Shoulder Dislocation and Reduction

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

General Basic Steps

Thorough examination of affected extremity, including neurovascular status

Analgesia/sedation/muscle relaxation

Reduction via preferred technique

Postreduction care and follow-up

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.

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.)

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.

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.)

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