eMedicine Specialties > Clinical Procedures > Musculoskeletal Procedures

Joint Reduction, Shoulder Dislocation, Anterior

Author: Elisa M Aponte, MD, Resident Physician, Department of Emergency Medicine, New York University Bellevue Hospital Center
Coauthor(s): Curt E Dill, MD, Service Chief, Emergency Medicine Department of Veterans Affairs, VA New York Harbor Healthcare Systems-NY; Assistant Professor, Department of Emergency Medicine, New York University School of Medicine
Contributor Information and Disclosures

Updated: Aug 2, 2009

Introduction

The shoulder is the most commonly dislocated large joint seen in the emergency department (ED), and anterior dislocations account for 90-98% of cases.1 Most dislocations are straightforward and easily reducible in the ED using one of several techniques. However, difficult cases do occur, and clinicians need to be mindful of coincident injuries and complications.

Clinical assessment

New shoulder dislocations generally require a great deal of force abducting and externally rotating the shoulder.2 However, in patients with recurrent dislocations, the forces may be relatively moderate.

The patient typically presents with an obvious squared-off shoulder with the humeral head located inferior and medial to the normal anatomic location. Patients generally hold the injured arm in abduction and resist attempts to adduct or internally rotate the arm.2

Management

A careful neurovascular examination should be performed prior to any attempts at reduction. The axillary nerve is the most commonly injured nerve in shoulder dislocations and can be evaluated by testing for sensation in the lateral upper arm and by palpating for contraction of the deltoid muscle while the patient abducts against resistance. The clinician should also assess for damage to other branches of the brachial plexus.

Arterial injury, though rare, is also possible and can present with paresthesias, diminished pulse, paleness or coolness of affected extremity, pain out of proportion to examination, or paralysis.2 Injury to the axillary artery is more common in the elderly population.3

The x-ray panel should include anteroposterior, lateral (Y), and axillary views of the shoulder and should be obtained for all but the most obvious cases. Radiographs are essential for first-time dislocations or those caused by direct trauma. Empiric reductions should be limited to young healthy patients with clinically apparent anterior shoulder dislocation if they have a history of recurrent dislocations, if they are neurovascularly intact, and if reduction can be performed easily and rapidly.

However, maintain a low threshold of suspicion for complicating factors and obtain prereduction radiographs liberally. Clinical factors that have been associated with clinically significant fractures include first episode, patient older than 40 years, or involvement in selected mechanisms of injury (ie, fall from more than one flight of stairs, fight or assault, motor vehicle collision).4 Some argue that prereduction films are necessary only in patients with these risk factors, especially those aged 40 years and older.5,6

Indications

The 4 types of anterior shoulder dislocation are subcoracoid, subglenoid, subclavicular, and intrathoracic. Subcoracoid and subglenoid dislocations account for 99% of anterior shoulder dislocations and are amenable to reduction by the emergency department physician. Subclavicular or intrathoracic dislocations, which are caused by large forces, are not easily corrected and should be referred to an orthopedic surgeon.2

Contraindications

Absolute contraindications

Standard shoulder reduction is absolutely contraindicated if prompt surgical consultation is indicated.2

  • Subclavicular or intrathoracic dislocations
  • Suspicion for major arterial injury: Require urgent angiography.
  • Associated fractures of the humeral neck: Attempts at reduction may result in avascular necrosis.

Relative contraindications

Minor neurovascular injuries and common fractures listed below do not prohibit reduction but require a prompt and atraumatic reduction with avoidance of multiple attempts.

  • Nerve injuries
    • The brachial plexus, axillary nerve, or musculocutaneous nerve may be injured.
    • Neurapraxias (contusions of the nerve) usually resolve within weeks.
  • Common fractures
    • The Hill-Sachs deformity, a compression fracture of the posterolateral aspect of the humeral head, and Bankart fracture, a detachment of the anterior aspect of the glenoid rim, may occur as the result of the dislocating force as the humeral head presses forcefully against the glenoid rim.2
    • Avulsion fractures of the greater tuberosity of the humeral head tend to heal well but require immediate orthopedic consult if the displacement is more than 1 cm.

