A 12 year old male presents with a 1 day history of pain and tenderness over his right ankle. He states that he stepped on another player’s foot at basketball practice and rolled his right ankle. He notes pain when trying to walk but is able to bear weight with a mild limp. He has been applying ice to the ankle since the day of injury with some relief of the pain.
Vital signs are normal. His exam is unremarkable except for the right ankle, which is positive for moderate swelling and tenderness over the tissues around the lateral malleolus. No ecchymosis or gross deformity is noted. Passive inversion and plantar flexion of the ankle produces pain. Anterior drawer test is negative for gross laxity. An X-ray of his ankle is obtained which does not reveal bony anomalies. He is advised to rest the affected joint for today and elevate his ankle and wear a compression bandage around the ankle. He is also instructed on performing range of motion exercises as tolerated and light activity as tolerated.
The ankle is one of the most common acute musculoskeletal injury sites, with sprains being the most frequent injury sustained in sports (1). A sprain refers to stretching or tearing of a ligament. The ankle joint is a hinge joint composed of the tibia, fibula, talus, and stabilizing ligamentous systems which normally permits movement in one plane (dorsiflexion and plantar flexion) with some axial rotation of the talus in the tibial mortise (2). The lateral ligamentous complex consists of the three fibular collateral ligaments: the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). These ligaments stabilize the ankle laterally and are commonly injured in ankle sprains. The most vulnerable and thus most commonly injured ligament is the ATFL, injured usually due to a combination of plantar flexion and inversion (1). Ankle sprains can also include injury to one or more of the four medial stabilizing ligaments of the fan-shaped deltoid ligament, which contain deep and superficial components to support the tibia, talus, calcaneus, and navicular bones. Medial ankle sprains may result in significant morbidity due to ankle instability. Ankle sprains range in severity from grade I to grade III based on degree of injury to lateral ligaments (3). Grade I refers to a partial tearing of the ligaments without significant laxity. Grade II refers to partial to complete tear of the ligaments, for example in a lateral ankle sprain, partial to complete tear of ATFL and partial tear of the CFL. Grade III involves complete rupture of a ligament, for example in a lateral ankle sprain, complete tear of ATFL and CFL and potentially damage to the PTFL (1). Because provocative ligament testing may be challenging to complete at the time of an acute injury, grading is usually subjective, focusing on the degree of swelling, pain, and ecchymosis (3).
Taking a complete history, including the mechanism of injury, allows the clinician to infer the most likely structures involved in the sprain. Patients will often report a twisting or rolling injury of the foot and ankle. The clinician should determine if there was inversion, eversion, rotation, or direct trauma to the joint (1). The signs and symptoms of ankle sprains are varying degrees of pain, tenderness, and swelling over the lateral aspect of the ankle. Other signs are mild to moderate ecchymosis, loss of motion and function, and mechanical instability. Careful physical examination should include inspection, palpation, assessment of ability to bear weight on the affected ankle, and additional special orthopedic tests (1,3). The anterior drawer test involves stabilizing the distal lower leg while applying anterior force on the calcaneus, with instability of the ATFL indicated by greater than 1 cm of translation of the foot compared with the uninjured ankle. The inversion stress test, or talar tilt test, is used to assess the integrity of the CFL (1). This test is considered positive when the angle between the talar dome and tibial plafond (the horizontal plane of the distal tibia) during forced heel inversion is more than 5 degrees different from the unaffected side. A positive squeeze test, which is occurrence of distal pain on compression of the fibula and tibia at the midcalf, may indicate the presence of a less common syndesmotic or high ankle sprain involving the membranous ligamentous connections between the tibia and fibula (1,3). All provocative tests of the affected ankle should be compared with the other, uninjured ankle (3).
Severe and unstable ankle injuries warrant plain film imaging. These injuries include suspected unstable or displaced fractures, open fractures, neurovascular compromise, fracture that include dislocation, and any other concerns for ankle instability. When ordering radiographs, a standard ankle X-ray series should include anteroposterior, lateral, and mortise views. These views should be obtained weight bearing if tolerated. If there is concern for an associated foot injury, a standard foot X-ray should include anteroposterior, lateral, and oblique views, also weight bearing if tolerated (1). Referral to a pediatric orthopedist and/or advanced imaging with computed tomography (CT) should be considered if diagnostics on a plain film are uncertain.
