Emergency Medicine Hub / Trauma & Orthopedics • 3 min read • 4 sections

Shoulder & Elbow Dislocations & Supracondylar Fractures

Comprehensive emergency evaluation and protocolized management of upper extremity dislocations and pediatric elbow trauma: diagnostic differentiation and closed reduction of Anterior Glenohumeral Dislocations using gentle, non-traction techniques (Cunningham massage, Davos auto-reduction, Milch technique); Axillary Nerve assessment over the 'regimental badge' deltoid patch; Hill-Sachs and Bankart osseous lesions; clinical hallmarks of frequently missed Posterior Shoulder Dislocations following seizures or electrical shocks ('lightbulb sign', fixed internal rotation); Acute Elbow Dislocations and neurovascular surveillance; and Pediatric Supracondylar Humerus Fractures (Gartland classification, fat pad signs, anterior humeral line, and prevention of Volkmann ischemic contracture).

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

Posterior Shoulder Triad

Seizure/Electrocution history + arm locked in internal rotation + 'Lightbulb sign' on AP radiograph -> Axillary view confirms posterior dislocation

Axillary Nerve Exam

Test sensation over the lateral deltoid ('regimental badge' patch) and deltoid motor tone before and after shoulder reduction

Cunningham Reduction

Pain-free anatomical reduction without sedation: patient seated upright, gentle manual massage of trapezius, deltoid, and biceps to relieve muscle spasm

Pediatric Posterior Fat Pad

Visualization of a POSTERIOR fat pad on a lateral elbow radiograph is ALWAYS pathologic, indicating an occult non-displaced fracture (90% supracondylar)

Anterior Humeral Line Rule

A line drawn down the anterior cortex of the humerus on lateral radiograph must intersect the MIDDLE THIRD of the capitellum; if anterior, Gartland fracture is present

Volkmann Contracture Prevention

Pain on passive extension of fingers in supracondylar fracture indicates deep volar compartment ischemia -> Splint elbow in < 90 degrees flexion and call Ortho stat

Sternoclavicular Dislocation

Posterior sternoclavicular dislocation is an orthopedic emergency; medial clavicle is displaced posteriorly into mediastinum compressing trachea, esophagus, or great vessels; urgent reduction required in OR.

Bennett & Rolando Fractures

Intra-articular fractures at base of first metacarpal (thumb); Bennett = 2-part fracture dislocation with abductor pollicis longus pull; Rolando = comminuted Y or T-shaped fracture; require thumb spica and operative fixation.

Bottom-Line Clinical Pearl

Posterior shoulder dislocations are missed on initial emergency department evaluation in more than 50% of cases: suspect posterior dislocation in any patient presenting following a generalized tonic-clonic seizure or high-voltage electrical shock whose arm is locked in **fixed internal rotation** (unable to externally rotate past neutral). Standard AP shoulder radiographs show a deceptive 'lightbulb sign' (internally rotated humeral head); an Axillary or Scapular Y view is mandatory. In pediatric supracondylar fractures (Gartland II/III), displacement of the proximal bony spike poses extreme hazard to the **brachial artery** and anterior interosseous nerve (AIN): an absent radial pulse or severe pain with passive finger extension indicates acute forearm ischemia requiring emergent orthopedic reduction to prevent **Volkmann Ischemic Contracture**.

1. Anterior vs. Posterior Glenohumeral Shoulder Dislocations

The glenohumeral joint is the most frequently dislocated large joint in the human body, owing to the shallow glenoid fossa and wide range of mobility. Accurately distinguishing anterior from posterior dislocations is essential:

