The Daily Differential — Wednesday, May 13, 2026

2 of 4

Shoulder Dislocations

Shoulder dislocation is the most common major joint dislocation in the ED, and delayed reduction increases pain, spasm, neurovascular risk, and reduction...

At the Bedside

Types
Anterior: most common; arm held abducted/external rotation, squared-off shoulder, humeral head anterior/inferior.
Posterior: classically after seizure/electrocution; arm adducted/internal rotation, cannot externally rotate.
Inferior/luxatio erecta: arm locked overhead; high neurovascular injury risk.
Key exam
Inspect contour, humeral head position.
Palpate clavicle, AC joint, proximal humerus, scapula.
Document axillary nerve: sensation over lateral deltoid/regimental badge area; deltoid contraction if tolerated.
Check radial/ulnar pulses, cap refill, motor/sensory median-radial-ulnar nerves.
Imaging
Obtain shoulder x-rays: AP, scapular Y, axillary view if possible.
Pre-reduction x-ray is generally recommended, especially first-time dislocation, trauma, age >40, focal bony tenderness, or concern for fracture.
Post-reduction x-ray confirms reduction and evaluates fractures.
Posterior dislocation clues: “lightbulb sign,” widened joint space, reverse Hill-Sachs; axillary view is key.
Analgesia/reduction options
Start early analgesia; reduce as soon as safe.
Options:
Intra-articular lidocaine: effective, avoids procedural sedation in many anterior dislocations.
Procedural sedation: useful for severe spasm, failed attempts, anxious patients, complex dislocations.
Regional anesthesia if available: interscalene/supraclavicular blocks by trained clinicians.
Reduction techniques:
Scapular manipulation.
External rotation/Hennepin.
Milch technique.
Cunningham.
Stimson prone hanging weight.
Traction-countertraction.
FARES.
Use gentle technique; avoid forceful maneuvers, especially in elderly or fracture risk.
Post-reduction care
Recheck/document neurovascular exam.
Sling/shoulder immobilizer.
Early ortho follow-up, especially first-time dislocation, fracture, neurologic deficit, recurrent instability, athlete, or young patient.
Disposition
Discharge if successfully reduced, pain controlled, neurovascularly intact, no significant fracture.
Urgent ortho/ED reduction under deeper sedation or OR if irreducible, open dislocation, vascular injury, fracture-dislocation, persistent neuro deficit, or luxatio erecta with complications.

A Classic Presentation

A 22-year-old male falls while playing flag football and presents holding his arm slightly abducted and externally rotated with a squared-off shoulder. He has decreased sensation over the lateral deltoid but intact pulses and hand motor function. X-ray shows anterior inferior glenohumeral dislocation without fracture. After intra-articular lidocaine and fentanyl, scapular manipulation successfully reduces the shoulder. Post-reduction x-ray confirms alignment, axillary sensation improves, and he is discharged in a sling with ortho follow-up.

Study Directive

Watch videos of scapular manipulation, external rotation, Milch, and Cunningham; know one low-force technique well.
Draw the x-ray findings of anterior vs posterior dislocation from memory.
Practice a shoulder post-reduction script: neurovascular reassessment, x-ray, sling, precautions, ortho follow-up.

Key Medications

Intra-articular lidocaine: 10–20 mL of 1% lidocaine injected into glenohumeral joint; max plain lidocaine 4.5 mg/kg. Technique and dose vary—check institutional protocol if unfamiliar.
Fentanyl: 0.5–1 mcg/kg IV, repeat cautiously.
Morphine: 0.05–0.1 mg/kg IV; titrate to effect.
Ketorolac: 15 mg IV/IM commonly used.
Propofol procedural sedation: commonly 0.5–1 mg/kg IV initial bolus, then 0.25–0.5 mg/kg increments; dosing varies with age/comorbidities—use institutional sedation protocol.
Etomidate: 0.1–0.15 mg/kg IV for short sedation; check local protocol.
Ketamine: 0.5–1 mg/kg IV for sedation/analgesia; dissociation often 1–2 mg/kg IV. Dose depends on goal—check sedation protocol.
Pediatrics: reduction and sedation dosing are weight-based and protocol-driven.

