What is the treatment for a shoulder dislocation?

Treatment for Shoulder Dislocation

The treatment for shoulder dislocation involves immediate reduction followed by appropriate immobilization, with procedural sedation often required for successful reduction in the emergency department setting. 1

Initial Management

Diagnosis and Imaging

• Standard radiographs should be obtained first before attempting reduction to rule out fractures:
  • Anteroposterior (AP) views in internal and external rotation
  • Axillary or scapula-Y view to confirm dislocation and identify associated injuries 2, 1
• Advanced imaging is not necessary before reduction but may be needed later to evaluate for associated injuries

Reduction Techniques

• Several reduction techniques exist, with success rates varying by technique and provider experience:
  • A gentle technique reported by Unfallchirurg involves positioning the patient sitting on a chair with the physician standing behind, placing one fist in the anterior axillary fossa for countertraction while applying gentle traction on the forearm until muscle relaxation occurs 3
  • This gentle technique achieved a 90.7% success rate with only 16.3% of patients requiring premedication 3

Procedural Sedation

• Procedural sedation is often required for successful reduction due to muscle spasm and pain
• Evidence supports several sedation options:
  • Etomidate provides effective sedation with shorter duration (median 10 minutes) compared to midazolam (median 23 minutes) 2
  • Propofol with fentanyl is another effective option but requires monitoring for potential respiratory depression 2
  • Both agents have comparable safety profiles when properly monitored 2

Post-Reduction Management

Immobilization

• Traditional immobilization involves a sling keeping the arm in internal rotation
• The duration of immobilization remains controversial:
  • Analysis of pooled data shows no significant difference in recurrence rates between patients immobilized for ≤1 week (41%) versus ≥3 weeks (37%) in patients under 30 years old 4
  • Some evidence suggests bracing in external rotation may provide benefit over traditional internal rotation slings (25% vs 40% recurrence), though this difference did not reach statistical significance 4

Rehabilitation

• After the initial immobilization period:
  • Begin with gentle range of motion exercises
  • Progress to rotator cuff and scapular stabilization exercises 1
  • Conservative management should be continued for 3-6 months before considering surgical referral 1

Surgical Considerations

Indications for Surgical Referral

• Young patients (<25 years) have high recurrence rates (up to 90%) with non-operative management 5
• The Bankart lesion (detachment of the anterior-inferior labrum) is present in approximately 85% of traumatic anterior dislocations 6
• Consider surgical referral for:
  • Young, active patients with high physical demands
  • Patients with recurrent instability
  • Failure of conservative management after 3-6 months 1

Timing of Surgery

• Delaying surgery can make stabilization more challenging due to:
  • Elongation of the capsule
  • Progressive labro-ligamentous injury
  • Increased prevalence and severity of glenoid bone loss 5

Special Considerations

Age-Related Factors

• Age <30 years is a significant predictor of recurrence 4
• Younger patients are more likely to have labroligamentous injury and persistent instability 2
• Older patients are more likely to have associated rotator cuff tears 2

Complications to Monitor

• Recurrent instability (especially in younger patients)
• Rotator cuff tears (especially in older patients)
• Development of osteoarthritis (higher risk with recurrent instability) 5

Remember that prompt reduction with appropriate analgesia/sedation followed by a structured rehabilitation program is the cornerstone of treatment for shoulder dislocations.