 I'm Anna Esparham. I am an MD. So I'm triple board certified right now in pediatrics, integrative medicine and medical acupuncture with a lot of specialty training and headache and pain medicine. And I've been practicing academic academic medicine for the past 12 years so we do both clinical. We do a lot of research so I've been published I have multiple manuscripts. We build a lot of medical curricula. We also serve so I've served on many national medical organizations I served as medical director chair. And now, as I just mentioned before I'm going to go back to residency to become quadruple board certified in osteopathic neural musculoskeletal medicine. Oh, I just see yeah every wants to go into pain management when care pain management's awesome. When care is so cool. I do love the procedural care, and I do find that's why I went, I'm going back to residency I actually start Monday. To do osteopathic neural musculoskeletal medicine I know most do's actually were the ones doing osteopathic neural musculoskeletal medicine but there has been some changes with the ACG me requirements that MDs and do's can now do the same and so I'm going to go learn what they do. I've been an MD advisor and pre med mentor for advanced clinical training for the past year, but I've mentored so many students throughout the years as I'm highly involved in education as an academic medicine doctor and I have also participated in the medical school operations processes and interviewed many students. So that was exciting and if you don't already know about advanced clinical training. It's basically an online self paced allied health certification program it's designed for you guys so pre health undergraduate and post bachelorette students. So, really with our mission to provide engaging accessible and affordable clinical certification programs and it is more affordable than other programs that I've seen out there to prepare you guys to get into medical school and to get into pharmacy dental and nursing school and those programs that we have several certification programs so we've got certified medical assistant certified patient care technician certified pharmacy tech advanced medical terminology certificate, the clinical research assistant and then also the physical therapy technician, and usually a lot of these programs can be done within eight weeks and it's really important that they have these certification programs because a lot of the school so nursing PA school medical school are going to be looking at these types of certifications, especially if you can work as like a medical assistant, a physical therapy tech, clinical research assistant, etc. But we also have another side to advanced the clinical training which is the mentorship programs and that's where I come in. And those are for students really really interested in going to what you guys are going into medical school physician physician assistant school dental school and pharmacy school. So, and then since you guys are doing this webinar today we have a special discount for you guys to get $300 off any of the certification or mentorship programs just use that coupon code actually I'll put it in the chat and then I'll kind of say it at the end as well and it's webinar 300. Yes, is the coupon code. And then what, and yeah you can go to ADV clinical.org is the website to learn more about the certification and the mentorship programs and Shabnam has just put that in the chat box as well. Oh wait no she sent it to me hold on let me get it for you. Okay. Okay there so there's the website just plugged it in so coupon code for today's webinar is webinar 300 to get $300 off any of the certification and mentorship programs and then go to the website to learn more about a lot of these programs that I just discussed today both the certification and the mentorship programs. Okay, so just a few housekeeping. Let's keep this as interactive as possible. I'll try and answer questions as we go. And I'll also try and keep looking at the chat box as well. So let me put these over here. And then I will also have some polls throughout just to make the questions interactive this is not to test you guys by any means is just to kind of keep it more fun, more interactive more engaged this is all for you to learn about how a case is presented how you guys would start thinking as a student whether you're a PA student medical student or a nursing school so I think you guys will like it. So, let's go on to the case. Let's move here. Let me pull it up. All right, so. All right guys here's the case acute onset left shoulder pain this goes by a pretty kick, pretty quick it's only a minute long so pay attention. Good evening. I'm Dr more over here at your name and hospital. How are you doing. Yeah, I'm sorry this happened. Can you just tell me what happened. Yeah, so my police organization works at the Coast Guard a lot we're out Coast Guard doing some compliance checks. You're born in a vessel did a safety check whether when it was time to get back onto the Coast Guard boat. I had one arm on the Coast Guard boat and one arm on the other person's boat. A big wave came and separated the two vessels and a cush, and it kind of took my left arm with it. And next thing I knew I heard three pops and I couldn't lift up my left arm. Okay. And your left arm here that's that's worth turning will compare this the right arm is fine right. Yeah. And this one here. See there's a little one is pretty tender there. Yes, I was okay. The arm down here is okay. Yes, an elbow. The pain kind of trickles down the arm. You really can't move that. Okay, well we're going to get an x ray and do an ultrasound like we talked about and be back with you okay. Okay, so for our first poll I just want to go over this because as a student in the healthcare field, you guys are either going to have to quickly at quickly or you can take your time