Shoulder Dislocation in Emergency Medicine Treatment & Management

Updated: Nov 12, 2017
  • Author: Sharon R Wilson, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

Approach Considerations

In patients with shoulder dislocation, 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. [28, 17]

Administer analgesics to decrease pain.

Prereduction and postreduction 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. Using US-guided interscalene block reduces time spent in the ED and lessens one-on-one health care provider time compared to procedural sedation. [29]

Immobilize the shoulder after reduction.

Perform careful prereduction and postreduction neurovascular examinations.

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.

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Emergency Department Care

The key to a successful reduction is slow and steady application of a maneuver with adequate analgesia and relaxation. Procedural sedation and analgesia (PSA) protocols in the ED assist in relaxing the musculature of the shoulder and make reduction a more comfortable and easier procedure. (For further information, see Procedural Sedation.)

Other adjuncts to facilitate reduction for patients who are high risk or may not be candidates for PSA include intra-articular lidocaine and ultrasound-guided interscalene (lidocaine) block of the brachial plexus.

Successful reduction is evidenced by marked reduction in pain and increased range of motion. A palpable or audible relocation ("clunk") may also be noted. The patient may be asked to touch the uninjured shoulder to safely demonstrate a successful reduction.

Some authors recommend an orthopedic consultation prior to reduction of posterior and inferior dislocations.

After the completion of all reductions, apply a shoulder immobilizer with a sling and swathe. A careful neurovascular examination must be performed prereduction and postreduction. Post-reduction radiography is still recommended, especially if the procedure was difficult.

Inappropriate traction and poor technique can result in complications with otherwise safe methods of reduction. The Kocher method has been discouraged because of the increased incidence of complications. [3] When performed correctly, it does not involve traction and has been demonstrated to be a safe technique. (For further information, see Joint Reduction, Shoulder Dislocation, Anterior.) In Kocher's original method, bend the arm at the elbow, press it against the body, rotate outwards until resistance is felt. Lift the externally rotated upper part of the arm in the sagittal plane as far as possible forwards and finally turn inwards slowly.

The Stimson technique requires that the patient lie prone on the bed with the dislocated arm hanging over the side. Traction is provided by up to 5-15 kg of weight attached to the wrist or above the elbow. Apply gentle internal/external humeral rotation. Reduction may take 20-30 minutes. [3]

In the external rotation method, while the patient lies supine, adduct the arm and flex it to 90° at the elbow. Slowly rotate the arm externally, pausing for pain. Reduce the shoulder before reaching the coronal plane. Often successful, this procedure requires only one physician and little force. Reduction usually occurs with the arm externally rotated between 70 and 110 degrees. [3]

For traction-countertraction, while the patient lies supine, apply axial traction to the arm with a sheet wrapped around the forearm and the elbow bent at 90°. An assistant should apply countertraction using a sheet wrapped under the arm and across the chest while the shoulder is gently rotated internally and externally to disengage the humeral head from the glenoid. [3]

Scapular rotation is a less traumatic technique and has success rates of more than 90% in experienced hands, often without sedation. With the patient lying prone, apply manual traction or 5-15 lb of hanging weight to the wrist. After relaxation, rotate the inferior tip of the scapula medially and the superior aspect laterally. Alternatively, the patient can be seated while an assistant provides traction-countertraction by pulling on the wrist with one hand and bracing the upper chest with the other. The same scapular rotation is then performed. [3]

For reduction of a posterior dislocation, apply gentle, prolonged axial traction on the humerus. Then, add gentle anterior pressure while coaxing the humeral head over the glenoid rim. Slow external rotation may be needed.

For reduction of an inferior dislocation, maintain gentle axial traction on the humerus while gentle abduction is applied. Apply countertraction across the ipsilateral shoulder. Following reduction, slowly adduct the arm. Buttonholing of the humeral head through the capsule usually requires open reduction.

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Medical 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.

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 Review of 5 randomized, controlled studies. [30] 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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