The low-risk ankle rule (LRAR) is recommended to assist in the decision to obtain radiographs in children with ankle injuries (4). If the ankle injury is considered low risk by the LRAR, no imaging is recommended, and the injury can be treated with supportive bracing and return to full activity over time as tolerated. Patients with low risk injuries, such as lateral ankle sprain, non-displaced Salter-Harris type 1 and 2 distal fibula fractures, and avulsion fractures of the distal fibula or lateral talus, include the following criteria: 1)Acute injury (<3 days). 2) Not at risk for pathological fractures (e.g., osteogenesis imperfecta or focal bone lesions). 3) Does not have congenital anomalies of feet or ankles. 4) The patient is able to reliably express pain or tenderness. 5) Tenderness or swelling localized to the distal fibula and/or adjacent lateral ligaments distal to the anterior tibial joint line.
The Ottawa Ankle Rules (OAR) have been shown to be relevant to addressing radiographic necessity in adults but are less accurate and effective in reducing unnecessary imaging in children (5). The OAR in children have a high sensitivity but lower specificity for high risk ankle injuries when compared to LRAR.
The differential diagnosis of acute ankle sprains can include fractures of the fibula, tibia, talus, or calcaneus. Additional soft tissue differential includes syndesmosis injury, peroneal tendon subluxation, tarsal coalition, subtalar dislocation, and Lisfranc (midfoot) injuries. Early management of acute ankle sprains includes RICE which is an acronym for rest, ice, compression and elevation (1). For most lateral sprains, early weightbearing as tolerated is encouraged, and gradual resumption of activity as tolerated may be recommended after resting for the first 72 hours. Gradual ambulation has been shown to result in faster recovery compared to total rest (1,6). Severe sprains may warrant use of a walking boot to control pain and allow for earlier weightbearing without crutch assistance. Ibuprofen and/or acetaminophen may help with pain relief. Surgery is generally indicated only in patients with recurrent instability following dedicated rehabilitation attempts with physical therapy. Most patients have excellent outcomes, with a minority of patients experiencing recurrent instability and associated deficits (1).
A 2 year old female presents with pain in her left upper extremity today. Her mother states that they were playing at the park and holding hands when the patient attempted to swing by her left arm prior to symptom onset.
Vital signs are normal. Her exam is unremarkable except for the left elbow, which has mild tenderness. The patient shows extreme discomfort with manipulation of the affected elbow and supports it in a protective manner with her right hand. No swelling or deformity is visible. A reduction is performed in the office and function of the affected elbow and arm is regained within 15 minutes.
Radial head subluxation (RHS) or nursemaid's elbow is an injury that occurs when infants or children are lifted or pulled by the hand or arm, resulting in axial traction on a pronated forearm with the elbow in extension. The radial head slips under the annular ligament, and the child will present with pain and inability to supinate the forearm (7,8). This is one of the most common elbow injuries in young children between the ages of 1 to 4 years, representing more than 20% of upper extremity injuries in this age group (8).
The clinical presentation classically features a child complaining of pain in the elbow, wrist or shoulder and refusing movement of their upper extremity. They typically will be holding their elbow extended at their side or seated with their forearm on their lap in complete pronation. Physical examination should not reveal significant swelling, ecchymosis, or deformity (7,8). The history commonly has a history of a pulling injury but this is not always the case. Typically, radiographs are unnecessary but if the history is not consistent with a pulling injury, or a fracture is suspected, radiographs can be obtained.
The differential diagnosis of radial head subluxation includes fracture of the bones of the elbow such as the supracondylar humerus, humeral epicondyles, olecranon, or proximal radius. A history of a traction injury makes a fracture unlikely, while a history of a fall directly onto the arm may prompt additional radiographic assessment.
If diagnosis of RHS is reasonably suspected, treatment involves reduction in which the forearm is hyperpronated or supinated. A click palpated at the level of the radial head is suggestive of a successful reduction (7,8). A favorable clinical response to reduction of the displaced ligament within 15 minutes is considered diagnostic. Though the child may continue to cry briefly, the child will be able to use the arm again, will be using arms symmetrically to play in the clinic, and there is usually no residual tenderness. If reduction is unsuccessful, re-evaluating for signs of fracture may be necessary. Immobilization is usually not required but a sling or acetaminophen can be given for pain as needed (7,8) . There is no activity restriction and follow-up is as needed. Parents are advised that this injury can recur up to the age 5 to 6 years, but it generally is not indicative of elbow problems in later childhood or adult life (8). It is prudent to minimize the risk of recurrent radial head subluxation by avoiding yanking and pulling on the affected limb. Parents can be taught to perform this reduction if the mechanism is a pulling injury, and no swelling or deformity are visible.