and so let's go over the appearance so when you first looked at her, did you find that she was very toxic was she in severe distress or she was just chilling she was cool she wasn't in that much pain, not sick not toxic very minimal distress and this is going to be your first poll so let me pull it up here. Okay, you can go ahead and put your answers and I'll just wait one minute. Okay, so pretty much wrapping up it looks like most of you are deciding non toxic and minimal distress. Okay, so good. Okay, I think that's about the max. Alright, so here you go. Everyone. Great job. You know this is really subjective for the most part but it just kind of helps you when you first take a look at a patient just from the door. So if you need to act fast or can you take your time and so this is really for someone in severe distress versus minimal distress and so if you look at this patients vitals. So she doesn't have a high temperature she's not running a fever her heart rate 62. So it doesn't seem like most people who are in pain, they their heart rate raises way up and so usually it'll be. People who are not athletic or not in shape or not physically fit their heart rate will be quite a bit higher so usually around 90 to sometimes 110 120. It might be because she's an athlete that her heart rate 62 and that she's just chilling so. She looks good respiratory rate is fine she's not breathing super fast pulse ox is fine so her oxygen saturation is good her blood pressure is perfect and blood pressure also goes up when they are in quite a bit of pain as well so blood pressure and heart rate definitely raised when people are in pain. She doesn't really have a lot of other red flags per her history. And so I think we can clarify. She's not toxic and not in severe distress, however, she still is in quite a bit of pain she's not moving her heart her arm her arm if you look I just want to show you. Okay, let's see. And it's kind of took my left arm with it. And next thing I knew I heard three pops and I couldn't lift up my left arm. Okay, and your left arm here that's that's where it's hurting we'll compare this the right arm is fine right. Yeah, this one here. See there's a little one is pretty tender there. Yes, okay. The arm down here is okay. Yes, an elbow. The pain kind of trickles down the arm. Okay, so her arm is in more of the so abducted position so add a deduct is where it adds to the body a B duck so a B deduction abduction is where it's stretched out, and then she also kind of has a little bit externally rotated so you can internally rotate your shoulder and you can externally rotate your shoulder and so she kind of has it out like that she does not want to move it because it caused her pain and pain is trickling down her arm as well so she is in pain she's just probably got a strong pain threshold. Fatima great question. She has a question about the difference between toxic and non toxic and so those terms are very typical when you go into the health care profession and what you need to know about your patient when you walk into the door. So this person look sick is this person have pallor or do they have diaphoresis or sweating, are they breathing hard. Do they look like gray for example so that means that they could have a severe infection, they could be bleeding internally, they are looking sick on the near verge of death and that's why when someone looks toxic, you got to go in as fast as you can you might have to run a code you got to call the team in and take care of that person right away so great question. Okay, so next question is going to be the differential diagnosis and so I'm going to have you guys do another poll. Let's start that. Alright, what is your differential of diagnosis of this patient's condition your best guess. Okay, so looks like the majority did say it is a shoulder dislocation and so. Yes, that is the correct answer but is very hard to tell because, you know, it, there can be definitely a shoulder muscle strain there can be a rotator cuff there can be a humorous or a clavicular fracture with the shoulder dislocation and there can be a brachial plexus injury so it was kind of a trick question but the main diagnosis is shoulder dislocation and so. So if you look here, as we talked about some of those red flags, we do have concern for fracture with any shoulder dislocation or any type of trauma whatsoever in addition to nerve damage and vessel damage. So the doctor in that emergency room he did not show you his neural vascular exam, but that is definitely something that you would have to do before and after you do any type of treatment. Okay, so we went over the differential diagnosis, the biggest brachial plexus injury that we're talking about especially for a shoulder dislocation is going to be the axillary nerve and and we'll show you why as well. Let's talk about work up. Okay, so. All right, what is your work up in diagnosing this patient's condition after you've done your physical exam and you suspect that shoulder dislocation, what would you do. Okay, looks like about everyone's answered and I'll share the results with you guys. So looks like everyone, a lot of you chose the x-ray of the shoulder so that is very typical, especially when you are not trained in the point of care ultrasound so this patient you'll see was in the emergency room and most emergency room docs are now trained in point of care ultrasound so ultrasound is usually only going to show you the actual separation of that humorous from that shoulder joint the glenohumeral shoulder joint. And so that's why most people will get the ultrasound plus an x-ray this doc is going to explain is only going to do the ultrasound, because he must have done a neuro vascular and a very good neuro physical an orthopedic physical exam beforehand and not showing you that during the case. But both of those answers are correct it's just usually