Treatment for Dislocated Shoulder
The most effective treatment for a dislocated shoulder is prompt closed reduction using procedural sedation with propofol or etomidate, followed by appropriate immobilization and rehabilitation to reduce the risk of recurrence and optimize functional outcomes.
Initial Management
Assessment and Diagnosis
- Obtain standard radiographs before reduction attempt:
- Anteroposterior views in internal and external rotation
- Axillary or scapula-Y view to confirm dislocation and rule out fractures 1
- Assess for neurovascular compromise (circulation, sensation, motor function)
- Determine if this is a first-time or recurrent dislocation
Pain Management and Sedation
- Procedural sedation is recommended for comfortable reduction:
- Alternative: Intra-articular lidocaine injection has fewer complications and requires shorter emergency department time than IV sedation with similar success rates 3
Reduction Techniques
Closed Reduction Methods
Several techniques can be used, with selection based on provider experience and patient factors:
Physician-performed techniques:
- Scapular manipulation
- External rotation method
- Milch technique
- Stimson technique
- Traction-countertraction method
Self-reduction technique (for recurrent dislocators):
- Modified Milch technique: Patient in supine position actively abducts and externally rotates the dislocated shoulder until overhead, then gently lowers the arm while applying anterior pressure to the shoulder 4
- Prakash's method has shown 97.06% success rate without anesthesia, with 91.18% reduced on first attempt 5
CAUTION: Avoid closed reduction attempts in cases of suspected fracture-dislocation without proper imaging, as manipulation may worsen fracture displacement 6
Post-Reduction Care
Immediate Post-Reduction
- Obtain post-reduction radiographs to confirm proper reduction and rule out fractures
- Provide appropriate analgesia (NSAIDs recommended as first-line) 1
- Apply local cold therapy for pain relief 1
Immobilization
- Traditional immobilization in internal rotation has not been shown to reduce recurrence rates 3
- Consider immobilization in external rotation, which may reduce recurrence rates 3
- Duration typically 1-3 weeks depending on patient age and risk factors
Rehabilitation Protocol
Follow a phased rehabilitation approach:
Phase 1 (Initial):
- Pain control measures
- Gentle range of motion exercises
- Proper positioning education
- Isometric exercises if pain-free 1
Phase 2 (Progressive):
- Progressive ROM exercises
- Light strengthening of rotator cuff and periscapular muscles
- Scapular stabilization exercises 1
Phase 3 (Advanced):
- Progressive resistance training
- Advanced scapular stabilization
- Sport or activity-specific training 1
Follow-up and Surgical Considerations
Follow-up Schedule
- Initial follow-up: 1-2 weeks after reduction
- Clinical reassessment: 6 weeks to evaluate progress
- Rehabilitation progress evaluation: 3 months 1
Surgical Referral Indications
Consider surgical consultation for:
- Young patients (<30 years) with high athletic demands
- Evidence of significant mechanical symptoms
- No improvement after 3 months of appropriate rehabilitation
- Significant Hill-Sachs lesion or Bankart tear on imaging 1
- Recurrent dislocations (arthroscopic surgery significantly reduces recurrence compared to non-operative approaches) 3
Special Considerations
- First-time dislocations in young, athletic patients have recurrence rates up to 80% 4
- Rare cases of chronic dislocations may become asymptomatic with minimal functional loss over time 7
- Return to play should be considered only when motion and strength are nearly normal and the athlete can perform sport-specific activities, though risk of recurrence remains 3