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Shoulder dislocation
The most common joint dislocation (approximately 50% of all joints)
| Mechanism | Presentation | Associated injuries | |
| Anterior | Indirect blow with arm in abduction, extension, and external rotation | Arm is held in abduction and slight external rotation with shoulder appearing “squared off.” | Axillary nerve injury
Fracture of humeral neck, anterior inferior glenoid rim (Bankart lesion), posterolateral head of humerus (hill sachs fracture) Axillary artery injury |
| Posterior | Indirect force that produces forceful internal rotation and adduction. | Arm is adducted and internally rotated. | Fracture of posterior glenoid rim, humeralhead, humeral shaft, lesser tuberosity |
| Inferior | Neck of the humerus is levered against the acromion | Humerus fully abducted, elbow flexed, hand on or behind head | Neurovascular compression injuries
Fractures of proximal humerus Rotator cuff tear |
Pain control:
- Morphine
- Procedural sedation
- Intra-articular lidocaine: Approximately 20 ml of 1% lidocaine. 2cm below lateral edge of acromion. Allow 15-20 minutes.
- US guided interscalene block: Approximately 30ml of 1% lidocaine into brachial plexus. Allow 20 minutes.
Imaging:
X-ray with: Y view, Valpeau view
Reduction techniques:
- Traction counter traction: patient supine, arm abducted and flexed to 90 degrees, Clinician>elbow. Assistant >thorax.
- Stimpson: Patient prone with 10 lb weight attached to the wrist.
- Milch: Patient supine, abduct and externally rotate arm to overhead position with elbow extended
- Scapular manipulation: Stimpson, while medially directing tip of lateral scalpula
- External rotation: Pt supine, elbow flexed to 90 degrees, arm externally rotated and adducted
References:
- Marx: Rosen’s Emergency Medicine – Concepts and Clinical Practice, 8th ed. Chapter 53. Shoulder
- Cheok, C. Y., Mohamad, J. A., & Ahmad, T. S. (2011). Pain relief for reduction of acute anterior shoulder dislocations: a prospective randomized study comparing intravenous sedation with intra-articular lidocaine. Journal of orthopaedic trauma, 25(1), 5-10.
- Blaivas, M., Adhikari, S., & Lander, L. (2011). A Prospective Comparison of Procedural Sedation and Ultrasound‐guided Interscalene Nerve Block for Shoulder Reduction in the Emergency Department. Academic Emergency Medicine, 18(9), 922-927.
- Kahn, J. H., & Mehta, S. D. (2007). The role of post-reduction radiographs after shoulder dislocation. The Journal of emergency medicine, 33(2), 169-173.
- Hendey, G. W., Chally, M. K., & Stewart, V. B. (2006). Selective radiography in 100 patients with suspected shoulder dislocation. The Journal of emergency medicine, 31(1), 23-28.
For more info check out this great FOAM resource: shoulderdislocation.net
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD
Editor in Chief of "The Original Kings of County"
Assistant Professor of Emergency Medicine
Assistant Residency Director
SUNY Downstate / Kings County Hospital
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