What is the immediate treatment for a shoulder dislocation?

Immediate Treatment for Shoulder Dislocation

The immediate treatment for a shoulder dislocation is procedural sedation followed by gentle closed reduction, with options including propofol (initial dose 1 mg/kg) or etomidate for sedation, and consideration of fentanyl for analgesia. 1

Initial Assessment and Imaging

1. Radiographic evaluation before reduction:

   • Standard radiographs including anteroposterior views in internal and external rotation
   • Axillary or scapula-Y view to evaluate fractures, dislocations, and shoulder alignment 1
   • Rule out associated fractures before attempting reduction

2. Type of dislocation:

   • Anterior dislocations (most common)
   • Inferior dislocations (rare, may require specific techniques) 2

Reduction Procedure

Sedation and Analgesia

• Procedural sedation is recommended for comfortable reduction 1
• Options include:
  • Propofol (initial dose 1 mg/kg)
  • Etomidate
  • Fentanyl for additional analgesia

Reduction Techniques

1. Traction-countertraction - traditional approach but may require multiple attempts and additional personnel 3

2. Alternative techniques to consider if initial attempt fails:

   • For inferior dislocations: "Two-step maneuver" - first converting to anterior dislocation, then reducing to anatomical position 2
   • Various other techniques exist as no single method is 100% successful 3

Key Principles During Reduction

• Use gentle force
• Minimize trauma to surrounding tissues
• Single practitioner can often perform the reduction
• May only require one attempt with proper technique 2

Post-Reduction Management

Immediate Post-Reduction Care

• Confirm successful reduction with post-reduction radiographs
• Apply local cold therapy for pain relief 1
• Immobilize the shoulder in a sling

Pain Management

• NSAIDs as first-line medication (if no contraindications)
• Acetaminophen or ibuprofen for pain relief
• Focus on tapering NSAIDs as tolerated 1

Rehabilitation Protocol

Phase 1 (Initial 1-2 weeks)

• Pain control measures
• Gentle range of motion exercises
• Proper positioning education
• Isometric exercises if no pain is present 1

Phase 2 (Weeks 2-4)

• Progressive ROM exercises
• Light strengthening exercises for rotator cuff and periscapular muscles
• Scapular stabilization exercises 1, 4

Phase 3 (Weeks 4-6)

• Progressive resistance training
• Advanced scapular stabilization
• Sport or activity-specific training 1, 4

Follow-up Care

• Initial follow-up: 1-2 weeks after treatment initiation
• Clinical reassessment at 6 weeks to evaluate progress
• Consider surgical consultation if:
  • No improvement after 3 months of rehabilitation
  • Patient is under 30 years of age with high athletic demands
  • Evidence of significant mechanical symptoms 1

Special Considerations

• Young athletes (under 25 years) have higher recurrence rates and may benefit from early orthopedic consultation 5
• First-time dislocations in young, athletic individuals may warrant more aggressive management due to high recurrence risk 5
• A properly designed 6-week physical rehabilitation program can effectively restore strength and range of motion 4

Pitfalls to Avoid

• Attempting reduction without adequate imaging to rule out fractures
• Inadequate sedation/analgesia leading to muscle guarding and difficult reduction
• Prolonged immobilization which may lead to stiffness and delayed recovery
• Returning to sports too early before adequate healing and rehabilitation
• Missing associated injuries (rotator cuff tears, labral tears) that may require additional treatment