Shoulder Dislocation in Emergency Medicine Medication

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

Medication Summary

Opiate analgesia should be given as needed for pain in patients with shoulder dislocation. Intravenous or intramuscular medications, intra-articular injections, and regional anesthetic techniques have been reported as successful aides for reduction of shoulder dislocations.

Procedural sedation and analgesia (PSA) is commonly used to achieve adequate pain control and muscle relaxation for reduction. A randomized, controlled trial of 30 patients compared intra-articular lidocaine with PSA (morphine and midazolam).[9] All patients who received intra-articular injections obtained adequate analgesia and muscle relaxation, were free of complications, and had significantly shorter emergency department stays (78 min vs 186 min; p=0.004).[9] A Cochrane Database of Systematic Reviews study of 113 patients with acute anterior shoulder dislocation who underwent intra-articular lignocaine injection and 98 patients who underwent intravenous analgesia with sedation found that intra-articular lignocaine injection may be associated with fewer side effects and a shorter stay in the emergency department, and may be less expensive than intravenous medication.[10]

Etomidate, fentanyl/midazolam, ketamine, or propofol is commonly used for PSA. Some ED physicians prefer etomidate because of its rapid onset (< 30 sec), short duration (about 5 min), and excellent muscle relaxation. Other physicians consider propofol superior in terms of side effects and duration. Propofol's high lipid solubility results in a rapid onset (30-60 sec) and a short plasma half-life (1.3-4.1 min). The result is a rapid decline of propofol concentrations, rapid awakening, and shorter recovery times.

An ED-based study evaluated the combination of propofol and remifentanil for sedation to reduce anterior shoulder dislocations.[11] Eleven patients were given propofol 0.5 mg/kg and remifentanil 0.5 mcg/kg, intravenous (IV) over 90 seconds. Further doses of propofol 0.25 mg/kg and remifentanil 0.25 mcg/kg were administered if needed. All patients had adequate sedation and analgesia within 3 minutes. Mean time to achieve reduction after dosage was 1.6 minutes, and mean time to being clinically alert was 3 minutes. However, postreduction time in the ED ranged from 30-312 minutes. Rapid recovery was a marked feature of this study. All subjects became alert quickly and were ambulatory without assistance in less than 30 minutes.

Next

Analgesics

Class Summary

These agents may be used for the relief of pain and relaxation of shoulder muscles. Pain control is essential to quality patient care. It ensures patient comfort, improves likelihood of successful reduction, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with injuries.

View full drug information

Fentanyl citrate (Duragesic, Sublimaze)

 

DOC because of its rapid, almost immediate onset and short duration of 30-60 min. Can be reversed easily by naloxone 2 mg IV as needed for respiratory depression. Often used as part of conscious sedation with midazolam (see Sedation). Useful for emergency department visits only. Not intended to be given on an outpatient basis.

View full drug information

Oxycodone and acetaminophen (Percocet)

 

Drug combination indicated for relief of moderately severe to severe pain.

View full drug information

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

 

Drug combination indicated for relief of moderately severe to severe pain.

Previous
Proceed to Follow-up
 
 
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].

 
Previous
Next
 
Y-view radiograph of the right shoulder shows anterior dislocation of the humeral head relative to the glenoid fossa.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.