you do want an x-ray to make sure there is no other fracture or other trauma that has occurred during this shoulder dislocation. Now, labs you don't really need to get any labs unless there is some kind of injury to the axillary artery which will discuss so if the patient is bleeding, if the patient has patient has more trauma and then later on this patient might get an MRI of the shoulder if she has persistent issues if she had potentially a rotator cuff tear, a labral tear. Let's see what would you suggest if an ultrasound or MRI doesn't show much information because doesn't an MRI show muscle tissue yeah so MRI would definitely get to more it's just usually when you're in the acute setting you don't go to the most expensive imaging that also can take usually up to now especially a most academic medical center sometimes several days to a couple weeks to get into MRI. So the quickest way to identify it is the ultrasound of the shoulder and the x-ray. Okay, so great question Isabella. Let me just look at the chat real quick. Okay good. Okay, so here's our work up. Just a sec. Okay. And then Avery asked when would an MRI be more appropriate for this situation. An MRI. Most typically, it would be very rare unless they would have to send this patient to orthopedic surgery and that's when potentially a CT scan or an MRI, whatever they can get first would be recommended. So that's usually if there is going to be neurovascular compromise, you want to get an MRI. If it's available if not then CT and then if they have some type of need like a humorous fracture that they have to go into surgery for then they're going to have to get that extra imaging so that the orthopedic surgeons can take care of them. For any shoulder injuries you most likely use an ultrasound first than an x-ray. Yes, typically, if you are skilled as a physician in the point of care ultrasound, usually you want to get the ultrasound the x-ray is really just to rule out the fracture or any other type of trauma for the x-ray or you can still diagnose with x-ray so if you don't know point of care ultrasound, so I'm not I'm not certified in point of care ultrasound I'm not an emergency room doctor because most of the time emergency room doctors are going to be seeing this type of patient, the shoulder dislocation that's most of the time, or I mean I was a medic out in the song great at Christo mountains in New Mexico and we did see a lot of shoulder injuries because the falls or people were diving from the cliffs. And so then they would get a shoulder dislocation but otherwise it's mostly acute care or urgent care providers at ER doctors that are going to see this. So, so yeah ultrasound is typically recommended for those who do have that certification and who do have that training. And then x-ray good, good question Fatima and then neuro vascular compromise what I mean by that and we'll get into this as well is more usually the axillary nerve damage or axillary artery damage so some type of vessel damage or some type of nerve damage and so typically with this shoulder dislocation and we'll get into this. And axillary nerve or the axillary artery is going to be damaged you're going to have a loss of feeling you're going to have peristegia as you could have loss of pulses poor cap refill you could have pallor the upper extremity is cold. And you can also have loss of sensation to that posterior part of the deltoid because of that axillary nerve damage. So, with shoulder dislocations. Yes, it can be a loss of blood flow that is is very dangerous the loss of blood flow. Because the axillary artery just opens up and it's just pouring blood into this compartment or this compartment and then it gets it can actually cause also compartment syndrome which blocks off the blood flow as well. Dislocations, it is a very superficial joint. And so it accounts for most of the major joint dislocations the anterior shoulder dislocation is most common and I'll show you in the case as well what that looks like, but the common causes either it's a blow to the shoulder when it's like abducted and externally rotated so externally rotated so this is immediately rotated, this is externally rotated, and then extended arm is when the arm is back so usually so you're like falling like this. So that's what happens with an anterior shoulder dislocation or like she was on the boat she could have had her arm like this and then it could have just been separated. So, so that's the most common cause so anterior shoulder dislocation accounts for majority of them this is mostly what you're going to see. And, and usually the arm. So if you saw our patient she had her arm like out like this and it was a little bit externally rotated and that was her position of comfort so that's how you're going to see them. And the chromium appears very prominent and so and again just as we talked about that neuro vascular compromise 40% of the time it is associated with that axillary nerve damage. But when you usually reduce it the axillary nerve damage goes away so you can heal that nerve if you can get that reduced, you know sooner than later so that nerve doesn't get damaged permanently. And then the labral tears of that shoulder joint can happen the fracture can happen in any other areas but especially if that humoral head is a very common picture. So let's go back and let's look at that patient and look at her acromion. Oh, hold on. Okay, there we go. Oops. I think it's. Oh it is. Okay good. Can you guys see the screen. Okay great. Thanks guys. Alright, so let's look back at her arm so let's see the other person's vote, a big wave came and separated the two vessels and I kind of and it kind of took my left arm with it and. Next thing I knew I heard three pops and I couldn't lift up my left arm. Okay, and your left arm here that's that's where it's hurting will compare this the right arm is fine right. Yes. This