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Three Part Question

In [adult patients with clinically presumed shoulder dislocations] is [ultrasound as reliable as radiography] in [identifying shoulder dislocation]?

Clinical Scenario

A 30-year-old man with a history of remote shoulder dislocation presents with left shoulder pain and decreased range of movement after quickly reaching for the telephone. There was no direct trauma and the clinician is wondering if a shoulder radiograph is necessary.

Search Strategy

PubMed from inception to 12/2015
"Shoulder Dislocation” AND ("Ultrasonography” OR “Ultrasound”) LIMIT to Human and English language

Search Outcome

83 papers were identified, of which there were 10 case reports and one relevant prospective, observational study.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Abbasi S et al 2013 Iran	73 patients with suspected shoulder dislocation over 7 months	Prospective, observational study	Diagnostic accuracy of ultrasound for confirming dislocation and reduction.	Ultrasound was 100% sensitive and specific for both dislocations and reductions. Ultrasound also identified all 11 associated fractures.	Small sample size, high proportion of dislocated shoulders in the sample.
Akyol et al, 2016 USA	103 patients over 15 years old with suspected shoulder dislocation on examination in the ED (98 patients had dislocation on X-ray)	Prospective, observational	Efficacy of Point of Care Ultrasound in ruling in and out shoulder dislocation in the ED	100% sensitivity and specificity of confirming shoulder dislocation and relocation. 100% sensitivity and 84.2% specificity in excluding associated fractures.	Requires ultrasound-trained staff. Some false-positive results.

Comment(s)

Both prospective studies demonstrated 100% accuracy for identifying both shoulder dislocations and subsequent reductions in a convenience sample of patients with suspect shoulder dislocation. Although there were no other, or larger, studies to support this evidence further, there were multiple case studies and are several online blog posts,3–5 which confirm the use and success of diagnosing shoulder dislocations, both in the ED and in the prehospital setting. Ultrasound has been shown to be accurate and successful in confirming shoulder dislocation, and reduction, in a patient group with a high incidence of dislocation. There is likely to be an element of operator dependency and so further studies would be required to validate this finding with a wider range of settings and operators. The presence of an associated fracture was also detected by this method with a high level of sensitivity although the numbers involved are very small and need to be interpreted with caution.

Clinical Bottom Line

The use of ultrasound shows promise as a method of confirming shoulder dislocation without requiring X-ray. Although both studies had sensitivity and specificity of 100% compared with plain X-rays, only two relatively small studies were found in the literature search; further validation of these findings would be required before recommending this as standard practice.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Abbasi S, Molaie H, Hafezimoghadam P et al. Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department. Ann Emerg Med. 2013;62:170–5
2. Akyol C, Gungor F, Akyol AJ, et al. Point-of-care ultrasonography for the management of shoulder dislocation in ED. Am J Emerg Med 2016:34:866–870.
3. Use of ultrasound to confirm shoulder dislocation. http://www.smartbrief.com/s/2015/04/ultrasound-may-beat-radiographs-ed-identification-shoulder-dislocation [Smartbrief Online] 2015
4. Clinical explanation of ultrasound use in suspected shoulder dislocation. http://broomedocs.com/2013/10/clinical-case-092-shoulder-shrugging/ [broomedocs Online] 2013
5. Blog review of referenced 2013 paper, with video guidance for ultrasound use in shoulder dislocation diagnosis and regional anaesthesia. https://sonospot.wordpress.com/2013/12/23/sonostudy-ultrasound-for-shoulder-dislocation-dx-to-anesthesia-reduction-foamed-foamus/ [Online 2013]