Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre

Abstract

BackgroundA high incidence of missed posterior shoulder dislocations is widely recognised in the literature. Concern was raised by the upper limb multidisciplinary team at a London major trauma centre that these missed injuries were causing serious consequences due to the need for surgical intervention and poor functional outcome.ObjectiveTo identify factors contributing to missed diagnosis and propose solutions.MethodsA local quality improvement report was performed investigating time from admission to diagnosis of simple posterior dislocations and fracture dislocations over a 5-year period. Factors contributing to a delayed diagnosis were analysed.ResultsThe findings supported current evidence: a posterior shoulder dislocation was more often missed if there was concurrent fracture of the proximal humerus. Anteroposterior and scapular Y view radiographs were not always diagnostic for dislocation. Axial views were more reliable in assessment of the congruency of the joint and were associated with early diagnosis and appropriate treatment of the injury.DiscussionAs a result of these findings a new protocol was produced by the orthopaedic and radiology departments and distributed to our emergency department practitioners and radiography team. The protocol included routine axial or modified trauma axial view radiographs for all patients attending the emergency department with a shoulder injury, low clinical suspicion for dislocation and a low threshold for CT scan. Reaudit and ongoing data collection have shown significant increase in axial view radiographs and improved diagnosis.

A pictorial presentation and the clinical use of the modified trauma axial (MTA) shoulder x‐ray view

“…Some scholars have reported using the modified axillary view 12 and the Velpeau view 6 in acute shoulder trauma because they do not require any patient arm movement while improving the sensitivity of the post‐reduction series. However, these views require patients to stand and lean forward 12 and backwards 6 enough to achieve a superior to inferior view of the shoulder, which might not be possible when the patient is unable to move or is sedated. The MTA view does not require any patient rotation or tilt, which is feasible for all patient conditions, especially in ED.…”

“…Axial shoulder projections are deemed most sensitive to detect bony abnormalities but require rotation or abduction of the arm 2,5 . Thus, these axial views are challenging to obtain in trauma situations, as patients tend to have limited range of movement, are experiencing considerable pain, or are sedated 2,3,6 …”

“…2,5 Thus, these axial views are challenging to obtain in trauma situations, as patients tend to have limited range of movement, are experiencing considerable pain, or are sedated. 2,3,6 A study conducted by Neep and Aziz found that using the AP and modified trauma axial (MTA) projection detected a significantly higher number of post-dislocation pathologies This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.…”