A 15 year old male presents with a 1 day history of right knee pain and swelling. He states that he injured his knee while playing soccer after pivoting to change direction and feeling a sudden pop, which was accompanied by immediate, extreme pain. He also describes swelling, decreased range of motion, and difficulty walking after the injury.
Vital signs are normal. His exam is unremarkable except for the globally swollen right knee. Ligamentous testing reveals increased anterior translation of the right tibia with both Lachman and anterior drawer tests, negative posterior drawer test, negative varus and valgus stress tests, and negative McMurray test. The patient is placed in a knee immobilizer and is trained to use crutches. He is referred to orthopedics for further management.
Knee injury is a common musculoskeletal presentation in primary care. The anatomy of the knee joint is complex. The tibiofemoral joint (knee) is a combination of hinge, sliding and gliding joint types. Several ligaments at this joint are susceptible to injury, including the anterior cruciate ligament (ACL) which resists anterior translation, posterior cruciate ligament (PCL) which resists posterior translation, medial collateral ligament (MCL) which resists valgus stress of the knee, and lateral collateral ligament (LCL) which resists varus stress. MCL injuries are more common than LCL injuries. The menisci of the joint act to deepen the articular surfaces for load transmission, reduce stresses on joint surfaces and serve as a secondary stabilizer to enhance joint stability (9). These structures are also susceptible to injury, particularly with pivoting or jumping activities.
The mechanism of injury is a key factor in evaluating knee injury. A non-contact pivoting injury with sensation of pop, subsequent diffuse knee swelling and difficulty bearing weight are suggestive of an ACL injury (9,10) A PCL injury may occur with a blow to the anterior tibia (e.g., a dashboard injury) or a fall on to a flexed knee with plantarflexed foot (9,11). A knee buckling sideways with varus or valgus forces increase the probability of LCL or MCL injury, respectively, and may be accompanied by an associated meniscal or ACL tear. Finally, joint pain and mechanical locking or a catching sensation following a twisting injury may indicate a meniscal tear or osteochondral injury with loose body (9). Physical examination of the knee includes observation, palpation of the soft tissues and bony anatomy and assessment of range of motion of the affected knee in comparison to the unaffected knee. Specific testing of the knee for laxity of ligaments and meniscal signs are helpful in making the diagnosis. The anterior drawer test and Lachman test are used to assess for ACL laxity. The anterior drawer test and Lachman test are similar tests used to assess ACL laxity. With the patient supine, the anterior drawer test is performed by bringing the knee into 90 degree flexion with the foot stabilized on the examiner's table. With one hand stabilizing the upper leg, the examiner then pulls on the lower leg just below the knee joint. Significant anterior mobilization of the lower leg compared to the uninjured knee is indicative of a likely ACL tear. The Lachman's test is performed similarly with the knee only flexed 20 to 30 degrees. The test may be aided by stabilization of the patient's foot on the examiner's table by sitting on the foot as the knee is pulled (9,10).
The posterior drawer test is utilized in assessing PCL laxity (11). Varus and valgus stress tests are completed at both 0 and 30 degrees of flexion to assess LCL and MCL integrity respectfully. Finally, McMurray’s, Thessaly, and Apley’s Grind tests can be used to assess for meniscal injury (9). McMurray's test is performed by fully internally or externally rotating the knee while it is flexed beyond 90 degrees. The test is considered positive if there is a palpable "clunk" at the joint line as the torn meniscus displaces (11). The Thessaly test can be performed with the examiner holding the patient's outstretched hands while the patient stands flatfooted on the floor with the knee kept in slight flexion at 20 degrees. The patient then rotates their knee and body internally and externally, three times. The test is considered positive if the patient experiences medial or lateral joint line pain (12). Apley’s test is done with the patient prone and knee flexed to 90 degrees. The lower leg is then pushed downward onto the knee joint while being held in external rotation. The test is considered positive if the maneuver produces pain (12).
Injury to one of the ligaments or menisci of the knee may be associated with other concomitant injuries to the knee. Therefore, in many cases, obtaining imaging is advised. Initially, standard radiographs of the knee with anteroposterior, lateral, and oblique views (internally or externally rotated) will help to rule out fractures. Sunrise or merchant views (axillary or tangential) can be help to identify patellar fractures. If there is concern for internal derangement based on the history and physical exam, additional notch view radiographs and a noncontrast knee MRI may be most appropriate to evaluate for ligamentous, meniscal, tendon, and muscle injuries. Treatment depends on the structure and severity of the injury. Interventions may include patellar stabilizing or hinged knee bracing, analgesics for pain, modified activities, physical therapy, and surgical intervention (9). Patient education on preventative measures, such as proper conditioning prior to athletic activity, correct sports biomechanics, and a focus on developmental coordination during times of rapid growth may improve outcomes.
