What is the best way to reduce an anterior shoulder dislocation?

From the Guidelines

The best way to reduce an anterior shoulder dislocation is to use the Stimson technique or the scapular manipulation method after providing adequate analgesia and muscle relaxation. For pain control, administer intravenous medications such as morphine 0.1 mg/kg or fentanyl 1-2 mcg/kg, combined with midazolam 0.05-0.1 mg/kg for sedation, as these methods have been shown to be effective in reducing pain and anxiety during the procedure 1. Alternatively, an intra-articular lidocaine injection (10 ml of 1% lidocaine) directly into the joint space can provide effective local anesthesia.

Key Considerations

• The Stimson technique involves placing the patient prone with the affected arm hanging off the edge of the bed with 5-10 pounds of weight attached to the wrist, allowing gravity to gradually fatigue the muscles and reduce the dislocation over 20-30 minutes.
• The scapular manipulation method involves positioning the patient prone or seated, applying forward pressure on the tip of the scapula while rotating the inferior tip medially, which often results in successful reduction.
• These techniques are preferred because they use gentle traction rather than forceful manipulation, reducing the risk of iatrogenic injury to the labrum, rotator cuff, or neurovascular structures, which is a significant concern in patients with anterior shoulder dislocation, particularly in younger patients who are more likely to have labroligamentous injury and persistent instability after dislocation 1.

Radiographic Evaluation

• Always obtain pre- and post-reduction radiographs to confirm the dislocation and successful reduction, and assess neurovascular status before and after the procedure, as radiography provides good delineation of bony anatomy to assess for fracture and appropriate shoulder alignment 1.
• Axillary or scapula-Y views are vital in evaluating traumatic shoulder injuries, as acromioclavicular and glenohumeral dislocations can be misclassified on AP views, and glenoid morphology and bone loss can play a significant factor in recurrent shoulder dislocations 1.

From the Research

Reduction Methods for Anterior Shoulder Dislocation

The following methods have been studied for reducing anterior shoulder dislocations:

• The Chair method, which was found to be the easiest and fastest reduction maneuver in a study by 2
• The Spaso method, which includes flexion of the shoulder and blocks muscle contraction somewhat, as described in 2
• The Kocher and Matsen methods, which were found to require more force for reduction and may cause patients to contract their muscles due to pain, as noted in 2
• A stepped care approach to reduction in the prone position, which does not require sedation/muscle relaxants in the majority of cases, as described in 3
• A painless technique for reposition of anterior shoulder dislocation, which is performed by a single person with the patient sitting on a chair, as reported in 4
• Gentle traction, abduction, and external rotation maneuver under sedative-free, which was found to be effective, simple, and safe in a study by 5
• The Legg reduction maneuver, which is easy to perform on site and requires no premedication, as described in 6

Key Findings

• The Chair method had the shortest reduction time in a study by 2
• The stepped care approach to reduction in the prone position is associated with shorter stay in the emergency department and has fewer complications, as noted in 3
• The painless technique for reposition of anterior shoulder dislocation has a high success rate and mostly avoids premedication, as reported in 4
• Gentle traction, abduction, and external rotation maneuver under sedative-free has a high success rate and is associated with high patient satisfaction, as found in 5
• The Legg reduction maneuver can be performed without sedation and decreases the potential for neurovascular injury, as described in 6