Shoulder Dislocation in Emergency Medicine
- Author: Sharon R Wilson, MD; Chief Editor: Trevor John Mills, MD, MPH more...
Shoulder dislocation is documented in Egyptian tomb murals as early as 3000 BC, with depiction of a manipulation for glenohumeral dislocation resembling the Kocher technique. Hippocrates detailed the oldest known reduction method still in use today and advocated treating chronic shoulder instability with cauterization of the deep tissues of the anterior shoulder.
Historical techniques to reduce dislocated glenohumeral joints have been shown to be safe when applied correctly. Kocher's method as originally described in 1870 did not involve traction and fell into disfavor when complications occurred with the application of large forces. Most dislocations are anterior, but less frequently, posterior, inferior (luxatio erecta), superior, and intrathoracic dislocations are also possible.
Recent data indicate that arthroscopic stabilization is performed in nearly 90% of shoulder stabilization surgeries in the United States. The percentage of arthroscopic stabilizations increased from 71% of stabilization procedures in 2004 to 89% in 2009, whereas the percentage of open stabilizations decreased from 29% in 2004 to 11% in 2009 (P < .0001).
The shoulder is the most frequently dislocated joint. It moves almost without restriction but pays the price of stability. The shoulder's integrity is maintained by the glenohumeral joint capsule, the cartilaginous glenoid labrum (which extends the shallow glenoid fossa), and muscles of the rotator cuff.
Anterior dislocations occur in as many as 98% of cases. Anterior displacement of the humeral head is the most common dislocation seen by emergency physicians and is depicted in the image below.
Posterior displacement is the next most frequently occurring dislocation. Inferior (luxatio erecta), superior, and intrathoracic dislocations are rare and are usually associated with complications.
Shoulder dislocations affect approximately 1.7% of the population and are most frequently secondary to trauma. The incidence of all traumatic shoulder dislocations has been estimated at 11.2 cases per 100,000 person-years, with a cumulative incidence rate of 0.7% for men and 0.3% for women up to age 70 years.
A more recent Greek study examined the demographic data and recurrence rates of shoulder dislocations of 308 patients (170 men and 138 women). Subjects were observed for approximately 6 years. The most frequent mechanism of injury was falling, and 92% of reductions were in the ED. The overall recurrence rate in all ages was 50%, but rose to almost 89% in the 14-20 year age group.
Gender distribution is bimodal, with peak incidence in men aged 20-30 years (with a male-to-female ratio of 9:1) and in women aged 61-80 years (with a female-to-male ratio of 3:1).
Shoulder dislocation occurs more frequently in adolescents than in younger children because the weaker epiphyseal growth plates in children tend to fracture before dislocation occurs.
In older adults, collagen fibers have fewer cross-links, making the joint capsule and supporting tendons and ligaments weaker and dislocation more likely.
Anterior dislocation is most commonly seen in those aged 18-25 years due to sporting injury. The second most common age group to sustain anterior dislocation is in elderly persons due to their susceptibility to falls.
Zhang AL, Montgomery SR, Ngo SS, Hame SL, Wang JC, Gamradt SC. Arthroscopic versus open shoulder stabilization: current practice patterns in the United States. Arthroscopy. 2014 Apr. 30(4):436-43. [Medline].
Kroner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg. 1989. 108(5):288-90. [Medline].
Hovelius L. Incidence of shoulder dislocation in Sweden. Clin Orthop Relat Res. 1982 Jun. (166):127-31. [Medline].
Chalidis B, Sachinis N, Dimitriou C, Papadopoulos P, Samoladas E, Pournaras J. Has the management of shoulder dislocation changed over time?. Int Orthop. 2007 Jun. 31(3):385-9. [Medline].
[Guideline] Shoulder complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. [Full Text].
Groh GI, Wirth MA, Rockwood CA Jr. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg. 2009 Oct 15. [Medline].
Khiami F, Gérometta A, Loriaut P. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol Surg Res. 2015 Feb. 101 (1 Suppl):S51-7. [Medline].
Kane P, Bifano SM, Dodson CC, Freedman KB. Approach to the treatment of primary anterior shoulder dislocation: A review. Phys Sportsmed. 2015 Feb. 43 (1):54-64. [Medline].
[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].
Mackenzie DC, Liebmann O. Point-of-Care Ultrasound Facilitates Diagnosing a Posterior Shoulder Dislocation. J Emerg Med. 2013 May. 44(5):976-8. [Medline].
Beck S, Chilstrom M. Point-of-care ultrasound diagnosis and treatment of posterior shoulder dislocation. Am J Emerg Med. 2013 Feb. 31(2):449.e3-5. [Medline].
Reid S, Liu M, Ortega H. Anterior shoulder dislocations in pediatric patients: are routine prereduction radiographs necessary?. Pediatr Emerg Care. 2013 Jan. 29(1):39-42. [Medline].
Kahn JH, Mehta SD. The role of post-reduction radiographs after shoulder dislocation. J Emerg Med. 2007 Aug. 33(2):169-73. [Medline].
Walz DM, Burge AJ, Steinbach L. Imaging of shoulder instability. Semin Musculoskelet Radiol. 2015 Jul. 19 (3):254-68. [Medline].
Ozaki R, Nakagawa S, Mizuno N, Mae T, Yoneda M. Hill-Sachs Lesions in Shoulders With Traumatic Anterior Instability: Evaluation Using Computed Tomography With 3-Dimensional Reconstruction. Am J Sports Med. 2014 Sep 17. [Medline].