More on Joint Reduction, Shoulder Dislocation, Anterior

Overview: Joint Reduction, Shoulder Dislocation, Anterior
Treatment & Medication: Joint Reduction, Shoulder Dislocation, Anterior
Multimedia: Joint Reduction, Shoulder Dislocation, Anterior
References
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References

  1. Westin CD, Gill EA, Noyes ME, Hubbard M. Anterior shoulder dislocation. A simple and rapid method for reduction. Am J Sports Med. May-Jun 1995;23(3):369-71. [Medline].

  2. Robert JR, Hedges RJ. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: W.B. Saunders Company; 2004.

  3. Allie B, Kilroy DA, Riding G, Summers C. Rupture of axillary artery and neuropraxis as complications of recurrent traumatic shoulder dislocation: case report. Eur J Emerg Med. Jun 2005;12(3):121-3. [Medline].

  4. Emond M, Le Sage N, Lavoie A, Rochette L. Clinical factors predicting fractures associated with an anterior shoulder dislocation. Acad Emerg Med. Aug 2004;11(8):853-8. [Medline].

  5. Emond M, Le Sage N, Lavoie A, Moore L. Refinement of the Quebec decision rule for radiography in shoulder dislocation. CJEM. Jan 2009;11(1):36-43. [Medline].

  6. [Guideline] New Zealand Guidelines Group (NZGG). The diagnosis and management of soft tissue shoulder injuries and related disorders. 2004;[Full Text].

  7. Miller SL, Cleeman E, Auerbach J, Flatow EL. Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations: a randomized, prospective study. J Bone Joint Surg Am. Dec 2002;84-A(12):2135-9. [Medline].

  8. Orlinsky M, Shon S, Chiang C, Chan L, Carter P. Comparative study of intra-articular lidocaine and intravenous meperidine/diazepam for shoulder dislocations. J Emerg Med. Apr 2002;22(3):241-5. [Medline].

  9. Fitch RW, Kuhn JE. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review. Acad Emerg Med. Aug 2008;15(8):703-8. [Medline].

  10. Ufberg JW, Vilke GM, Chan TC, Harrigan RA. Anterior shoulder dislocations: beyond traction-countertraction. J Emerg Med. Oct 2004;27(3):301-6. [Medline].

  11. Kothari RU, Dronen SC. Prospective evaluation of the scapular manipulation technique in reducing anterior shoulder dislocations. Ann Emerg Med. 1992;21(11):1349-52. [Medline].

  12. Marinelli M, de Palma L. The external rotation method for reduction of acute anterior shoulder dislocations. J Orthop Traumatol. Mar 2009;10(1):17-20. [Medline].

  13. Ugras AA, Mahirogullari M, Kural C, Erturk AH, Cakmak S. Reduction of anterior shoulder dislocations by Spaso technique: clinical results. J Emerg Med. May 2008;34(4):383-7. [Medline].

  14. Yuen MC, Yap PG, Chan YT, Tung WK. An easy method to reduce anterior shoulder dislocation: the Spaso technique. Emerg Med J. Sep 2001;18(5):370-2. [Medline].

  15. Halberg MJ, Sweeney TW, Owens WB. Bedside ultrasound for verification of shoulder reduction. Am J Emerg Med. Jan 2009;27(1):134.e5-6. [Medline].

  16. Dodson CC, Cordasco FA. Anterior glenohumeral joint dislocations. Orthop Clin North Am. Oct 2008;39(4):507-18, vii. [Medline].

  17. Brophy RH, Marx RG. The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Arthroscopy. Mar 2009;25(3):298-304. [Medline].

  18. Marx JA, Hockberg RS, Walls RM. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. CV Mosby, Inc.; 2002.

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Further Reading

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Keywords

anterior shoulder dislocation, anterior shoulder reduction, Hill-Sachs deformity, Bankart fracture, Stimson maneuver, scapular manipulation, traction-countertraction, Milch technique, Spaso technique, Waldron’s variation

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Contributor Information and Disclosures

Author

Elisa M Aponte, MD, Resident Physician, Department of Emergency Medicine, New York University Bellevue Hospital Center
Elisa M Aponte, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Curt E Dill, MD, Service Chief, Emergency Medicine Department of Veterans Affairs, VA New York Harbor Healthcare Systems-NY; Assistant Professor, Department of Emergency Medicine, New York University School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
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