A 16 year old female presents to the emergency room after falling off a ladder onto her left shoulder. The shoulder is visibly deformed, with the humeral head anterior to the shoulder, acromion prominent, and shoulder appearing squared off laterally. She is holding the arm in slight abduction and external rotation. The arm is painful to rotate. Neurovascular exam reveals normal capillary refill but decreased sensation over the lateral deltoid.
X-rays confirm an anterior glenohumeral dislocation. A closed reduction is performed, and post reduction radiographs confirm anatomic alignment of the shoulder joint with no fracture. The affected arm is immobilized in a shoulder immobilizer for two weeks.
The differential diagnosis for shoulder injury in the young athlete most commonly includes fractures of the clavicle or proximal humerus, rotator cuff injury, acromioclavicular joint sprain, or glenohumeral dislocation (13) Anterior glenohumeral dislocation is the most common direction of primary shoulder instability and comprises 95% to 97% of all shoulder dislocations (14). Pertinent anatomy of the shoulder contributing to stability includes static structures, such as the labrum, the capsule and ligamentous complex. Dynamic stability to the shoulder is provided by the rotator cuff musculature, including supraspinatus, infraspinatus, teres minor, and subscapularis (13). Anterior dislocation typically occurs when anterior force is applied to an abducted and externally rotated shoulder position such as during overhand throwing, spiking a volleyball, and tennis serving (13,15).
A thorough history and physical examination are key to identification of shoulder instability. In patients with an acute injury, pertinent historical information includes arm dominance, previous episodes of injury or dislocation, and presence of neurologic symptoms. Position of the extremity and direction of the force when the injury occurred should be noted. Examination should include palpation of the shoulder joint lines, musculature, and the bony anatomy, including cervical spine, scapula, clavicle, sternum, ribs, and humerus, as well as assessment for downstream neurovascular pathology. Rotator cuff strength and range of motion, as well as documentation of external rotation are important findings that suggest acute dislocation. With anterior glenohumeral dislocation, subluxation, and multidirectional instability, patients often present holding the arm in slight abduction and external rotation. Injured patients report pain upon attempting to rotate the arm, which is secondary to the spasticity of the rotator cuff muscles activating to stabilize the joint post injury (13,15). An anterior shoulder dislocation is often visibly evident, as the humeral head may be visible and palpable over the anterior shoulder in the deltopectoral groove and the acromion is prominent, giving a squared off appearance to the lateral shoulder (13). Axillary nerve injury occurs in approximately 42% of cases and presents as decreased strength and loss of sensation over the lateral deltoid (15) It should be noted that fractures of the humerus are more common than shoulder dislocation in younger children, while shoulder dislocations are more common in adolescents (16).
Standard assessment of traumatic shoulder injury and suspected dislocation includes X-ray confirmation, but this is often not done in clinical practice since a dislocation will require a reduction procedure, after which X-ray confirmation is useful to confirm anatomic reduction and whether a fracture is present. In a skeletally mature patient with an anterior shoulder dislocation, reduction without imaging is commonly done; however, since a proximal humerus fracture is more common than a dislocation in younger patients and these can be difficult to distinguish clinically, it is wise to obtain X-rays in young children prior to a reduction procedure attempt. If obtaining imaging, the standard three views of the shoulder should include anteroposterior, scapular Y, and axillary views (15). Given the high risk of internal injury of the soft tissues of the shoulder or damage to the bony structure of the glenoid after a primary dislocation, many providers obtain a shoulder MRI with arthrogram after an initial dislocation episode to better identify damage to the joint, but these are typically not obtained in emergency departments.
