Shoulder Dislocation in Emergency Medicine Follow-up

  • Author: Sharon R Wilson, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Oct 7, 2011
 

Further Inpatient Care

  • After procedural sedation with longer-acting sedating agents (eg, midazolam), the patient with shoulder dislocation should be observed for the necessary period and then discharged in the care of family or friends.
  • Patients who require operative reduction and repair should be admitted by the orthopedic surgery service.
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Further Outpatient Care

  • Arrange orthopedic follow-up in 5-7 days.
  • The patient's shoulder should remain in the immobilizer until his or her orthopedic clinic appointment.
  • Primary surgical repair of initial acute traumatic shoulder dislocations in young adults engaged in highly demanding physical activities (eg, sports, military) is supported by a Cochrane Database Systematic Reviews of 5 randomized, controlled studies.[12] Subsequent shoulder instability was significantly less frequent in the surgical group (relative risk, 0.20; 95% CI, 0.11-0.33), with half of the conservatively treated patients opting for subsequent surgery. Functional assessment measures of the shoulder were also more favorable in those treated surgically. Since this demographic group is at far greater risk of recurrent dislocation, these results cannot be generalized to other groups.
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Inpatient & Outpatient Medications

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be taken as needed for pain and inflammation.
  • A few days of narcotic analgesia, with an agent such as hydrocodone or oxycodone, is often helpful.
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Deterrence/Prevention

  • The patient should remain in the immobilizer until under the care of an orthopedic surgeon.
  • To prevent recurrent dislocation, patients should avoid immediate participation in contact or sporting activities. Simple activities that involve abduction and external rotation of the arm, such as combing their hair should also be avoided.
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Complications

  • Recurrent shoulder dislocation (See Prognosis).
  • Fractures and soft-tissue injuries (See Other Problems to be Considered.)
    • Hill-Sachs lesions occur when the edge of the glenoid causes an impaction fracture in the posterolateral aspect of the humeral head during anterior dislocation and in the anterolateral aspect in posterior dislocation (referred to as a "reverse Hill-Sachs" lesion).
    • A Bankart lesion is fracture of the anterior rim of the glenoid labrum associated with joint capsule rupture and inferior glenohumeral ligament injury. Significantly displaced anterior or posterior glenoid rim fractures require operative management. Most initial shoulder dislocations produce a Bankart lesion, particularly in younger patients.
    • Fracture of the greater tuberosity, acromion, coracoid, clavicle, and humeral neck also occur.
    • Rotator cuff traction injury is most common in elderly patients and in association with inferior dislocations. This is a commonly missed injury, with an average time of 7 months from injury to diagnosis of rotator cuff rupture in patients older than 40 years.
  • Nerve injury (See Other Problems to be Considered.)
    • Approximately 3% (and higher in some series) of dislocations involve injury to the axillary nerve. Injury may resolve spontaneously or require surgical exploration and possible nerve grafting.
    • Patients exhibit numbness in the area of the deltoid muscle and weakness with abduction and external rotation.
    • Axillary nerve injury does not change initial treatment, but pre-reduction and post-reduction neurologic examinations are important.
    • Radial nerve injury should also be determined. The axillary and radial nerves both arise from the posterior cord. The thumb, wrist, and elbow will be weak on extension, and the dorsal hand will be numb.
  • Vascular injury (See Other Problems to be Considered.)
    • Axillary artery injuries are rare but have been reported to occur with anterior, inferior, and intra-thoracic dislocations. Especially susceptible are older adults with atherosclerotic axillary arteries. Arterial injury may be associated with decreased radial pulse.
    • Lateral chest wall ecchymosis with associated axillary hematoma and bruit may be noted on physical examination.
    • Angiography should be considered with any brachial plexus injury.
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Prognosis

