Polytrauma luxatio erecta shoulder relocation with ED interscalene block

26yoF struck by an auto as a pedestrian presented in with an obvious tib/fib fracture with her shoulder in this position:

 The patient was confused, agitated with unbearable left shoulder pain.   Any attempt to manipulate the shoulder was not tolerated.  A preliminary FAST exam was concerning for possible intraperitoneal hemorrhage.  The trauma team wanted to urgently pan CT scan the patient would not fit into the CT scanner gantry because of the arm position.  A portable xray was obtained:

Diagnosis of luxatio erecta inferior shoulder dislocation with scapular fracture was confirmed.

After a thorough neurologic exam of the affected extremity found no deficits, pneumothorax was excluded on both CXR and POC US, the decision was made to place an interscalene brachial plexus block. Given the possibility of phrenic nerve paralysis and the generally undifferentiated condition, it was determined that a short acting blockade was preferable.

2-chloroprocaine is an ester with very low toxicity.  This is reassuring in the high-pressure and potentially stressful acutely injured trauma patient scenario, where procedural errors are more common.  Additionally, the onset of 3% chloroprocaine is very fast, potentially faster than any other option.  The down-side is short duration of action, which is actually a benefit in cases like these where the physical reduction should dramatically reduce the pain, and a prolonged block could introduce concerns for evaluation of neurologic function or an inadavertent plexus associated, prolonged phrenic block could complicate management.

We prefer a stay-away approach where the needle tip is positioned underneath the middle scalene fascia and observed to spread into the interscalene groove, but we do not seek to position the needle tip between the nerve roots. 

1) Sternocleidomastoid 2)anterior scalene muscle 3) middle scalene muscle 4) carotid artery 5) C5/C6/C7 roots 6) needle

10 minutes after an interscalene block was placed with 25mL chloroprocaine, the shoulder was easily reduced with minimal discomfort. To access the lateral neck, manual c-spine immobilization was used during the the block procedure.  Post-reduction the patient was able to be comfortably positioned for pan CT scans which where negative for serious injury. During the hospital stay, the orthopedic injuries where repaired without complications.