one here. See there's a little. So you can kind of see before you put, let me look right here. Okay so you can kind of see her little shoulder bump right there. So basically her chromium is sticking out and so this is what happens because the humerus is not in. The shoulder joint anymore so it's kind of hanging down right here. So, so let's talk now about the outcomes and so what they're going to do in this case is, which there's multiple ways to treat a shoulder dislocation so usually we do it via sedation that's very typical in the emergency room and and this there's a couple new techniques instead of doing sedation they are doing some nerve blocks so there's a couple different ways to do it. There is a super clavicular nerve block and then there's an interscaling nerve block and so I'll show you that what the scalenes are so the scalenes are two muscles and the brachial plexus runs through those muscles. Basically right through here and so when you block that you can block this entire area so she won't feel much when they do reduce it. Okay, so this is actually what the dislocated shoulder looks like on ultrasound. So if you look here here is basically the spine of the scapula and so and then here's the kind of round edge of that humeral head and so and so really it needs to be that humeral head is usually a budding right here so it's much closer here and so it's separated so you can see it's clunked down. So that's how they figured out that yes on ultrasound this patient does have an anterior shoulder dislocation. And so they just show you down here there's that space between the humerus and the chromium. And so this is something to use lidocaine injection. It depends on how long you think you're going to be able to reduce this so they think it's only going to take several minutes to reduce this otherwise it was going to take several hours, you'd want to add another numbing medicine that lasts for several hours like you pivot cane. And so this gets more advanced into the point of care ultrasound but they're actually going to show you what they're doing here. So here's the needle coming and here's this brachial plexus right in this area. So here's on the middle scaling here's over here is the anterior scaling. And so in between that is this brachial plexus and so they're trying to go down there now it comes with risk because that phrenic nerve is there. So if you hit that phrenic nerve. It's very difficult to breathe because it's going to stop that diaphragm one side of the diaphragm. And so. You kind of have to be pretty good with the ultrasound to do it. And so I think this is the block that they show you. So lidocaine burns if you don't buffer it. And so it's not the most pleasant medications but then it gets numb after a few seconds they usually can buffer it depending upon what type of lidocaine it is but yeah lidocaine definitely burns. Quite a bit. Let's see I think this is just showing the injection again. Okay yeah so not much to see there based on what we've already seen. Look at this here. Again they're just showing you that needle so that needles coming through here. And it's going into this plexus. See that needle hold on. This is a few times see this needle coming in so this is exactly what he was doing. And then he gets to inject it right into that plexus where all these nerves are. One more time. Yeah. Okay so. Again they're just showing a little still picture. Here's the needle and trying to get into this nerve bundle here. Okay so let's go over a couple other issues with the shoulder dislocation and then let's go into the treatment. Okay so there's a couple other shoulder dislocations and but they're a little bit more rare so posterior shoulder dislocation. This is more two to four percent and on physical exam the arm is more abducted and internally rotated so it's kind of in that sling position so that's what they'll present with so it'll be more like this. So adduction is where you're adding it to the body and then internal rotation is where it's kind of like medially rotated. This is caused by a blow to this side of the shoulder so obviously if it's going to get the the arm the humerus is going to go back that way so it's more like a blow to this so it pushes the shoulder that pushes the arm that way. Especially when it's adducted so shoulder so it's typically this in order for it to go a little bit back that way. And this one oops sorry is associated more with a higher risk of humeral head neck and tears of the labrum and the rotator cuff so definitely getting an x-ray probably getting an MRI at some point in time after this is reduced. The anterior shoulder location is much less in terms of incidence and this is caused by hyper abduction with an axial loading of an abducted arm so so hyper abduction so again abduction and this is adduction so axial loading of an abducted arm is usually. So axial load is just kind of like like this so would be a big blow to to the arm like this. This is highly associated with axillary nerve and artery injury so definitely probably going to be getting extra imaging after you do the ultrasound the x-ray and then potentially either a CT or MRI depending upon the patients. Clinical presentation so she said our patients said as on the clinical presentation she had three pops and so that is very typical anybody who has a shoulder dislocation usually can hear that popping sound or that feel that sensation of a pop and then all of a sudden they have pain and and really can't move their arm and again so. The people with the anterior shoulder dislocation it's going to be abducted and externally rotated posterior they're going to kind of have it more like in the sling position. So you didn't see the neurovascular examination this is I think this got a little bit blurry but here is this. So it's a pretty big artery that comes comes down with that brachial plexus so