High-Yield Pearls

Test the axillary nerve before and after reduction; injury may be from the dislocation, not the reduction.
Posterior dislocations are commonly missed without an axillary or scapular Y view.
First-time young anterior dislocators have high recurrence risk; older patients have higher associated rotator cuff/fracture risk.

Board Question

A patient has a shoulder dislocation after a seizure. The arm is held adducted and internally rotated, and he cannot externally rotate the shoulder. AP x-ray shows a “lightbulb” humeral head. What is the diagnosis?

AAnterior shoulder dislocation
BPosterior shoulder dislocation
CAC joint separation
DProximal humerus fracture

Reveal answer

Correct: B

Posterior shoulder dislocation is classically associated with seizure or electrocution. The arm is internally rotated/adducted, external rotation is limited, and AP x-ray may show a lightbulb sign.

Recent Literature

Review or guideline First-time traumatic anterior shoulder dislocation: current concepts
J ISAKOS, 2023 · cited 30×

Full text · open access
Recent clinical Pre-operative methicillin-resistant Staphylococcus aureus colonization increases the risk of 90-day medical and 2-year implant-related complications following primary total shoulder arthroplasty: a propensity-matched analysis
J Shoulder Elb Arthroplast, 2026

Full text · open access

3 of 4

Shoulder Injuries

“Shoulder pain after trauma” includes fractures, ligament injuries, tendon ruptures, sternoclavicular injuries, and neurovascular threats—not just...

At the Bedside

History
Mechanism: fall onto outstretched hand, direct lateral blow, seizure/electrocution, traction injury, high-energy MVC.
Dominant arm, occupation/athlete status, prior dislocations/surgery.
Red flags: neurologic symptoms, vascular symptoms, chest pain/dyspnea/dysphagia after SC injury.
Exam
Inspect clavicle, AC joint, shoulder contour, scapula.
Palpate: sternoclavicular joint, clavicle, AC joint, coracoid, proximal humerus, scapular spine.
ROM:
Active and passive ROM limitation suggests fracture/dislocation/severe pain.
Weakness with preserved passive ROM suggests rotator cuff injury.
Neurovascular:
Axillary nerve, brachial plexus screen, radial pulse, cap refill.
Common injuries
Clavicle fracture: midshaft most common; sling, analgesia. Ortho urgently for open fracture, skin tenting, neurovascular compromise, floating shoulder, markedly displaced/comminuted distal fractures.
AC separation: direct fall onto shoulder. Pain over AC joint; x-ray may show elevated distal clavicle. Type I–II sling/NSAIDs; higher grades ortho.
SC dislocation: anterior usually less dangerous; posterior is emergency due to mediastinal compression. Symptoms may include dyspnea, dysphagia, hoarseness, venous congestion. CT/CTA and ortho/thoracic surgery.
Proximal humerus fracture: older patients after fall; assess axillary nerve. Sling for minimally displaced; ortho for displaced multi-part, fracture-dislocation, neurovascular injury.
Scapular fracture: high-energy trauma; look for thoracic injuries, rib fractures, pneumothorax. CT often needed.
Rotator cuff tear: pain/weakness with abduction or external rotation; older patient after fall or younger after forceful injury. Sling briefly, analgesia, early ortho/sports follow-up if acute full-thickness suspected.
Biceps tendon rupture: “Popeye” deformity, ecchymosis, weakness supination; outpatient ortho depending age/function.
Labral injury: clicking/catching/instability, often sports-related; outpatient ortho/MRI if persistent.
Imaging
Shoulder series: AP internal/external rotation, scapular Y, axillary view.
Clavicle x-rays for clavicular tenderness.
AC views may help; weighted views are less commonly needed acutely.
CT for complex fractures, scapula, suspected posterior SC dislocation, unclear x-rays.
Ultrasound can identify rotator cuff tears in skilled hands but not usually definitive ED test.
Management
Analgesia, ice, sling/immobilizer.
Avoid prolonged immobilization in older patients to prevent adhesive capsulitis unless fracture/dislocation requires it.
Early ROM instructions when appropriate.
Tetanus/antibiotics for open injuries.
Disposition
Discharge: stable, closed, neurovascularly intact, pain controlled, appropriate immobilization/follow-up.
Urgent ortho: open fracture, neurovascular compromise, fracture-dislocation, posterior SC dislocation, skin tenting, compartment syndrome concern, unreduced dislocation, high-grade AC separation in selected patients.

