eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Dislocation, Shoulder: Treatment & Medication

Author: Sharon R Wilson, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of California at Davis Medical Center
Coauthor(s): Daniel D Price, MD, Director of Ultrasound Fellowship, Department of Emergency Medicine, Highland General Hospital, Alameda County Medical Center
Contributor Information and Disclosures

Updated: Feb 27, 2008

Treatment

Prehospital Care

  • Stabilize and treat associated trauma as indicated.
  • Allow the patient to assume a position of comfort while maintaining cervical spine immobilization if necessary.
  • A pillow between the patient's arm and torso may increase comfort.

Emergency Department Care

  • Administer analgesics to decrease pain.
  • Pre-reduction and post-reduction radiographs are recommended. Patients with frequent recurrent dislocations can safely avoid radiographs.
  • Procedural sedation and analgesia (PSA) protocols, intra-articular lidocaine, and ultrasound-guided brachial plexus nerve block assist in making reduction an easier and more comfortable procedure.
  • Immobilize the shoulder after reduction. 
  • Perform careful pre- and post-reduction neurovascular examinations.

Consultations

Orthopedic consultation may be helpful for dislocations with concomitant fractures, for posterior or inferior dislocations, and for cases in which the patient's shoulder cannot be reduced in a timely fashion.

Medication

Opiate analgesia should be given as needed for pain. 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).5 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).5

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.

A recent ED-based study evaluated the combination of propofol and remifentanil for sedation to reduce anterior shoulder dislocations.6 Eleven patients were given propofol 0.5 mg/kg and remifentanil 0.5 mcg/kg, 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, post-reduction 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.

Analgesics

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.


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.

Adult

0.5-1 mcg/kg/dose IV/IM q30-60min; titrate to pain relief in 50-mcg IV increments

Pediatric

2-3 mcg/kg IV; titrate to pain relief

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse effects

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation


Oxycodone and acetaminophen (Percocet)

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

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving (do not exceed 4,000 mg/24 h of acetaminophen); higher doses may cause liver toxicity


Hydrocodone bitartrate and acetaminophen (Vicodin ES)

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

Adult

1-2 tab PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen or 5 mg of hydrocodone bitartrate/dose
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity

Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates, because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

More on Dislocation, Shoulder

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Differential Diagnoses & Workup: Dislocation, Shoulder
Treatment & Medication: Dislocation, Shoulder
Follow-up: Dislocation, Shoulder
Multimedia: Dislocation, Shoulder
References
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References

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Further Reading

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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 Ultrasound Fellowship, Department of Emergency Medicine, Highland General Hospital, Alameda County Medical 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.

Medical Editor

James E Keany, MD, FACEP, Medical Director, JetWest International Air Ambulance; Consulting Staff, Department of Emergency Services, Mission Hospital Regional Medical Center; Host of Healthbuzz at Jim.MD
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, 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 and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

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, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

 
 
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