the brachial plexus comes down with that axillary artery and then also wraps around that humor so it's highly likely it could just share and and have a big you know vessel injury and so. Axillary nerve also comes off this brachial plexus and wraps around the humerus as well so you can see how a shoulder dislocation or fracture can really rip that and that's why it's very high 40% so what happens when you have that axillary nerve injury so it really provides. sensation to that deltoid especially kind of lateral or the posterior part of the deltoid, and then it also helps you abduct the arm so it's motor to the deltoid and the Terry's minor so kind of externally rotate and then abduct as well. And then so treatment, which we're going to get into. I'm going to show you guys as soon as I answer what's the procedure if the person injecting the needle accidentally injects at or near the phrenic nerve so symptomatic until so. That's why light a case so that's why they love to use just light a cane because it only lasts several minutes so once that light a cane wears off hopefully that phrenic nerve comes to life as long as they didn't like injected straight into that phrenic nerve which is very rare. Especially if ultrasound you typically wouldn't but light a cane can spread all around so you're diffusing a whole bunch of liquid into this area and so that can diffuse into all those different fashion all the different tissues. And so you could highly likely, you know, numb that phrenic nerve and when you numb that phrenic nerve then you have difficulty breathing if you have enough difficulty breathing and where it's going to cause respiratory distress. They could probably just bag or they could give oxygen it just depends on the patient's case but they're probably going to treat them symptomatically until that light a cane wears off. So, and then test via what happens if the axillary nerve gets damaged. So, if the axillary nerve gets damaged it. Well, actually it typically does so 40% of the time it does get damaged in the shoulder dislocations. When you reduce it, it usually goes away now sometimes there's long term damage and so then if there is axillary nerve damage it is pretty prevalent there typically they'll refer to the orthopedic surgeon before they do any shoulder reduction so that they don't damage it anymore. And then what they'll do is they'll typically go to rehab and physical therapy to get those nerves to work again most of the time you can. People get acupuncture people get physical therapy do rehab, and then they can get their nerve to function again some people don't but it's a very rare condition. Okay, I think I answered all those. Okay. So let's look at the reduction because they don't show you how to reduce it and you guys would absolutely want to know this because this happens so commonly just like if you're playing sports, if you guys are out on vacation and someone falls. You guys can be the hero and reduce it on your own you don't like three force of the time you don't need sedation or medication to reduce it. You just have to have the skills to do it. Okay, so let's look. The best video I found was through the BC emergency medicine network. And so, it's about 15 minutes he shows you several different techniques but the most common one I think. The most research one he does a different one but the most research one was the scapular manipulation and that works about 80 to 100% of the time I think he shows that the very end he does describe everything at the very end he goes through a lot very quickly in the beginning but then he describes each method at the very end. The reason very gentle traction helps to alleviate pain and helps them to relax is that it removes the painful pressure of the humeral head held by muscle spasm against the inferior glenoid rim. This x-ray belongs to the patient in the following video, which demonstrates initiation of patient positioning and relaxation techniques. The patient was really keen not to receive any medication. He relaxed very well and tolerated a trial of several painless gentle reduction maneuvers that didn't end up working. Very gentle traction. It should feel better. Really gentle. Read into your nose and out through your mouth and just let your muscles go. Kind of pretend you're just lying in a warm water bed and just let your body go. We're going to lie back a little bit. I'm just going to lay your back a little bit back. That's what it's supposed to do. It's supposed to feel better. Just relax it. Your whole body relax. Go into your nose and out through your mouth. And I've got your shoulder so you just let it go. It's really natural shoulder to go. Your whole body relax. Good. Now, every time you breathe out, that's your shoulder to go. In through your nose, out through your mouth. Nice big grass. Let it go. In through your nose, out through your mouth. We got an x-ray to rule out significant unpredicted fractures. The x-ray confirmed simple anterior dislocation, which was then easily reduced using some procedural sedation. In my clinical experience with over 1,000 shoulder reductions over the years, I use analgesia and or sedation about 25% of the time for one reason or another, which means that roughly three out of four shoulders go back in easily and painlessly without analgesia or sedation. Traction counter traction is often described as overcoming the muscle spasm when in fact large forces are not required. It should be gentle. So the traction is where he's pulling on the arm. The counter traction is using that sheet to provide some gentle counter traction. It's important that you just relax your shoulder back down against the bed. If they don't reduce with simple traction, you can continue with forward elevation. If they don't reduce during forward elevation, you can continue to spasso positioning with mild traction vertically or use fares, fast, reliable