A Classic Presentation

A 67-year-old woman falls onto her outstretched hand and has severe shoulder pain with inability to actively abduct. The shoulder contour is preserved, but she has proximal humerus tenderness and mild decreased sensation over the lateral deltoid. X-rays show a minimally displaced surgical neck fracture of the humerus. Pulses are intact. She receives analgesia, is placed in a sling, given pendulum exercise precautions when cleared, and discharged with urgent orthopedic follow-up.

Study Directive

Build a shoulder trauma checklist: clavicle → AC → SC → humeral head/neck → scapula → neurovascular.
Review Rockwood AC types and Neer proximal humerus fracture principles.
Practice interpreting shoulder x-rays using AP, scapular Y, and axillary views.

Key Medications

Acetaminophen: 1,000 mg PO/IV once; max 3,000–4,000 mg/day depending patient factors.
Ibuprofen: 400–600 mg PO q6–8h PRN.
Naproxen: 250–500 mg PO BID PRN.
Ketorolac: 15 mg IV/IM once commonly used in ED.
Oxycodone: 5 mg PO q4–6h PRN severe pain; use short course if necessary.
Hydromorphone: 0.2–0.5 mg IV increments for severe pain; titrate carefully.
Open fracture antibiotics:
- Cefazolin: 2 g IV; 3 g IV if >120 kg.
- Add broader coverage depending contamination/institutional protocol—check reference if uncertain.
Tdap: 0.5 mL IM if indicated.

High-Yield Pearls

Posterior SC dislocation is a mediastinal injury until proven otherwise.
Weak active abduction with preserved passive ROM after trauma suggests rotator cuff tear, not just “shoulder strain.”
Scapular fractures usually require high-energy trauma evaluation—look for chest injuries.

Board Question

A 19-year-old football player is hit directly over the medial clavicle. He has pain at the sternoclavicular joint, dyspnea, dysphagia, and venous congestion of the neck. What is the most appropriate next step?

ASling and outpatient orthopedic follow-up
BBedside closed reduction without imaging
CCT angiography and urgent orthopedic/thoracic surgery consultation
DWeighted clavicle radiographs only

Reveal answer

Correct: C

Posterior sternoclavicular dislocation can compress mediastinal structures and is a true emergency. CT/CTA defines the injury and vascular involvement; reduction should occur with appropriate surgical backup.

Recent Literature

Review or guideline Risk Factors of Overuse Shoulder Injuries in Overhead Athletes: A Systematic Review
Sports Health, 2020 · cited 167×

Full text · open access
Recent clinical Upper extremity lacrosse injuries presenting to United States emergency departments - 10 year review
JSES Rev Rep Tech, 2026

Full text · open access

4 of 4

Splinting

Good splinting reduces pain, limits soft-tissue injury, protects neurovascular structures, and prevents fracture displacement. Bad splinting causes pressure...

At the Bedside

Before splinting
Identify injury pattern and required immobilization.
Remove jewelry/watches.
Inspect skin and wounds.
Document neurovascular status: pulses, cap refill, sensation, motor function.
Reduce gross deformity/dislocation when indicated before splinting unless contraindicated.
Provide adequate analgesia.
Core principles
Splints should immobilize the injured bone/joint plus adjacent joint(s) when appropriate.
Use padding generously, especially over bony prominences.
Avoid circumferential constriction with acute swelling.
Mold splint with palms, not fingertips, to avoid pressure points.
Maintain functional position when possible.
Recheck neurovascular status after placement.
Common ED splints
Volar wrist splint: wrist/hand soft tissue injuries, distal radius buckle/minor fractures.
Sugar-tong forearm splint: distal radius/ulna fractures; limits pronation/supination.
Thumb spica: scaphoid fracture/suspected scaphoid injury, thumb UCL injury.
Ulnar gutter: 4th/5th metacarpal or phalanx fractures; MCP flexed ~70–90°.
Radial gutter: 2nd/3rd metacarpal or phalanx fractures.
Posterior long arm: elbow fractures/dislocations, distal humerus, proximal forearm.
Posterior short leg: ankle fractures, foot fractures, Achilles injury.
Stirrup ankle splint: ankle injuries; controls inversion/eversion.
Posterior short leg + stirrup: unstable ankle fractures.
Knee immobilizer: patellar fracture, knee dislocation post-reduction, extensor mechanism injury.
Long leg splint: tib/fib fractures, unstable knee injuries.
Sling/shoulder immobilizer: clavicle, proximal humerus, shoulder dislocation post-reduction.
Special positions
Intrinsic-plus hand position: wrist 20–30° extension, MCP 70–90° flexion, IP joints extended, thumb abducted.
Scaphoid: thumb spica; include thumb MCP, wrist slight extension/radial deviation depending local practice.
Achilles rupture: posterior splint in plantarflexion/equinus.
Ankle fracture: neutral dorsiflexion if tolerated, unless reduction position dictates otherwise.
After splinting
Reassess pain, skin, cap refill, pulses, sensation, motor function.
Give instructions:
Elevate.
Keep dry.
Do not insert objects.
Return immediately for worsening pain, numbness, weakness, blue/pale digits, excessive swelling, foul odor, fever, or tightness.
Disposition
Splint and discharge if stable, closed injury, neurovascularly intact, pain controlled, reliable follow-up.
Ortho consult/admit for open fracture, neurovascular compromise, compartment syndrome concern, unstable fracture/dislocation, failed reduction, septic joint/tenosynovitis, or unreliable follow-up with high-risk injury.