Horst K, Von Harten R, Weber C, Andruszkow H, Pfeifer R, Dienstknecht T, et al. Assessment of coincidence and defect sizes in Bankart and Hill-Sachs lesions after anterior shoulder dislocation: a radiological study. Br J Radiol. 2014 Feb. 87(1034):20130673. [Medline]. [Full Text].
Jordan RW, Naeem R, Srinivas K, Shyamalan G. A comparison of magnetic resonance arthrography and arthroscopic findings in the assessment of anterior shoulder dislocations. Skeletal Radiol. 2015 May. 44 (5):653-7. [Medline].
Helfen T, Ockert B, Pozder P, Regauer M, Haasters F. Management of prehospital shoulder dislocation: feasibility and need of reduction. Eur J Trauma Emerg Surg. 2015 Jul 9. [Medline].
Kanji A, Atkinson P, Fraser J, Lewis D, Benjamin S. Delays to initial reduction attempt are associated with higher failure rates in anterior shoulder dislocation: a retrospective analysis of factors affecting reduction failure. Emerg Med J. 2015 Jun 25. [Medline].
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. 2011 Sep. 18(9):922-7. [Medline].
Matthews DE, Roberts T. Intraarticular lidocaine versus intravenous analgesic for reduction of acute anterior shoulder dislocations. A prospective randomized study. Am J Sports Med. 1995 Jan-Feb. 23(1):54-8. [Medline].
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. 2011 Apr 13. 4:CD004919. [Medline].
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. 2006 Jan. 23(1):57-8. [Medline].
Handoll HH, Almaiyah MA, Rangan A. Surgical versus non-surgical treatment for acute anterior shoulder dislocation. Cochrane Database Syst Rev. 2004. (1):CD004325. [Medline].
Rhee YG, Cho NS, Cho SH. Traumatic anterior dislocation of the shoulder: factors affecting the progress of the traumatic anterior dislocation. Clin Orthop Surg. 2009 Dec. 1(4):188-93. [Medline]. [Full Text].
Hawkins RJ, Neer CS, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am. 1987 Jan. 69(1):9-18. [Medline].
Begaz T, Mycyk MB. Luxatio erecta: inferior humeral dislocation. J Emerg Med. 2006 Oct. 31(3):303-4. [Medline].
Blaivas M, Lyon M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am J Emerg Med. 2006 May. 24(3):293-6. [Medline].
Cunningham NJ. Techniques for reduction of anteroinferior shoulder dislocation. Emerg Med Australas. 2005 Oct-Dec. 17(5-6):463-71. [Medline].
De Palma AF. Surgery of the Shoulder. 3rd ed. 1983.
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. 2004 Nov. 86-A(11):2431-4. [Medline].
Elberger ST, Brody G. Bilateral posterior shoulder dislocations. Am J Emerg Med. 1995 May. 13(3):331-2. [Medline].
Freeman BL, Gustilo RB, Kyle RF, eds. Fractures and Dislocations. 1993. 341-363.
Hansen ST, Swiontkowski MF. Orthopaedic Trauma Protocols. Raven Press; 1993. 86-87.
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. 1996 Nov. 78(11):1677-84. [Medline].
Jagim M. Procedural sedation in the emergency department: where do we draw the line?. J Emerg Nurs. 2007 Oct. 33(5):488-91. [Medline].
Kelley SP, Hinsche AF, Hossain JF. Axillary artery transection following anterior shoulder dislocation: classical presentation and current concepts. Injury. 2004 Nov. 35(11):1128-32. [Medline].
Kuhn JE. Treating the initial anterior shoulder dislocation--an evidence-based medicine approach. Sports Med Arthrosc. 2006 Dec. 14(4):192-8. [Medline].
Liu HH, Lee YH, Yang SW, Wong CY. Fracture of the proximal humerus with intrathoracic dislocation of the humeral head. J Trauma. 2007 Aug. 63(2):E37-9. [Medline].
Medical Economics Data. Physicians' Desk Reference. Medical Economics Data; 2005.
Mirick MJ, Clinton JE, Ruiz E. External rotation method of shoulder dislocation reduction. JACEP. 1979 Dec. 8(12):528-31. [Medline].
Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res. 1993 Jun. (291):103-6. [Medline].
Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia: W B Saunders; 2003.
Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 3rd ed. Philadelphia: W B Saunders; 1998.
Sagarin MJ. Best of both (BOB) maneuver for rapid reduction of anterior shoulder dislocation. J Emerg Med. 2005 Oct. 29(3):313-6. [Medline].
Simon RR, Koenigsknecht SJ, Stevens C. Emergency Orthopedics: The Extremities. 2nd ed. Appleton & Lange; 1987.
Simonet WT, Melton LJ 3rd, Cofield RH, Ilstrup DM. Incidence of anterior shoulder dislocation in Olmsted County, Minnesota. Clin Orthop Relat Res. 1984 Jun. (186):186-91. [Medline].
Socransky SJ, Toner LV. Intra-articular lidocaine for the reduction of posterior shoulder dislocation. CJEM. 2005 Nov. 7(6):423-6. [Medline].
Summers A. Shoulder dislocation: reduction without sedation in the emergency department. Emerg Nurse. 2007 Apr. 15(1):24-8. [Medline].
Vastamaki M. Recurrent anterior shoulder dislocation. A review. Ann Chir Gynaecol. 1996. 85(2):133-6. [Medline].
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. 2003 Dec. 32(12):601-3. [Medline].
Zahiri CA, Zahiri H, Tehrany F. Anterior shoulder dislocation reduction technique--revisited. Orthopedics. 1997 Jun. 20(6):515-21. [Medline].