and safe method. With both techniques, external rotation of the humeral head presents more articular smooth cartilage to the glenoid rim and unhooks the hill sacs compression injury, allowing it to slide more easily over the rim and into the socket. External rotation should be performed gently and slowly so as not to induce muscle spasm. If external rotation doesn't work, you can easily progress to forward elevation, the full extent of which wasn't even required in this next case. It's pretty externally rotated, you know, up and up, and if they're going to go in, they go in by now. Yeah, so his main option. Yeah, okay. Maintain your traction. Don't move that. And then that's it. You might have to stand. You went in. Relaxed him. Perfect. That's great. That's great. Thanks a lot. The following video shows Emma, who was a nurse in our emergency department trying out some massage and then external rotation on a patient who presented with a dislocated shoulder. Just an hour earlier, Emma had helped me video the final clip in this presentation, which demonstrates how to move fluidly between the different techniques. Got it now for you. This was a great opportunity for Emma to try a couple of techniques she'd never tried before. And the next thing that you're going to do is just lay him back a little bit here. And then we're going to maintain the traction with your right hand and then start to do very gradual patient. Yeah, that's good. Into your nose, into your nose out through your mouth. You're relaxing. Into your nose out through your mouth every time you blow out, let your shoulder go completely. Good job. Now your left hand is going to his wrist and very gentle, slow external rotation, maintaining the traction with your right hand. Very, very slowly, very, very slowly. Into your nose, out through your mouth. Into your nose, out through your mouth. Let your shoulder go. It's going to go perfect. Relax, relax, relax. You did really, really well. Awesome. Now just check. Just check for a little bit of internal external rotation. Yeah, just very gentle back and forth to make sure that he's in. And he is right. That's all you've got to do. It's great. Awesome. Thank you. With the milch technique, it often takes five to 10 minutes to get painlessly into the fully abducted externally rotated position. This recreates the position of injury usually and exposes the human. So just let you know for this one. So all of these that he's showing he's not doing any sedation on he hasn't done any nerve blocks on so he's doing just deep breathing calming them down making sure they're not tensing. There's when you have that shoulder dislocation, you're having a ton of muscle spasms. And so you just have to be very, very gentle, very, very careful, slow traction, getting them into that position. So you're going to have to slowly pull it slowly externally rotate in terms of some of the ones that he's presented. In this case they're doing acupressure on the ear that ear actually has some pretty good pain control and just at that antitragus and tragus it actually represent many of the areas of the brain and some of those pain pathways and so just by applying pressure poking them with needles like I do can provide pain control. Humeral head to the bank art here, which allows it to slide back into the socket. The central push on the humeral head helps the so called gentle pulsion maneuver. There is usually no clunk, and it is often imperceptible, and perhaps only detected by a sense by the patient that something has changed. So you then must gently check position by maintaining traction and main and bring the arm back down to the side. This scientist from Russia in the 70s was bound and determined to avoid medication, referring to have his daughter who was an internist apply acupressure to his ear lobes. And he went through all the reduction maneuvers up to an including milch and finally had success with the milch technique, and it took about nine minutes to reduce his shoulder. He was very proud. Oh, no. It's lit in. Oh, see it's lit in that's milk milk just relax now. Just gonna test. Okay. You did it. Nice job. Capular manipulation is very useful when the patient presents in the middle of the night, slightly drunk usually with their arm hanging down in front of them like an elephant's trunk. In the following video I'm using scapular manipulation first on the right and then the left in two different patients. Neither patient was inebriated and in the first video it's a paramedic who was actually helping me with the maneuver. You can actually lead them over to a bed lie them down, pump up the bed high shoulder buddy how to apply gentle traction with supination, and then you rotate the scapula down towards the humeral head, clockwise on the right counterclockwise on the left. It helps if you can get your thumb underneath the inferior angle of the scapula and relax, relax, relax, relax, relax. The method consists of doing whatever seems best for the patient and not being limited by only knowing a couple of techniques. This will depend on how they present. You can start with scapular manipulation if they present in a position where lying prone is easiest. If they present sitting you can start with gentle traction and perhaps some massage is described by Cunningham. If necessary to external rotation, then forward elevation, spassal positioning or try the fast and reliable technique. And then if their shoulder still hasn't reduced move to milch positioning, maintaining very gentle traction throughout all maneuvers, so as not to induce pain and result in muscle spasm. If the procedural sedation is necessary or desired, ensure adequate procedural sedation so you don't have to exert large forces or pull hard as this predisposes to the chances of traction, axillary nerve injury. The following video demonstrates progressing seamlessly from one