  • Age is a major factor in the likelihood of sustaining a recurrent shoulder dislocation.[13]
  • Approximately 80-94% of patients younger than 20 years at the time of the initial dislocation have a recurrence. The major pathology in this age group is thought to be a Bankart lesion with associated inferior glenohumeral ligament injury.
  • Of patients younger than 40 years, 26-48% develop recurrent dislocation. The major pathology for this age group is thought to be disruption of the labral attachment of the glenohumeral ligaments.
  • Dislocation recurs in only 0-10% of patients older than 40 years. Rotator cuff tear is the major pathology.
  • Minor trauma that results in a dislocation is associated with an 86% recurrence rate. Many orthopedic surgeons believe that more than one complete anterior dislocation justifies considering surgical repair.
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Patient Education

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Contributor Information and Disclosures
Author

Sharon R Wilson, MD  Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of California at Davis Medical Center

Sharon R Wilson, MD is a member of the following medical societies: American Association of University Women, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel D Price, MD  Director of International Ultrasound, Department of Emergency Medicine, Alameda County Medical Center, Highland Hospital and Trauma Center

Daniel D Price, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

James E Keany, MD, FACEP  Medical Director, TravelMDAssist; Staff Physician, Department of Emergency Services, Mission Hospital Regional Medical Center

James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and California Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Tom Scaletta, MD  Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Kroner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg. 1989;108(5):288-90. [Medline].

  2. Hovelius L. Incidence of shoulder dislocation in Sweden. Clin Orthop Relat Res. Jun 1982;(166):127-31. [Medline].

  3. Chalidis B, Sachinis N, Dimitriou C, Papadopoulos P, Samoladas E, Pournaras J. Has the management of shoulder dislocation changed over time?. Int Orthop. Jun 2007;31(3):385-9. [Medline].

  4. [Guideline] Shoulder complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. [Full Text].

  5. Groh GI, Wirth MA, Rockwood CA Jr. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg. Oct 15 2009;[Medline].

  6. [Guideline] Steinbach LS, Daffner RH, Dalinka MK, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Shoulder trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. [Full Text].

  7. Kahn JH, Mehta SD. The role of post-reduction radiographs after shoulder dislocation. J Emerg Med. Aug 2007;33(2):169-73. [Medline].

  8. Blaivas M, Adhikari S, Lander L. A Prospective Comparison of Procedural Sedation and Ultrasound-guided Interscalene Nerve Block for Shoulder Reduction in the Emergency Department. Acad Emerg Med. Sep 2011;18(9):922-7. [Medline].

  9. Matthews DE, Roberts T. Intraarticular lidocaine versus intravenous analgesic for reduction of acute anterior shoulder dislocations. A prospective randomized study. Am J Sports Med. Jan-Feb 1995;23(1):54-8. [Medline].

  10. Wakai A, O'Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults. Cochrane Database Syst Rev. Apr 13 2011;4:CD004919. [Medline].

  11. Dunn MJ, Mitchell R, Souza CD, Drummond G. Evaluation of propofol and remifentanil for intravenous sedation for reducing shoulder dislocations in the emergency department. Emerg Med J. Jan 2006;23(1):57-8. [Medline].

  12. Handoll HH, Almaiyah MA, Rangan A. Surgical versus non-surgical treatment for acute anterior shoulder dislocation. Cochrane Database Syst Rev. 2004;(1):CD004325. [Medline].

  13. Rhee YG, Cho NS, Cho SH. Traumatic anterior dislocation of the shoulder: factors affecting the progress of the traumatic anterior dislocation. Clin Orthop Surg. Dec 2009;1(4):188-93. [Medline].

  14. Hawkins RJ, Neer CS, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am. Jan 1987;69(1):9-18. [Medline].

  15. Begaz T, Mycyk MB. Luxatio erecta: inferior humeral dislocation. J Emerg Med. Oct 2006;31(3):303-4. [Medline].

  16. Blaivas M, Lyon M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am J Emerg Med. May 2006;24(3):293-6. [Medline].