Acute dislocation requires prompt reduction. While there are over 20 different techniques to reduce a shoulder joint, there are several more common reduction methods, the choice of which is patient and provider dependent. A few of the more popular reduction methods are described below. Sedation and analgesia (e.g., intranasal midazolam or fentanyl) can be helpful to facilitate relaxation of the spastic rotator cuff muscles. Intra-articular lidocaine administration has been advocated by some experts. All of the reduction techniques can be performed with or without pharmacologic sedation and analgesia. 1) The external rotation reduction method requires the least assistance and equipment. With the patient lying supine or sitting upright, the procedure starts with the elbow flexed at 90 degrees with the forearm in a position of comfort and the humerus and elbow held adducted against the side of the chest. The humerus is slowly externally rotated using the forearm as a lever, keeping the elbow against the body. With gradual external rotation, glenohumeral reduction occurs spontaneously as the forearm approaches the coronal plane (i.e., extreme external rotation) (14). 2) The Milch technique involves the patient lying supine. The clinician holds the wrist or elbow and applies axial traction while gradually externally rotating and abducting the arm (14,15). 3) The Stimson technique utilizes a weight which is affixed to the wrist to apply traction to the joint. The patient lies prone with the weighted upper extremity hanging over the side of an elevated gurney, with reduction occurring gradually as the rotator cuff muscles relax and stretch (14). This method cannot be used for tall patients since the weight will be touching the ground even at maximum gurney elevation. 4) The scapular manipulation technique involves moving the glenoid rather than the humeral head. To perform this technique, the provider attempts to rotate the inferior end of the scapula medially to disengage the humeral head from the rim of the glenoid and allows the humeral head to be reduced into the glenohumeral joint space with slight axial traction (14,15).
Following reduction, one should obtain confirmatory post-reduction radiographs and immobilize the arm for two to three weeks in a shoulder immobilizer (a sling held against the body by another strap) (13,15). In actual clinical practice, post-reduction X-rays aren’t always obtained because an X-ray could have been obtained prior to the reduction procedure and it might not be necessary to always obtain pre and post reduction X-rays on all of these cases. Yet the post reduction X-ray will occasionally demonstrate a small fracture and it can be unclear whether the fracture occurred during the injury or during the reduction procedure. In some instances of recurrent dislocation and reduction, no X-rays are obtained as long as the patient is completely comfortable after reduction. Rehabilitation of the injured shoulder involves exercises targeting range of motion, strength, and function. Close follow-up with a physical therapist or athletic trainer is typically very beneficial. Even with optimal management following a primary shoulder dislocation, recurrent episodes of instability are extremely common in adolescents and young adults. In contact sport athletes younger than 25 years old, recurrent dislocation injury has been reported in up to 92% of cases (15). Hence, some providers recommend orthopedic surgical consultation for shoulder stabilization procedures after a patient’s first dislocation episode and particularly in individuals with repeated dislocation or subluxation.
Questions
1. What is the most common mechanism of injury resulting in a lateral ankle sprain?
2. Which ankle ligament is most commonly injured?
3. Early management of acute ankle sprain employs RICE. What does this mnemonic stand for?
4. Following a stable lateral ankle sprain, how long before gradual resumption of activity is recommended?
5. What is the most common mechanism of injury for radial head subluxation (nursemaid elbow)?
6. How do you reduce a subluxation of the radial head?
7. If you suspect an ACL rupture, what specific tests can assess for ACL laxity?
8. What nerve is commonly injured in an anterior dislocation of the shoulder? What are the typical deficits associated with this injury?
9. Describe two procedures to reduce an anterior shoulder dislocation.
10. For which of the following is an X-ray of the shoulder highly recommended?
a. 8 year old male with a suspected anterior shoulder dislocation
b. 16 year old female with a recurrent shoulder dislocation
c. 9 year old female soccer player with pain over the clavicle
d. 12 month old male with a pulling injury
Related x-rays
Ankle sprain: Inaba AS. Ankle Injuries: A Sprained Ankle ? In: Yamamoto LG, Inaba AS, DiMauro R. Radiology Cases In Pediatric Emergency Medicine, 1995, volume 3, case 3. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v3c03.html
Series of ankle x-rays: Inaba AS, Yamamoto LG. Test Your Skill In Reading Pediatric Ankles. In: Yamamoto LG, Inaba AS, DiMauro R. Radiology Cases In Pediatric Emergency Medicine, 1995, volume 3, case 5. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v3c05.html
Shoulder dislocation: Yamamoto LG. Closed Reduction of a Dislocated Shoulder. In: Yamamoto LG, Inaba AS, DiMauro R. Radiology Cases In Pediatric Emergency Medicine, 1996, volume 4, case 12. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v4c12.html
References
1. Melanson SW, Shuman VL. Acute Ankle Sprain. In: StatPearls. StatPearls Publishing; 2022. Accessed March 6, 2022. http://www.ncbi.nlm.nih.gov/books/NBK459212/
2. Brockett CL, Chapman GJ. Biomechanics of the ankle. Orthopaedics and Trauma. 2016;30(3):232-238. doi:10.1016/j.mporth.2016.04.015
3. Halabchi F, Hassabi M. Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World J Orthop. 2020;11(12):534-558. doi:10.5312/wjo.v11.i12.534
4. Boutis K, Grootendorst P, Willan A, et al. Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries. CMAJ. 2013;185(15):E731-738. doi: 10.1503/cmaj.122050
5. Boutis K, Komar L, Jaramillo D, et al. Sensitivity of a clinical examination to predict need for radiography in children with ankle injuries: a prospective study. Lancet. 2001;358(9299):2118-2121. doi: 10.1016/S0140-6736(01)07218-X
6. Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52(15):956. doi:10.1136/bjsports-2017-098106
7. Zitelli BJ, McIntire SC, Nowalk AJ, Garrison J. Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis. Eighth Edition. Elsevier; 2023.