A Classic Presentation

A 28-year-old punches a wall and has pain/swelling over the 5th metacarpal neck. X-ray shows a boxer’s fracture with acceptable angulation and no rotational deformity. After analgesia, you place an ulnar gutter splint with the wrist slightly extended and MCP joints flexed, check post-splint cap refill/sensation/motor function, and discharge with hand follow-up and return precautions.

Study Directive

Practice placing: thumb spica, ulnar gutter, sugar-tong, posterior short leg + stirrup.
Memorize which splint goes with which injury using flashcards.
Create a post-splint checklist: skin, padding, position, neurovascular exam, patient instructions, follow-up.

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Mechanism Pearl of the Day: Today’s topics all center on preventing secondary injury from swelling and mechanical compression. Rings, dislocations, fractures, and splints can all compromise venous outflow first, then arterial inflow and nerve function—so repeated neurovascular exams before and after interventions are a core EM habit.

Key Medications

Acetaminophen: 1,000 mg PO/IV once; max 3,000–4,000 mg/day depending patient factors.
Ibuprofen: 400–600 mg PO q6–8h PRN.
Ketorolac: 15 mg IV/IM once commonly used.
Fentanyl: 0.5–1 mcg/kg IV for painful reductions/splinting.
Morphine: 0.05–0.1 mg/kg IV, titrate.
Hematoma block for distal radius fracture: lidocaine 1% often 5–10 mL into fracture hematoma; max plain lidocaine 4.5 mg/kg. Technique/dose varies—check institutional protocol.
Procedural sedation meds may be required for reductions before splinting; dosing varies by agent/patient—follow ED sedation protocol.
Pediatric splinting: positions similar, but analgesic/local anesthetic dosing must be weight-based.

High-Yield Pearls

Splints are preferred over casts acutely because swelling can expand; circumferential casts increase compartment/pressure risk.
Pain out of proportion after splinting is not “normal”—remove/loosen and reassess for pressure injury or compartment syndrome.
Always check rotational alignment in metacarpal/phalangeal fractures before splinting.

Board Question

A patient with a suspected scaphoid fracture has snuffbox tenderness but initial x-rays are negative. What is the best ED management?

AReassure and discharge without immobilization
BThumb spica splint and outpatient follow-up/repeat imaging
CUlnar gutter splint and no follow-up
DImmediate operative fixation in all cases

Reveal answer

Correct: B

Scaphoid fractures can be radiographically occult initially. Immobilize in a thumb spica and arrange follow-up with repeat imaging or advanced imaging to prevent nonunion/avascular necrosis.

Recent Literature

Review or guideline Carpal Tunnel Syndrome: Diagnosis and Management
Am Fam Physician, 2016 · cited 130×
Recent clinical Comparative outcomes of resting splints and elastic bandages in adult lower extremity soft tissue trauma: A retrospective cohort study
Medicine (Baltimore), 2026

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At the Bedside

Study Directive

Recent Literature

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Splinting

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