Feature	Anterior Shoulder Dislocation (95% to 97%)	Posterior Shoulder Dislocation (2% to 4%)
Precipitating Mechanism	Abduction, external rotation, and extension (e.g., throwing a football, falling backward on an outstretched arm).	Violent, simultaneous internal rotator muscle contractions during generalized tonic-clonic seizures, high-voltage electrocution, or lightning strikes (latissimus dorsi, pectoralis major, and subscapularis overpower weaker external rotators).
Physical Examination	Arm held in slight abduction and external rotation; loss of normal rounded deltoid contour ('squared-off shoulder'); palpable subcoracoid fullness.	Arm locked in fixed ADDUCTION and INTERNAL ROTATION. The patient CANNOT externally rotate the humerus past neutral. Prominent coracoid anteriorly; fullness posteriorly.
Radiographic Hallmarks	Humeral head displaced medially and inferiorly beneath the coracoid process. - Bankart Lesion: Tear or fracture of anterior-inferior glenoid labrum. - Hill-Sachs Deformity: Compression fracture of posterolateral humeral head.	THE DECEPTIVE AP RADIOGRAPH: Humeral head is internally rotated, appearing perfectly circular and symmetrical on AP view ('The Lightbulb Sign' or 'drumstick sign'). Absence of normal elliptical overlap between humeral head and glenoid. MANDATORY VIEW: Axillary view or Scapular Y view definitively shows the humeral head resting posterior to the glenoid.
Neurovascular Risk	Axillary Nerve (C5-C6): Tested by assessing sensation over the lateral deltoid muscle ('regimental badge' patch). Motor branch tested by deltoid contraction.	High risk of missed diagnosis (> 50% missed on initial presentation!), leading to chronic locked dislocation and avascular necrosis.

2. Modern Non-Traumatic Shoulder Reduction Techniques

Traditional traction-countertraction (Hippocratic technique: foot in the axilla) causes severe brachial plexus neuropraxia and labral damage and is obsolete. Modern techniques utilize biomechanics and gentle relaxation:

Reduction Technique	Stepwise Procedural Action	Advantages & Clinical Pearls
Cunningham Technique (Pain-Free/No Sedation)	1. Patient sits upright in a chair with back supported. 2. Examiner sits facing the patient, placing the patient's affected wrist on the examiner's shoulder. 3. Examiner instructs patient to relax shoulders and breathe slowly. 4. Examiner uses both hands to gently massage the trapezius, deltoid, and biceps brachii muscles consecutively.	Success rate > 85-90% without procedural sedation or intravenous opioids! Relieving biceps spasm allows the humeral head to glide spontaneously back over the glenoid rim under the weight of the arm.
Davos (Autoreduction) Technique	1. Patient sits on stretcher with hips and knees flexed to 90 degrees. 2. Patient clasps both hands together around the ipsilateral knee (or tie wrists together with an elastic bandage). 3. Patient slowly leans head and neck backward while extending the elbows.	Self-reduction technique: the patient's own body weight applies gentle, perfectly aligned axial traction while the patient controls the force. Zero sedation required.
Milch Technique	Patient supine. Examiner slowly, gently abducts the arm overhead into full forward elevation while gently externally rotating the humerus, then applies gentle thumb pressure to the humeral head in the axilla.	Relies on aligning the humerus with the line of pull of the pectoralis major and latissimus dorsi, eliminating muscular resistance.
Stimson (Prone Hanging Weight) Technique	Patient lies prone on stretcher with affected arm hanging freely over the side. Attach 5 to 10 pounds (2.5-5 kg) of weight to the wrist.	Continuous gravity traction gradually fatigues the shoulder girdle musculature over 15 to 20 minutes, leading to atraumatic reduction.

3. Acute Elbow Dislocations & Neurovascular Complications

Elbow dislocations are classified by the position of the radius and ulna relative to the distal humerus. Posterior and posterolateral dislocations account for > 90% of cases, resulting from a fall onto an extended, abducted arm:

Feature	Clinical Presentation & Anatomy	Reduction Technique & Warnings
Neurovascular Hazards	1. Brachial Artery Injury: Sheared over the prominent distal humerus. 2. Ulnar & Median Nerve Neuropraxia: Stretched or entrapped across the joint.	Assess radial and ulnar pulses, capillary refill, and motor/sensory function of median (AIN: 'OK' sign), ulnar (abduction of fingers), and radial (wrist extension) nerves before and after reduction!
Closed Reduction Technique	Under procedural sedation: 1. Assistant stabilizes the distal humerus. 2. Examiner applies continuous in-line distal traction to the wrist while the elbow is flexed to 20 to 30 degrees. 3. Examiner applies anteriorly directed pressure to the posterior olecranon with the thumbs until a palpable 'clunk' is felt. 4. Gently flex the elbow past 90 degrees.	Immobilize in a long-arm posterior splint with the elbow at 90 degrees of flexion and neutral forearm rotation. The Terrible Triad of the Elbow: Elbow dislocation + Radial head fracture + Coronoid process fracture -> Highly unstable; mandates operative fixation.

