Necessity of radiographs in the emergency department management of shoulder dislocations

Study objective: To determine the necessity of radiographs in the emergency department management of patients with suspected shoulder dislocation. Methods: A prospective, observational study was conducted at a university-a ffiliated, level I trauma center ED with an emergency medicine residency pr ogram. Physicians entered all patients with a suspected shoulder dislocatio n and reported whether they were certain that the patient's shoulder was di slocated or reduced, before obtaining radiographs. Outcome measures were th e assessments of joint position and the radiology reports of prereduction a nd postreduction films. Results: One hundred four patients were enrolled in the study, including 98 with shoulder dislocations, and 191 physician assessments were performed ( 96 prereduction, 95 postreduction). Twenty-eight patients had recurrent dis locations with an atraumatic mechanism (group 1), and 76 had no prior dislo cation or a blunt mechanism of injury (group 2). There were no fractures in group 1 patients; the accuracy of confident assessments was 100% (95% conf idence interval 92% to 100%). In group 2, the accuracy of confident assessm ents was 98% (95% confidence interval 94% to 100%). Incorrect assessments o ccurred only in patients with fractures. A derived algorithm would have red uced radiographs by 51%. Conclusion: Physicians are highly accurate in the clinical determination of shoulder dislocation and relocation. Radiographs should be obtained when t he physician is uncertain of dislocation or reduction. Prereduction films s hould be obtained for patients with a blunt traumatic mechanism of injury, and postreduction for those found to have a fracture-dislocation. However, postreduction films add little in patients without fractures, and neither p rereduction nor postreduction films are likely to affect the ED management of patients with recurrent dislocation by an atraumatic mechanism. Prospect ive validation of the derived algorithm is suggested.