulder injuries.

·          You might start with gentle stretching exercises that become more intense as you get better. But don't start exercising without talking to your doctor first.

·          Whatever you do, don't rush things. For young athletes; ease back into your sport. If you play baseball, start by tossing the ball and work up to throwing at full speed. People who play contact sports need to be especially careful that they are fully healed before playing again.

Don't try to return to your previous level of physical activity until:

1.       You can move your injured shoulder as freely as your uninjured shoulder.

2.       Your injured shoulder feels as strong as your uninjured shoulder.

3.       If you start using your shoulder before it's healed, you could cause permanent damage. Getting back in the game early is not worth the risk of a lifelong disability.

4.       Since the joint has been damaged and is unstable, the sling or shoulder immobilizer will need to be worn for a few weeks. At the same time, the physical therapist and orthopaedic surgeon may decide to do range of motion exercises to balance the achievement of joint stability, while minimizing the loss of function. A solid shoulder that doesn't move can limit an individual's mobility and lifestyle dramatically.

5.       Unfortunately, in young people and athletes, the re-dislocation rate is high (up to 90%), and the non-surgical approach that can work for the older person may not work as well for somebody who wants to use the arm aggressively. The conservative, non-surgical approach can take more than three months until return to full activity can be expected

Progression of treatment, further notes:
May 23, 2013: using range of motion exercises, in order to regain freedom of shoulder movement. Unable to lift and at the same time bring left my left arm across in front of my body, unless assisted with my right. Still experience considerable pain in doing so and there is still some swelling and evidence of bruising.

May 26, 2013: yesterday,which would be the 25th; was very discouraged with the way shoulder was coming along; was unable to bring elbow across in front of body and then lift it at all unassisted. Pain had also increased; to the point that decision was made to started wearing the sling again and keep the arm supported pretty well all day. Today, found that not only can   arm be lifted to about mid-chest level unassisted but the pain is again greatly diminished. Will continue to use the sling to give the arm support for the rest of the day however. Appears that real progress has been made but must be careful not to overdo it on the exercising.
June 3, 2013-still experiencing a feeling of numbness in the back of  arm and shoulder. Also feeling some deep joint pain. Still have difficulty bringing arm to a raised position in front of body and would not be able to toss a ball into the air for say a tennis serve,would not feel safe driving a vehicle,would not trust  joint or shoulder to support body weight. Continue to take 2, 500mgs, extra strength, Acetaminophen, apply Volterin rub-found to be more effective than a heat liniment- and wear sling for support after careful daily range of motion exercise.  

.© Al (Alex-Alexander) D. Girvan. All rights Reserved.