Trauma

Anterior shoulder dislocation at a beach volleyball tournament

Intermediate

Adult · 24yr · male

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 — this is outside EHS scope. Explain to the patient clearly and respectfully.
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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Signs/Symptoms	Severe right shoulder pain after landing on outstretched arm. Visible shoulder deformity — squared-off contour. Unable to raise or move arm. Reports mild numbness over the outer upper arm (lateral deltoid region) — present from time of injury.
Allergies	NKDA.
Medications	Nil regular medications.
Pertinent History	One prior right shoulder dislocation — reduced in the Emergency Department approximately 2 years ago following a surfing injury. Nil rotator cuff surgery. Active sportsperson. No other medical history.
Last Oral Intake	Water before the match. Lunch approximately 3 hours ago.
Events Leading	Player was competing in a beach volleyball carnival tournament. Dived to retrieve a shot, landed with his right arm outstretched and the shoulder in an abducted and externally rotated position — classic mechanism for anterior glenohumeral dislocation.
Treatment Prior	Teammates tried to support his arm. One teammate suggested they 'pull it back in' — patient declined.

Onset	Immediate, at the moment of landing during the dive.
Pain	Severe, constant pain in the right shoulder and upper arm. 9/10.
Quality	Severe, constant aching with sharp pain on any attempted movement.
Radiates	Pain radiates to the right upper arm. Mild numbness over the lateral deltoid (outer shoulder area).
Severity	9/10.