Anterior shoulder dislocation at a beach volleyball tournament

Patient Information

Dispatch: You are called to the beach volleyball courts at a summer sports carnival where a 24-year-old male (Tom Ricci) has been injured diving for the ball. He is sitting on the sand cradling his right arm, unable to move it. Teammates say his shoulder 'popped out'.
Patient: Tom Ricci — 24yr (82kg)
Incident History: Patient dived laterally for the ball, landed on his outstretched right arm with the arm abducted and externally rotated. Felt an immediate 'pop' and severe pain in the right shoulder. Unable to move the arm. No head or neck injury. No other trauma. Right-hand dominant.
Emergency Contact: Marco Ricci (Father) — 0412 229 446

Initial Rapid Assessment

Response: Alert
Airway: Patent. Speaking clearly.
Breathing: Comfortable. RR 14. No respiratory distress.
Circulation: Left radial pulse strong. Right radial pulse present — palpable at the wrist. Skin warm and dry. CRT <2s bilaterally.
Disability: GCS 15 (E4V5M6). Alert and orientated. In significant pain. Protective of right shoulder and arm.
Exposure: Right shoulder — visible loss of normal rounded contour ('squared-off' appearance). Arm held in slight abduction and external rotation. A fullness is palpable anteriorly (humeral head displaced anteriorly). Unable to touch right hand to left shoulder. No open wound. No bruising yet.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	99% (RA)	Nil	14	92	126/80	<2s	15	4 4 ++	37	–	9
15 mins	99% (RA)	Nil	14	84	124/78	<2s	15	4 4 ++	37	–	6

History Taking

Treatment Response

Diagnosis

Anterior glenohumeral (shoulder) dislocation of the right dominant arm. Classic presentation: arm held in abduction and external rotation, squared-off shoulder contour, anterior fullness (displaced humeral head). Neurovascular complication: axillary nerve injury (C5, C6) — presents as reduced or absent sensation over the lateral deltoid (the 'regimental badge' area). Sensation is partially reduced in this scenario. Radial pulse is intact. Joint reduction is NOT within EHS scope — immobilise in position of comfort, provide analgesia, and arrange CSP transport to Emergency Department for X-ray and formal reduction under sedation. History of prior dislocation is relevant — recurrent dislocations can occur with less force and may indicate significant ligamentous laxity.

Facilitator Triggers — if trainees miss a critical step

! (If a trainee attempts to reduce the shoulder — patient cries out and teammate shouts 'stop!' Facilitator note: shoulder reduction is NOT within EHS scope. Reduction without imaging risks associated fracture displacement, neurovascular injury, and requires sedation/analgesia in a clinical setting. Immobilise in position found and transport.)
! (If trainees do not assess axillary nerve sensation — prompt: 'He reports numbness in the upper arm — where specifically? What structure might be affected?' Expected: trainee checks light touch sensation over the lateral deltoid (outer upper arm / regimental badge area). Sensation is partially reduced in this scenario — document and include in handover.)
! (If trainees do not check the right radial pulse — prompt: 'The axillary artery runs anterior to the joint — what vascular check should you perform?' Expected: right radial pulse palpated and confirmed present.)
! (If trainees do not offer analgesia before attempting immobilisation — patient becomes very resistant to any movement. Prompt: 'He's in severe pain — is there something you should do before trying to position him?' Facilitator note: Methoxyflurane prior to immobilisation significantly improves cooperation and patient experience.)
! (If trainees are pressured by the patient to 'just pop it back in' because he has had it done before — facilitator note: patient expectations do not change EHS scope. Explain clearly and respectfully that reduction carries risks without imaging and sedation, and that the correct management is prompt transport for emergency reduction.)

Treatment Objectives

1 Ensure scene safety — clear spectators, create working space around patient.
2 Don appropriate PPE.
3 Perform Primary Survey — no life-threatening injury. Right shoulder isolated trauma.
4 Obtain history — confirm mechanism (FOOSH/abduction-external rotation), prior dislocation, nil other injury.
5 Inspect the right shoulder — note squared-off contour, arm held in abduction and external rotation, anterior fullness.
6 Assess neurovascular status BEFORE immobilisation:
7 — Right radial pulse: palpate and confirm present.
8 — Sensation: light touch over the lateral deltoid ('regimental badge area') — assessing axillary nerve (C5). Document: partially reduced in this scenario.
9 — Distal motor: ask patient to flex and extend fingers and wrist — intact.
10 Do NOT attempt reduction. Explain to the patient clearly and respectfully that the arm will be immobilised in the position found and further care arranged.
11 Offer Methoxyflurane (Penthrox) for analgesia — patient self-administers while you prepare for immobilisation.
12 Immobilise the arm in the position of comfort — typically in slight abduction and external rotation (the position the patient holds it naturally). Use a sling with padding under the arm if required. Do NOT force the arm into adduction.
13 Reassess right radial pulse and sensation after immobilisation — confirm no deterioration from the sling.
14 Complete Vital Sign Survey.
15 Contact CSP — patient requires ambulance transport to Emergency Department for X-ray (to exclude associated fracture) and formal reduction under procedural sedation.
16 Document: axillary nerve finding (partial sensory deficit over lateral deltoid), right radial pulse intact, mechanism, and prior dislocation history — all critical for handover.
17 Scenario ends on CSP arrival and IMISTAMBO handover.
18 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Musculoskeletal Injuries · Methoxyflurane · Primary Survey · Secondary & CNS Survey · Pain Assessment

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