technique to the next in a volunteer without a dislocated shoulder. Keep in mind the flow in this video will for demonstration purposes progress more quickly than in a real patient because you need to go slowly and gently so that you are less likely to cause pain or muscle spasm. At the end I will demonstrate how you might apply sheets to the patient and yourself to facilitate reduction under procedural sedation for posterior dislocations or those anterior dislocations that you are unable to reduce by the other methods. And so to demonstrate on someone that doesn't have a dislocated shoulder, how to flow between techniques, I'm going to be doing this fairly quickly, not taking the usual amount of time that would not wearing a mask just so that you'll be able to hear me. So patient presents with an anterior dislocation clinically and I perform my history and physical, and they have agreed to try to have it reduced without any analgesia. So you can start off to gain the patient's trust in the relief pain, simply by trying to apply a little bit of traction, not a lot just a little bit. What that does is it helps to unhinge the humeral head from the inferior glenoid rim. You should start to feel a little bit better, and then you can actually take their, their arm, and while you're talking to them, just saying things like okay, let me have your shoulder relax working your breathing into your nose out to your mouth. You can try if you want to a little bit of gentle massage described in the cutting hand technique of the trapezius coming down into the bicep. The important thing is once you've initiated your traction, don't let go or change it. Otherwise, it'll cause pain and resulted muscle spasm. So they mean, what we do for kids is often clinical hypnosis so we do a lot for those of us certified, especially in the pain field do quite a bit of hypnosis for kids so that they don't have to undergo scary needles or scary procedures and they are really good at it and get into a lot of pain reduction just using the power of their imagination. They reduce right there. If they don't, you can very easily go into maintaining your traction, very simple external rotation, again telling the patient to concentrate on their breathing in through the nose to the mouth relax and make the movement very, very slow. If your rotation doesn't work, you can continue on into forward elevation and bring them down and maintain the traction. And at this point, you can either decide to or not put a sheet. So he's going to go through all the methods right now so he hasn't been able to reduce it but he's going to go through it all so you guys can learn all the methods for yourself so you can try this at home underneath them. If you're doing very gentle traction, you shouldn't have to put a sheet for the purpose of illustration will put one just to show you how you would do it if you chose to do it. So again, I'm maintaining the traction, putting a sheet there but I'm not going to be pulling hard. So here's simple traction. Now when I do this, I supinate the forearm so that I externally rotate the humeral head, which presents more articulate surface to the glenoid rim so it slides in and over. If it doesn't go in with very simple traction, I can then do forward elevation. Sometimes what I'll do is just lie them down a little bit, get them in a position where it's easier to do the forward elevation. Again, maintaining consistent gentle traction. Then, if it hasn't reduced, you can proceed. Sometimes it's easier to cross over and take them this way and do forward elevation. As we do forward elevation, it often goes in right about there. If it doesn't, you can continue right up into the spasso position and continue with traction in spasso position. If it doesn't go in, you can continue, come back down. Again, maintaining that same degree of traction. I like to hold their hand because that just helps them to relax. You can try the so-called fast, easy, reliable method or Ferris technique where you just very simply oscillate 10 degrees or so as you come up into abduction. If it still doesn't go in, you can simply maintain your traction and by taking them at the elbow, bring them up into preparation for the modified milch maneuver. So now we have them at 90 degrees of abduction and now we're going to very, very slowly and gradually take them into 90 degrees of external rotation. And again, I'm going faster than you would. You don't want to cause pain and muscle spasm. And sometimes I'll change hands here, maintain the traction, never move the shoulder once you've started, continue the external rotation. If it doesn't go in, you can try the so-called gentle pulsion maneuver of the humeral head, just giving it a little bit of a push over the glenoid rim. If it's going to go in here, there won't be a clunk. The patient may just say, hmm, something feels different and then you can't really tell because it's anatomically different, you won't see the sulcus sign as well. So then you have to check to see if it's in. And then by maintaining your traction so you don't hurt them, if it isn't in, then maintain your traction and bring them back down. And then you'll be able to see if it's slid back in or not. If it hasn't slid in at this point, then you can decide if you want to try the prone position, the scapular manipulation position, or you may decide if this is too difficult. I'm going to get an x-ray and do some sedation. And then I'll just point out the three-sheet technique for relocating either a difficult anterior shoulder dislocation or a posterior shoulder dislocation. So they've been off to x-ray, they've come back, they're procedurally sedated. And now with the three-sheet technique, what we do is we already have our sheet in a position for this. My sheet, I'm going to get my assistant to come around and tie it on me as I get ready. So the patient's sedated