Shoulder Dislocation and Reduction

Olabiyi Akala and Maureen Gang

INDICATIONS

 History and clinical examination consistent with shoulder dislocation

    Anterior Dislocation (~95%)

       Mechanism

         Force applied to an externally rotated, abducted, and extended arm

         Rarely secondary to a blow to the posterior shoulder

       Examination

         Prominent humeral head anteriorly and a shallow depression inferior to the acromion may be observed

         Affected extremity usually held in abduction and external rotation

    Posterior Dislocation (2%–4%)

       Mechanism

         Axial loading of adducted and internally rotated arm

         Less commonly due to direct blow to anterior shoulder or fall on an outstretched arm

         May result from violent muscle contractions: e.g., seizures, electric shock, psychiatry patients

       Examination

         Prominence of posterior shoulder with flattening anteriorly; may be subtle

         Affected extremity typically held in adduction and internal rotation

         Patient usually unable to externally rotate affected extremity

    Inferior dislocation (luxatio erecta)—rare

       Mechanism

         Forceful hyperabduction of the affected extremity

       Examination

         Affected arm is held above the head

         Patient is unable to adduct the affected extremity

 Radiographs demonstrate glenohumeral dislocation

CONTRAINDICATIONS

 Any associated fracture—particularly fracture of the humeral neck

    Obtain orthopedic consultation

 Any associated neurologic deficit

    Closed reduction may still be attempted but multiple attempts should be avoided

RISKS/CONSENT ISSUES

 Recurrent dislocation

    Risk dependent on age at initial dislocation, with recurrence risk up to 90% for those <20, up to 70% for those between 20 and 40 and between 2% and 4% for those older than 40

 Increased risk of associated rotator cuff injuries in patients >40 years of age

 Complications of reduction

    Risks associated with procedural sedation

    Neurovascular injury

    Fracture of humerus and glenoid

LANDMARKS—FIGURE 62.1

 Technique

    Physical Examination

       Compare both the affected and unaffected extremities

       Perform a thorough neurovascular examination of the injured extremity

         A sensory deficit over the deltoid (the so-called sergeant’s-stripe pattern) or an impaired deltoid contraction implies an axillary nerve injury

         All major nerves to the arm should be assessed as injuries to the brachial plexus, ulnar, and radial nerves have been reported

    Radiographs

       Obtain before reduction if the clinician is unsure of the position/type of dislocation or if there is concern for an associated fracture

       May defer prereduction films if the clinician is confident of an anterior dislocation based on physical examination, the patient is <40, with a history of recurrent dislocations, and the mechanism of the dislocation is not associated with direct trauma

       Anteroposterior (AP), scapular Y, and axillary lateral view should be obtained

         A single x-ray view should never be used to diagnose a shoulder dislocation

       In anterior dislocations, the humeral head is anterior in the axillary view (using the coracoid process as a point of orientation, and anterior to the center of Y in the trans-scapular view

       In posterior dislocations, the AP view may be diagnostic if it shows a partial vacancy of the glenoid fossa (vacant glenoid sign) and >6 mm space between the glenoid rim and humeral head (positive rim sign). The humeral head is posterior on axillary view and posterior to center Y on trans-scapular view.

    Sedation, Analgesia, and Muscle Relaxation

       Adequate analgesia, muscle relaxation, and/or sedation help facilitate successful reduction

         A recent systematic review of intra-articular lidocaine vs procedural sedation showed no significant difference in reduction success rates, pain during reduction, and pain after reduction

         It is reasonable to attempt initial reduction with intra-articular local anesthetic; if unsuccessful, the clinician may consider procedural sedation for subsequent attempts

         Ensure that the patient relates the use of intra-articular lidocaine to the orthopedic surgeon during follow-up

       Intra-articular Injection of Lidocaine

         Cleanse the shoulder with povidone–iodine solution

         Insert the needle 2 cm inferiorly and directly lateral to the acromion, in the lateral sulcus left by the absent humeral head

         Fill a 20-mL syringe with 1% lidocaine. Attach a 1.5-inch 20-gauge needle to the syringe (FIGURE 62.2).

         Withdraw to ensure you are not in a blood vessel prior to the injection of 15 to 20 mL of lidocaine into the joint space

    Shoulder Reduction

       The guiding principle for all methods of reduction should be a gradual and gentle application of technique (FIGURE 62.3)

       The treating physician should be comfortable with several methods of reduction because no technique is 100% effective. The following techniques are described in this chapter:

         Stimson maneuver

         Scapular manipulation

         Traction–countertraction

         Milch technique

         Hennepin or external rotation method

         Cunningham technique

         Posterior dislocation reduction

    Postreduction Care

       Obtain postreduction x-rays

       Perform a postreduction neurovascular assessment and document the findings

       Position at discharge is controversial. Evidence regarding external rotation splinting is still evolving. Patients should be placed in a shoulder immobilizer or sling and swath for 2 to 3 weeks.

       Arrange orthopedic follow-up in 1 to 2 weeks

         Older patients (<40) should have early follow-up within ~1 week to prevent adhesive capsulitis (frozen shoulder)

 Stimson Maneuver

    Patient is positioned prone with dislocated arm overhanging the bed

    Weight of 5 to 15 lb (initially supported by the physician) is strapped to the wrist of the affected extremity

    Traction is gradually exerted on the shoulder by slow and steady release of the physician’s support

    Up to 30 minutes of sustained, steady traction may be necessary for reduction

    Reduction may be facilitated by delicate external rotation of the affected extremity

    Advantages: Can be performed by the lone practitioner without assistance

    Disadvantages: Often requires more time and materials (weights and straps) than may be readily available (FIGURE 62.4). Not appropriate for all patients, particularly those with respiratory compromise.

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