  17. Cunningham NJ. Techniques for reduction of anteroinferior shoulder dislocation. Emerg Med Australas. Oct-Dec 2005;17(5-6):463-71. [Medline].

  18. De Palma AF. Surgery of the Shoulder. 3rd ed. 1983.

  19. Eachempati KK, Dua A, Malhotra R, Bhan S, Bera JR. The external rotation method for reduction of acute anterior dislocations and fracture-dislocations of the shoulder. J Bone Joint Surg Am. Nov 2004;86-A(11):2431-4. [Medline].

  20. Elberger ST, Brody G. Bilateral posterior shoulder dislocations. Am J Emerg Med. May 1995;13(3):331-2. [Medline].

  21. Freeman BL, Gustilo RB, Kyle RF, eds. Fractures and Dislocations. 1993:341-363.

  22. Hansen ST, Swiontkowski MF. Orthopaedic Trauma Protocols. Raven Press; 1993:86-87.

  23. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. Nov 1996;78(11):1677-84. [Medline].

  24. Jagim M. Procedural sedation in the emergency department: where do we draw the line?. J Emerg Nurs. Oct 2007;33(5):488-91. [Medline].

  25. Kelley SP, Hinsche AF, Hossain JF. Axillary artery transection following anterior shoulder dislocation: classical presentation and current concepts. Injury. Nov 2004;35(11):1128-32. [Medline].

  26. Kuhn JE. Treating the initial anterior shoulder dislocation--an evidence-based medicine approach. Sports Med Arthrosc. Dec 2006;14(4):192-8. [Medline].

  27. Liu HH, Lee YH, Yang SW, Wong CY. Fracture of the proximal humerus with intrathoracic dislocation of the humeral head. J Trauma. Aug 2007;63(2):E37-9. [Medline].

  28. Medical Economics Data. Physicians' Desk Reference. Medical Economics Data; 2005.

  29. Mirick MJ, Clinton JE, Ruiz E. External rotation method of shoulder dislocation reduction. JACEP. Dec 1979;8(12):528-31. [Medline].

  30. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res. Jun 1993;(291):103-6. [Medline].

  31. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 3rd ed. Philadelphia: W B Saunders; 1998.

  32. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia: W B Saunders; 2003.

  33. Sagarin MJ. Best of both (BOB) maneuver for rapid reduction of anterior shoulder dislocation. J Emerg Med. Oct 2005;29(3):313-6. [Medline].

  34. Simon RR, Koenigsknecht SJ, Stevens C. Emergency Orthopedics: The Extremities. 2nd ed. Appleton & Lange; 1987.

  35. Simonet WT, Melton LJ 3rd, Cofield RH, Ilstrup DM. Incidence of anterior shoulder dislocation in Olmsted County, Minnesota. Clin Orthop Relat Res. Jun 1984;(186):186-91. [Medline].

  36. Socransky SJ, Toner LV. Intra-articular lidocaine for the reduction of posterior shoulder dislocation. CJEM. Nov 2005;7(6):423-6. [Medline].

  37. Summers A. Shoulder dislocation: reduction without sedation in the emergency department. Emerg Nurse. Apr 2007;15(1):24-8. [Medline].

  38. Vastamaki M. Recurrent anterior shoulder dislocation. A review. Ann Chir Gynaecol. 1996;85(2):133-6. [Medline].

  39. Yamamoto T, Yoshiya S, Kurosaka M, Nagira K, Nabeshima Y. Luxatio erecta (inferior dislocation of the shoulder): a report of 5 cases and a review of the literature. Am J Orthop. Dec 2003;32(12):601-3. [Medline].

  40. Zahiri CA, Zahiri H, Tehrany F. Anterior shoulder dislocation reduction technique--revisited. Orthopedics. Jun 1997;20(6):515-21. [Medline].

 
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Y-view radiograph of the right shoulder shows anterior dislocation of the humeral head relative to the glenoid fossa.
 
 
 
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