4. Pediatric Supracondylar Humerus Fractures: Gartland Staging

Supracondylar fractures are the most common pediatric elbow fracture (peak age 5 to 7 years), caused by hyperextension of the elbow during a fall onto an outstretched hand (FOOSH). Because the brachial artery and anterior interosseous nerve (AIN) cross the anterior supracondylar region, displaced fractures represent an orthopedic emergency:

Gartland Classification	Radiographic Criteria & Fat Pad Signs	Emergency Management Strategy
Gartland Type I (Non-Displaced)	Bone cortices are intact. Anterior Humeral Line (AHL) passes normally through the middle third of the capitellum on lateral view. - Posterior Fat Pad Sign: Visualization of a lucent fat stripe behind the distal humerus (PATHOGNOMONIC FOR OCCULT INTRA-ARTICULAR FRACTURE). - Anterior 'Sail Sign': Elevation of anterior fat pad.	Immobilize in a long-arm posterior splint with elbow at 80 to 90 degrees of flexion. Outpatient orthopedic follow-up in 3-5 days.
Gartland Type II (Displaced with Intact Posterior Cortex)	Fracture is displaced, but the posterior bony cortex is intact (hinged). The Anterior Humeral Line passes anterior to the middle third of the capitellum (or completely misses the capitellum anteriorly).	Urgent closed reduction and percutaneous pinning (CRPP) by Orthopedic Surgery in the operating room.
Gartland Type III & IV (Completely Displaced/Multi-Directional)	Complete cortical disruption with zero bone contact; significant rotational or translational displacement.	ORTHOPEDIC SURGICAL EMERGENCY: High incidence of Brachial Artery and Anterior Interosseous Nerve (AIN) entrapment. - Emergent CRPP in the operating room. - If hand is pale/pulseless: immediate gentle in-line traction and splinting in extension; if pulse fails to return, emergent open vascular exploration.
Volkmann Ischemic Contracture (The Feared Disaster)	Brachial artery spasm or forearm compartment syndrome leads to ischemic necrosis of the deep flexor muscles of the forearm (flexor digitorum profundus and flexor pollicis longus).	THE EARLIEST WARNING SIGN: Severe, excruciating pain with passive extension of the fingers! Within hours, necrotic muscle fibroses into an irreversible claw-hand deformity with permanent flexor contracture.

The Post-Seizure Shoulder Miss & The Pink Pulseless Pediatric Elbow

Two catastrophic pitfalls occur in upper extremity emergencies. First, never assume a post-ictal patient's shoulder pain is a 'muscle strain' without obtaining an axillary radiograph: up to 50% of posterior shoulder dislocations are missed on initial presentation because standard AP radiographs look deceptively normal (the symmetrical 'lightbulb sign'). If a patient cannot externally rotate their shoulder after a seizure or electrocution, they have a posterior dislocation until proven otherwise by a Scapular Y or Axillary view. Second, in pediatric supracondylar fractures, beware the 'Pink Pulseless Hand': a displaced Gartland III fracture where the hand is warm and pink due to collateral flow, but the radial pulse is absent. DO NOT flex the elbow past 90 degrees during splinting! Acute elbow flexion kinking the brachial artery converts partial collateral flow into complete forearm ischemia, triggering Volkmann Ischemic Contracture (permanent muscle necrosis and claw deformity) within 4 to 6 hours. Splint the elbow in slight extension (< 70-80 degrees) and consult orthopedic surgery immediately for emergent closed reduction and pinning.

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