Sound Waves for Shoulder Dislocations
/Biancardi, M. A. A., Jarman, R. D. & Cardona, T. Diagnostic accuracy of point-of-care ultrasound (PoCUS) for shoulder dislocations and reductions in the emergency department: a diagnostic randomised control trial (RCT). Emerg. Med. J. 39, 655–661 (2022).
Clinical Question: What is the impact of point of care ultrasound in adults with acute traumatic shoulder pain when used as an adjunct to physical examination?
BACKGROUND
Shoulder injury and dislocations are common reasons for patients to present to the emergency department (ED) for evaluation. As ED physicians we often must determine whether the shoulder is fractured, dislocated, or both. Most of the time this is done through the use of physical examination in addition to the use of a plain film radiograph of the shoulder.
The use of ultrasound in the diagnosis and management of musculoskeletal injuries is becoming more common. While it currently does not supplant the use of radiographs, it can be a useful adjunct to the management of these patients.
STUDY DESIGN
A prospective, open randomized trial at a single emergency department in Malta assessed the impact of point-of-care ultrasound on physical examination in patients presenting to the ED with acute traumatic shoulder pain.
EXCLUSION CRITERIA
Patients younger than 16 years of age, chronic shoulder pain, polytrauma requiring surgery, referred with diagnosis of shoulder dislocation or fracture, or unable to provide consent were excluded from the study.
METHODS & DEFINITIONS
Adults presenting to the ED for acute traumatic shoulder pain were eligible for enrollment in the study. Interestingly, the 21 ED physicians at the site were recruited to be study investigators and the ED nurses were recruited to be the study coordinators. All ED physicians performed their own ultrasound after attending a 2-hour training course. A total of 1206 patients were enrolled and randomized into the study.
The CONSORT diagram for this study is particularly impressive, indicating that there were no patients who declined to participate, crossed study arms, were excluded from analysis, or were lost to follow-up.
RESULTS
A total of 290 dislocations (control group, n=132; experimental group, n=158) and 332 proximal humerus fractures (control group, n=154; experimental group, n=178).
For diagnosis of shoulder dislocation, examination alone had a sensitivity of 78.8% and a specificity of 61.1%, whereas examination plus POCUS had a sensitivity of 100% and a specificity of 95%. For diagnosis of humeral fracture, examination alone had a sensitivity of 83.1% and a specificity of 32.7%, whereas examination plus POCUS had a sensitivity of 96.6% and a specificity of 99.1%.
All test characteristics including accuracy, NPV, and PPV improved with the addition of POCUS to the physical examination.
LIMITATIONS
The major limitation in this study is the lack of blinding to the study hypothesis which may have influenced self-reported confidence in the physical examination findings.
TAKEAWAY
In this study, the authors show that the use of POCUS in addition to physical examination significantly improves our diagnostic accuracy for dislocations, proximal humerus fractures, and reduction relocations.
While we are not currently practicing in a time where POCUS will replace our use of plain radiographs in the diagnosis or treatment of patients with acute shoulder injury, it’s safe to say that POCUS is a nice adjunct and adds value to the evaluation of these patients in certain situations. For example, the use of POCUS during a shoulder reduction to confirm relocation.
Authorship
Written by: Jazmyn Shaw, MD, PGY-3, University of Cincinnati Department of Emergency Medicine
Peer Review and Editing by Jeffery Hill, MD MEd, University of Cincinnati Department of Emergency Medicine
Cite As: Shaw, J. Hill, J. Sound Waves for Shoulder Dislocations. TamingtheSRU. www.tamingthesru.com/blog/journal-club/sound-waves-shoulder. ***
