MEDICAL MALPRACTICE INSIGHTS: Don’t miss a posterior shoulder dislocation

Author: Chuck Pilcher, MD, FACEP (Editor, Med Mal Insights) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Here’s the second monthly post from Medical Malpractice Insights – Learning from Lawsuits, a free monthly opt-in email newsletter. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits.

Chuck Pilcher MD, FACEP, Editor, Med Mal Insights

Don’t miss a posterior  shoulder dislocation

Critical thinking makes the diagnosis easy

Facts: A 42 yo well-dressed businessman presents to the ED with pain in his left shoulder after slipping and falling on his outstretched arm on a wet sidewalk about 2 hours earlier. He has no prior history of shoulder problems. Exam shows very limited and painful ROM with the shoulder held in adduction and internal rotation. There is a normal appearing “deltoid bulge” indicating no anterior dislocation. An impacted humeral head fracture is suspected. An x-ray is read by both the ED physician and the radiologist as normal. The patient is placed in a sling and discharged to follow up with an orthopedic surgeon. Two days later the orthopod finds the patient has a posterior dislocation The patient notifies the ED. The hospital’s Risk Management Department goes into action.

Plaintiff: My pain and limited ROM was way off the scale compared to a minor sprain. Both the ED doc and the radiologist misread my x-rays. You should have suspected a posterior shoulder dislocation and done a CT scan. Your failure to recognize this caused me more pain, time off, and medical expenses. We need to talk.

Defense: You’re right. We’re sorry. We want to make this right.

Result: The orthopedic surgeon was gracious. The ED physician and radiologist both called the patient and apologized. After discussions with the patient (a forgiving and reasonable gentleman), his attorney, and the hospital risk management department, an agreement was reached to forgive all bills, pay his expenses for relocating the shoulder and therapy, compensate him for time loss from work, plus a small amount for pain, suffering, and inconvenience. The total amount was under $100,000, split between the radiologist, the ED physician, and the hospital. The patient recovered nicely.

Takeaway:

• Saying you’re sorry helps, along with having a good relationship with your backup docs and risk management department.
• Posterior shoulder dislocations are uncommon but commonly missed.
• FOOSH is the typical mechanism, with seizures second.
• Pain and limited ROM are impressive – as one can imagine. The patient just hurts too much for nothing to be wrong. This alone should trigger the “critical thought”: “Could this be a posterior dislocation?”
• The shoulder is usually held in adduction and internal rotation.
• The humeral head on x-ray may be internally rotated and appear as a “lightbulb on a stick,” but it may also be read as normal.
• High index of suspicion required. A CT will make the diagnosis, especially if one suspects a humeral head fx and finds none..

http://eorif.com/Shoulderarm/Images/Shoulder-dislocationP1.jpg

References/Further Reading:

1. Lightbulb on a stick image: http://eorif.com/Shoulderarm/Images/Shoulder-dislocationP1.jpg
2. Posterior Shoulder Dislocation. Life in the Fastlane (blog). Mike Cadogan http://lifeinthefastlane.com/posterior-shoulder-dislocation/ (includes excellent x-ray images)

“There are no mistakes, save one: the failure to learn from a mistake.” – Robert Fripp