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Three Part Question

What is the [diagnostic accuracy] of [point-of-care ultrasound (POCUS)] for identifying [shoulder dislocation in emergency department patients] when compared with [standard radiographs]?

Clinical Scenario

A 23-year-old male presents with right shoulder pain after falling and catching himself. Physical exam demonstrates a squared off right shoulder with anterior fullness, with the patient holding his arm in slight abduction and external rotation. Anterior shoulder dislocation is suspected. The x-ray department is backed up, and you are wondering if point-of-care ultrasound is appropriate for diagnosing a shoulder dislocation.

Search Strategy

Medline 1966-07/21 using PubMed, Cochrane Library (2021), and Embase
[(Shoulder Dislocation/diagnostic imaging [MAJR]) AND (Ultrasonography [MAJR])]. LIMIT to English language.

Search Outcome

105 studies were identified: three studies addressed the clinical question. These studies include a meta-analysis, a systematic review, and a prospective observational study that was published after the meta-analysis and systematic review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gottlieb et al April 2019 USA	7 studies (739 total patients) including patients of all ages who underwent both ultrasonography and confirmatory imaging (plain radiography or CT)	Meta-analysis	Overall sensitivity and specificity of ultrasound for diagnosing shoulder dislocations	Sensitivity was 99.1% and specificity was 99.9%	No randomized controlled trials; providers performing ultrasound were not blinded to physical exam findings
			Overall sensitivity and specificity of ultrasound for detecting presence of associated fracture	Sensitivity was 97.9% and specificity was 99.8%
Entezari et al Oct 2019 Iran	6 studies and 1 unpublished data (467 total patients) including patients of all ages who underwent both ultrasonography and plain radiography	Systematic review	Sensitivity of ultrasound for diagnosing shoulder dislocations	Sensitivity was 100% in four studies. One study found a sensitivity of 99% and other study found a sensitivity of 54%	No randomized controlled trials. Includes data from relatively small studies (n=5 and n=10), and one unpublished study. Providers performing ultrasound were not blinded to physical exam findings
			Specificity of ultrasound for diagnosing shoulder dislocations	Specificity was 100% in five studies. Specificity was 60% in one study.
Secko et al August 2020 USA	65 total patients aged 18 and older from two university-based emergency departments who underwent both ultrasonography and plain radiography	Prospective observational study	Sensitivity and specificity of ultrasonography	Sensitivity was 100% and specificity was 100%	Ultrasounds were performed by ultrasonography fellows or fellowship-trained emergency physicians; convenience sample; and not randomized.
			Proportion of associated fractures identified by ultrasonography	52% of fractures identified on radiographs were also identified by ultrasonography
			Time to diagnosis from triage	51 min for ultrasonography versus 101 min for radiography

Comment(s)

Shoulder dislocations are common injuries encountered in emergency departments. Potential benefits of point-of-care ultrasonography over plain radiography for diagnosing shoulder dislocations include decreased time to diagnosis and radiation exposure, and the ability to confirm reduction rapidly at bedside while the patient is still sedated. The available evidence suggests that ultrasonography is an appropriate alternative to plain radiography for diagnosing shoulder dislocations.

Clinical Bottom Line

Point-of-care ultrasound has high sensitivity and specificity for diagnosing shoulder dislocations.

References

1. Gottlieb M, Holladay D, Peksa GD. Point-of-care ultrasound for the diagnosis of shoulder dislocation: A systematic review and meta-analysis. Am J Emerg Med 2019 Apr;37(4):757-761.
2. Entezari P, Jalili M, Seyedhosseini J, Doosti-Irani A, Mirfazaelian H. Accuracy of Ultrasonography in Diagnosis of Shoulder Dislocation: A Systematic Review. Adv J Emerg Med 2019 Oct 16;4(1):e9.
3. Secko MA, Reardon L, Gottlieb M, Morley EJ, Lohse MR, Thode HC Jr, Singer AJ. Musculoskeletal Ultrasonography to Diagnose Dislocated Shoulders: A Prospective Cohort. Ann Emerg Med 2020;76:119-128.