now, so you don't have to worry too much about pain. So yeah, so you're going to wrap it around here and then tie it up behind my back, low down in your hips, throw that, once that's tied, then you and your assistant can just provide gentle traction counter traction. One thing of this is that now I can control external internal rotation very easily while I'm applying as much traction as I want to do. And in the case of sometimes while usually anterior dislocation and sometimes posterior dislocation, a little bit of external rotation will unhook them, and they'll go back in. This is how posterior dislocations are described. In my experience, what I found is that in fact, there's often a reverse dill sacs lesion, and you have to actually internally rotate them slightly. And then they'll slide in. If they don't slide in like this, then you get another assistant, and this can be a physician colleague or someone else to come around and apply a sheet from the side nice and wide. And then as you're providing very gentle traction counter traction, making sure they're adequately sedated so you don't have to traction hard. You just exert a little lateral pull as well. And that slides the humeral head over into the socket. That's it. Yep. All right, so I just have one last poll for you all. As we've learned all the cool techniques, especially without sedation. What do you need to make sure that the patient does not have before you reduce the shoulder dislocation that you can have multiple answers I think to this. And then after this, I just got a couple more slides and then we're done. So any questions, just let me know. Oh, yeah, you guys are so smart. Okay, perfect. Okay, so yes, pretty much all right. Let's go over that. Okay. So, yes, so what you want to avoid is definitely an axillary nerve injury, you want to avoid an arterial injury you want to avoid doing it for a fracture of a humeral neck because that could lead to a vascular necrosis. And then there is one thing that we didn't talk about but what very rarely but especially in the elderly because of the fragility, they can actually get their humerus dislodged in their ribs and so it's an intrathoracic dislocation, or it can get dislodged underneath the clavicle. And so this is pretty significant. So you always want to refer to orthopedic surgery before you do any shoulder reduction and then all you have to do is just once you reduce the shoulder put the patient in the sling. Make sure you do their neurovascular exam after reduction so before and after just to make sure that axillary nerve if it did have any damage before it doesn't now. Get any post reduction imaging make sure that humerus is back in that glen or humeral area. And then usually you do want to do fall with the orthopedic surgeon because there can be that rotator cuff issues or injuries you can have those labral tears and so some of these people likely will need physical therapy after their shoulder dislocation so what if all the moves don't work and what does the doctor do well so he was very, very gentle in most of his maneuvers, even though he did it very fast at the, at the end. Oftentimes, why we do sedation is just so we can do it a little bit, we can do it a little bit more forcefully. So it typically works with sedation if it doesn't, then we just get orthopedic surgery referral on board and have them take a look at it. So great question. Any other questions before we wrap up and then I'm also going to put that webinar 300 for you guys who are interested in our certification programs and our mentorship programs. Webinar 300 and then make sure to check out our website at adbclinical.org. Well, let me put this in here. So you can check out all our programs and it was so great to be here with you. Yes, I think they did record it. So I think it will be somewhere to watch. Good question. And if there is vast neurovascular damage what step would you take for treatment. So, Linda, this is where we actually have to typically refer to orthopedic surgery sometimes we have to refer to vascular surgery especially if there is an arterial artery damage. We do have to be pretty quick with those urgent referrals because there can be some significant damage especially with the compartment syndrome if like the blood gets stuck in the fashion it causes ischemia, which is decreased blood flow and causes kind of tissue necrosis after the neurovascular damage, and then obviously PT for the most part and pain control if there is nerve damage. We yes you get a certificate I think it should be emailed to you in the next 24 hours you get one hour of the virtual shadowing certificate Isabella, and then purity, you have a question. Yes, it's the certification programs. Medical assistant, research assistant, those types of certifications and then also the mentorship program so if you're considering medical school dental school, PA school pharmacy school then you can use that webinar 300. So, in there. Yes, there will be more sessions like this Fatima. We love putting on the webinars so look out for your email when we have more I hope to see you again. Oh that's awesome. Oh great Catherine I'm glad you passed your medical assistant exam. Okay, let us know what you're up to next time we see you. You are so welcome Arizo. And then the mentorship we have a question about how long are the mentorships it is one year so 12 months. You guys are so welcome have a great weekend I hope this spring time is so much better for you than the winter. Yes, you there is a mentorship program available so I am one of the I'm the MD advisor in the premed mentor for getting into medical school. Yeah you guys are all welcome it was so great to be here. Okay, look out for your emails and you'll get that one hour virtual shadowing certificate and then. Thank you guys I'll see you hopefully at next webinar you guys all take care. Alright everyone. Bye.