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JarkkoPajarinen

Dislocation of the Shoulder

Essentials

  • Usually occurs when the shoulder joint is forcefully twisted or rotated e.g. in association of falling.
  • Fresh dislocation is reduced on an emergency basis. There are several methods of reduction. Sufficient relaxation and pain relief are important. The result is always to be controlled with x-ray.
  • Blood circulation and neurological functioning in the hand must be checked before and after reduction.
  • An arm sling is worn for 1-3 weeks; a gradually progressing exercise program is started during this period.

Aetiology

  • Usually a fall associated with twisting of the shoulder joint (abduction and external rotation)
  • Sometimes some other forceful twisting of the shoulder joint e.g. in association with a seizure, which may lead to a rare posterior dislocation.

Findings

  • The joint is aching and there is pain on movement.
  • The limb is often in a forced position in mild abduction and flexion. In posterior dislocation this is absent.

Investigations

  • X-ray is often diagnostic. Posterior dislocation is most reliably identified in the so-called axillary projection.
    • In young patients (less than 30 years of age) in good condition, the reduction can be performed in typical or recurring cases without prior x-ray, because in this patient group shoulder dislocation is very rarely associated with a fracture. The older the patient, the more important it is to exclude fracture before reduction is tried.
    • After reduction, an x-ray is taken of all patients.
  • Circulation and neurological functions (pulses, skin sensation, functioning of the distal part of the upper extremity) are checked before and after reduction.

Management Surgical Versus Non-Surgical Treatment for Acute Anterior Shoulder Dislocation, Surgical Interventions for Anterior Shoulder Instability

  • Reduction of a fresh dislocation should be performed as an emergency measure.
  • The reduction is more likely to be successful if the patient can relax the shoulder region. Calm the patient, tell him/her what you are doing, and take care of proper pain relief. If needed, also benzodiazepine medication can be used to help the patient to relax.
  • Pain can be effectively and safely managed by intra-articular anaesthesia e.g. with 20 ml of 1% lidocaine Intra-Articular Lidocaine Vs. Intravenous Analgesia for Manual Reduction of Shoulder Dislocation injected into the joint cavity from the upper-lateral direction.
  • Reduction is not a question of force but of skill. There are many methods of reduction, and it is good to master two or three of them. Reduction may be done e.g. in the following order:
    1. Dangling of the arm (known as the Stimson's method)
      • While supporting the arm, help the patient to lie down on the examination couch in prone position, with the injured shoulder outside the edge of the couch and the arm hanging down freely. You can intensify the traction by binding a weight (for example a bag of sand weighing 2-3 kg) to the forearm. Encourage the patient to relax the shoulder.
    2. Reduction while dangling, if the shoulder was not reduced with the first method within approximately 20 minutes
      • Position the patient's forearm in the horizontal plane. Push the limb downwards at the bended elbow joint and simultaneously rotate the shoulder joint gently.
    3. Reduction by pulling upward (known as the Hippocrates technique)
      • The patient lies supine. The upper extremity is positioned in approximately 45° abduction and 30° flexion.
      • Attempt the reduction of the joint by employing a calm and steady pull on the limb in the direction described above. At the same time, an assisting person directs a counterforce at the armpit of the patient e.g. with a thick rolled towel. All the movements during the reposition should be slow and calm, and the upper arm should be gently rotated during the procedure.
    4. If the reduction is not successful, refer the patient to a hospital for a possible operative reduction.

Further treatment

  • Successful reduction can be felt when the shoulder slips back to its socket. Pain is often relieved instantly.
  • Reposition is always verified by x-ray.
  • Check the circulation and neurological status in the arm and hand anew. Pay special attention to possible injury of the axillary nerve by investigating skin sensation on the deltoid muscle and voluntary contraction of the muscle.
  • The arm is supported with a sling in adducted and pronated position for 1 to 3 weeks Conservative Management after Closed Reduction of Traumatic Anterior Dislocation of the Shoulder. Gradually progressing exercises are started during this period.
  • External rotation over the neutral position is avoided for 6 weeks.
  • Young patients (< 30 years of age) who are especially active in sports or whose work entails special requirements for the stability of the elbow joint are referred in future as a non-urgent case to surgical evaluation.
  • In elderly patients, associated injuries often include, in addition to fractures, rotator cuff tears.

Recurrent dislocation

  • Recurrent total or partial dislocations sometimes occur without significant injury and are often easily reduced.
  • Immobilized after reduction as instructed above
  • Referred to surgical evaluation for the consideration of operative treatment

References

  • Fitch RW, Kuhn JE. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review. Acad Emerg Med 2008 Aug;15(8):703-8. [PubMed]

Evidence Summaries ⬆