8. Nardi NM, Schaefer TJ. Nursemaid Elbow. In: StatPearls. StatPearls Publishing; 2022. Accessed March 8, 2022. http://www.ncbi.nlm.nih.gov/books/NBK430777/
9. Miller M, Dempsey I. Chapter 14: Overview of the Knee and Lower Leg. In: Miller MD, Hart JA, MacKnight J M (eds). Essential Orthopaedics, 2nd edition, 2020. Elsevier; Philadelphia, PA. pp:574-585.
10. Evans J, Nielson J l. Anterior Cruciate Ligament Knee Injuries. In: StatPearls. StatPearls Publishing; 2022. Accessed March 11, 2022. http://www.ncbi.nlm.nih.gov/books/NBK499848/
11. Raj MA, Mabrouk A, Varacallo M. Posterior Cruciate Ligament Knee Injuries. In: StatPearls. StatPearls Publishing; 2022. http://www.ncbi.nlm.nih.gov/books/NBK430726/ Accessed March 11, 2022.
12. Blyth M, Anthony I, Francq B, et al. Diagnostic accuracy of the Thessaly test, standardised clinical history and other clinical examination tests (Apley’s, McMurray’s and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis. Health Technol Assess 2015;19(62):1-62. doi: 10.3310/hta19620
13. Ho C. Chapter 29. Upper Extremity Injuries. In: Herring J (ed). Tachdjian’s Pediatric Orthopaedics, 6th edition. Elsevier, Philadelphia, PA. 2022:pp1175-1273.
14. Alkaduhimi H, van der Linde JA, Flipsen M, et al. A systematic and technical guide on how to reduce a shoulder dislocation. Turk J Emerg Med. 2016;16(4):155-168. doi:10.1016/j.tjem.2016.09.008
15. Pak T, Kim AM. Anterior Glenohumeral Joint Dislocation. In: StatPearls. StatPearls Publishing; 2022. Accessed March 11, 2022. http://www.ncbi.nlm.nih.gov/books/NBK557862/
16. Pediatric Orthopaedic Society of North America (POSNA). Shoulder Dislocation/Instability. https://posna.org/Physician-Education/Study-Guide/Shoulder-Dislocation-Instability Accessed March 11, 2022.
Answers to questions
1. Combination of plantar flexion and inversion.
2. Anterior talofibular ligament (ATFL).
3. Rest, Ice, Compression, Elevation.
4. 72 hours, but this depends on the severity of the sprain. Minor injuries can ambulate sooner.
5. Traction (pulling) injury resulting from being lifted or pulled by the hand or forearm.
6. Supination or hyperpronation of the forearm at the elbow.
7. Lachman and anterior drawer tests assess ACL laxity.
8. Axillary nerve injury. Injury to the axillary nerve can result in deltoid weakness and paresthesia to the lateral aspect of the shoulder.
9. External rotation method, Milch technique, Stimson technique, scapular manipulation. See text for detailed descriptions.
10. A. Young children suspected of shoulder dislocation are more likely to have a fracture of the proximal humerus than a dislocation. The yield from initial shoulder X-rays in recurrent dislocation cases is low, other than demonstrating a dislocation which was already determined clinically. A clavicle X-ray should be done in a clavicle fracture, but if examination of the shoulder is normal, X-rays of the shoulder are low yield. Young children with nursemaid elbows will sometimes appear to have pain in their wrist, elbow, or shoulder. If it is a pulling injury and there is no focal tenderness, swelling, or deformity, then reduction should be attempted before X-rays.