A potentially serious injury can unfold in the split second it takes for a student to land awkwardly on the playground or collide with an opponent on the basketball court. Even less dramatic incidents, like a student clutching their arm after a seemingly minor bump or twist, can cause concern. As a school nurse, you are often the first point of contact for these injuries, and recognizing the signs of a potential shoulder dislocation is a crucial skill. While not as common as fractures in younger children, shoulder dislocations in older students and adolescents can be painful and debilitating and require prompt and appropriate management. Let's delve into what school nurses need to know to effectively support students when a shoulder goes astray. 

Why Dislocations Happen

Shoulder dislocations occur when the humeral head is displaced from the glenoid fossa, the shoulder blade's shallow socket, disrupting the shoulder joint's stability. The mechanism behind shoulder dislocations typically involves a fall onto the shoulder or a blunt trauma that applies substantial force to the arm when it is in a vulnerable position—abducted, extended, and externally rotated.

In children under age 10, shoulder dislocations are relatively rare due to the anatomical characteristics of their developing bones. Specifically, the growth plates at the ends of long bones are typically weaker than the surrounding muscles and tendons. However, as children enter adolescence, the strength of their bones and growth plates increases, making dislocations more likely. Consequently, the prevalence of shoulder dislocations rises significantly during this period, particularly among adolescents aged 10 to 20, who are also more prone to such injuries due to increased physical activity and participation in sports. 

What Dislocations Look Like

Several key signs may point toward a possible dislocation when assessing a student with a shoulder injury. Observe for a noticeable alteration in the usual rounded shape of the affected shoulder, as the normal contour may appear flattened or squared. The student will likely exhibit a limited range of motion and experience significant pain with any attempt at movement. Other tell-tale signs can include:

• The student holding the arm across their chest or supporting it with their other arm.
• Possible deltoid muscle weakness or loss of sensation anywhere in the arm.
• The student describing a "pop" or feeling their shoulder "come out" at the time of injury.
• Swelling and bruising around the shoulder.

How to Provide First Aid

Delayed treatment of shoulder dislocation can not only make reduction more difficult but it can lead to serious complications. These include nerve damage, avascular necrosis, and osteoarthritis, as well as poor long-term outcomes like persistent pain, stiffness, and functional limitations. When a shoulder dislocation is suspected, school nurses should arrange for immediate transfer to the Emergency Department (ED) and inform parents/guardians of the situation and the need for urgent medical evaluation. Other school nursing interventions include:

• Immobilization: Apply a sling to support the injured arm, keeping it close to the body in a position of least discomfort.
• Ice: Apply ice to the shoulder to reduce pain and swelling.

The court, the field, or the playground—wherever the action unfolds at school, school nurses are there to ensure that injuries don't become major setbacks and that their students always have a 'shoulder' to lean on.