C: Joint Reduction

Shoulder Dislocation and Reduction

Olabiyi Akala and Maureen Gang


imagesHistory and clinical examination consistent with shoulder dislocation

   imagesAnterior Dislocation (~95%)


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

        imagesRarely secondary to a blow to the posterior shoulder


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

        imagesAffected extremity usually held in abduction and external rotation

   imagesPosterior Dislocation (2%–4%)


        imagesAxial loading of adducted and internally rotated arm

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

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


        imagesProminence of posterior shoulder with flattening anteriorly; may be subtle

        imagesAffected extremity typically held in adduction and internal rotation

        imagesPatient usually unable to externally rotate affected extremity

   imagesInferior dislocation (luxatio erecta)—rare


        imagesForceful hyperabduction of the affected extremity


        imagesAffected arm is held above the head

        imagesPatient is unable to adduct the affected extremity

imagesRadiographs demonstrate glenohumeral dislocation


imagesAny associated fracture—particularly fracture of the humeral neck

   imagesObtain orthopedic consultation

imagesAny associated neurologic deficit

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


imagesRecurrent dislocation

   imagesRisk 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

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

imagesComplications of reduction

   imagesRisks associated with procedural sedation

   imagesNeurovascular injury

   imagesFracture of humerus and glenoid

imagesGeneral Basic Steps

   imagesThorough examination of affected extremity, including neurovascular status

   imagesAnalgesia/sedation/muscle relaxation

   imagesReduction via preferred technique

   imagesPostreduction care and follow-up



   imagesPhysical Examination

      imagesCompare both the affected and unaffected extremities

      imagesPerform a thorough neurovascular examination of the injured extremity

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

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


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

      imagesMay 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

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

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

      imagesIn 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

      imagesIn 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.


FIGURE 62.1 The essential anatomy of the shoulder. (From Sherman S. Shoulder injuries. In: Wolfson AB, ed. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:248, with permission.)

   imagesSedation, Analgesia, and Muscle Relaxation

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

        imagesA 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

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

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

      imagesIntra-articular Injection of Lidocaine

        imagesCleanse the shoulder with povidone–iodine solution

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

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

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

   imagesShoulder Reduction

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

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

        imagesStimson maneuver

        imagesScapular manipulation


        imagesMilch technique

        imagesHennepin or external rotation method

        imagesCunningham technique

        imagesPosterior dislocation reduction

   imagesPostreduction Care

      imagesObtain postreduction x-rays

      imagesPerform a postreduction neurovascular assessment and document the findings

      imagesPosition 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.

      imagesArrange orthopedic follow-up in 1 to 2 weeks

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

imagesStimson Maneuver

   imagesPatient is positioned prone with dislocated arm overhanging the bed

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

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

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

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

   imagesAdvantages: Can be performed by the lone practitioner without assistance

   imagesDisadvantages: 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.


FIGURE 62.2 A, B: Normal shoulder joint. C, D: Anterior dislocation of the shoulder. (From Young GM. Reduction of common joint dislocations and subluxations. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:1083, with permission.)

Only gold members can continue reading. Log In or Register to continue

Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on C: Joint Reduction
Premium Wordpress Themes by UFO Themes