What is the best approach for reducing a shoulder dislocation?

From the Guidelines

The best approach for reducing a shoulder dislocation is the Stimson technique or the scapular manipulation method, both of which are gentle and effective, and should be performed after achieving adequate analgesia and muscle relaxation using medications such as intravenous midazolam (2-5mg) combined with morphine (5-10mg) or fentanyl (50-100mcg) 1.

Key Considerations

• Before attempting reduction, it is essential to achieve adequate analgesia and muscle relaxation to minimize patient discomfort and facilitate a successful reduction.
• The Stimson technique involves placing the patient prone with the affected arm hanging off the edge of the bed with a 10-15 pound weight attached to the wrist for gentle traction.
• The scapular manipulation method is performed with the patient prone or seated, applying pressure to the tip of the scapula while rotating the inferior angle medially.
• These techniques work by relaxing the shoulder muscles and using gravity to help guide the humeral head back into the glenoid fossa.

Important Steps

• Confirm successful reduction with post-reduction radiographs, including anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view 1.
• Immobilize the shoulder in a sling for 1-3 weeks following reduction.
• If these gentle techniques fail after 15-20 minutes, alternative methods like the Kocher technique or external rotation method may be necessary, but these carry higher risks of complications.

Special Considerations

• Immediate orthopedic consultation is warranted for irreducible dislocations or those with associated fractures or neurovascular compromise.
• Radiography should be performed upright because malalignment of the shoulder can be underrepresented on supine radiography 1.

From the Research

Reducing Shoulder Dislocation

• The best approach for reducing a shoulder dislocation can vary depending on the specific circumstances and the patient's condition.
• Studies have shown that several techniques can be effective, including the external rotation method 2, scapular manipulation technique (SMT) 3, and assisted self-reduction technique 4.
• The external rotation method was successful on first attempt in 80% of cases in one study 2, while SMT achieved a success rate of 87.5% without medication at the first attempt and 97.3% overall in another study 3.
• The assisted self-reduction technique was found to be simple, effective, and gentle, with a success rate of 98% without recourse to intravenous sedation 4.
• Other studies have compared the use of different medications, such as diazepam and midazolam, in conjunction with fentanyl for procedural sedation and analgesia during shoulder dislocation reduction 5.
• A comprehensive review of reduction techniques found that each technique has distinct advantages and limitations, and that emergency physicians should be familiar with multiple different reduction techniques in case the initial reduction attempt is unsuccessful 6.

Techniques for Reducing Shoulder Dislocation

• External rotation method: involves external rotation of the arm to help reduce the dislocation 2
• Scapular manipulation technique (SMT): involves manipulation of the scapula to help reduce the dislocation 3
• Assisted self-reduction technique: involves the patient performing the reduction themselves with the guidance of a physician 4
• Traction-countertraction method: involves the use of traction and countertraction to help reduce the dislocation 4

Medications for Procedural Sedation and Analgesia

• Diazepam and fentanyl: found to be effective for procedural sedation and analgesia during shoulder dislocation reduction, with a shorter onset of muscle relaxation and time taken to reduction compared to midazolam and fentanyl 5
• Midazolam and fentanyl: also found to be effective, but with a shorter patient recovery time and total procedure time compared to diazepam and fentanyl 5