Welcome to the Emergency Medicine Cases Podcast.

I'm your host, Dr. Anton Hellman, bringing you Canada's brightest minds in emergency medicine from EMC Studios in Toronto.

I have a new respect for my shoulder patients that I see in the emergency department since I broke my humorous mountain biking last summer. That was actually the seed for this podcast. And I also really wanted to have the dynamic duo of Aaron C.L. The brains behind Casted and Dale Dancer, upper extremity orthopedic surgeon

wizard back on the show after their stellar performance on the elbow injuries episode.

As I started brushing up on this topic of emergency shoulder injuries, I quickly realized

that there's a little more to know about the

shoulder than anterior shoulder dislocations and the dozens of ways to reduce them.

It turns out that we sometimes miss or mismanaged shoulder injuries because we're lured into

thinking that a normal x-ray means no serious injury.

So we're going to dig into the differential diagnosis to think through when you see a normal x-ray in a patient with a shoulder injury. So we're going to dig into the differential diagnosis to think through

when you see a normal x-ray in a patient with a shoulder injury. We'll call it the occult

shoulder injury. We'll also discuss the nuances of diagnosis and management of the various

kinds of shoulder dislocations, proximal humorous fractures, and clavicle fractures. But before we dive in, I'd like to start off by stepping back a bit, take a broader perspective,

if you will, and ask Dr. C.L.

In general, why do we miss orthopedic injuries so often?

Well, you're absolutely right, Anton.

It is commonly missed and emerged, probably the most common thing that we miss and emerged diagnostically would be orthopedic injuries. And I think the biggest issue is we over-relie in the x-ray and we underperform when it comes to the common things like history and physical. So we let the x-ray do way more work than it's capable of doing. So we don't do that for anything else.

We take x-ray normal to be a diagnosis, meaning some soft tissue injury, and that's probably the biggest issue. So short-changing the history, not understanding age-related prevalence, the patient to whom

the injury occurred, not examining patients. These are big pitfalls orthopedically. Often these patients

are in the fast track or the ambulatory area. We want to be kind of fast and keep our numbers up,

and that leads to shortcuts. Then we take an x-ray and we may not be the right x-ray, or we didn't

look at it properly, or we looked at one view, and we didn't use the x-ray tool as best as we could.

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