What are the steps for treating an anterior shoulder dislocation?

Step-by-Step Maneuver for Anterior Shoulder Dislocation Treatment

The most effective treatment for anterior shoulder dislocation involves a systematic approach with procedural sedation followed by gentle traction-based reduction techniques, with careful attention to pain control and post-reduction care. 1

Pre-Reduction Assessment

1. Confirm anterior dislocation with standard radiographs:

   • Anteroposterior views in internal and external rotation
   • Axillary or scapula-Y view to confirm direction of dislocation 1

2. Assess for associated fractures:

   • Type I injury: Anterior dislocation with greater tuberosity fracture (safe for sedation reduction)
   • Type II injury: Fracture involving surgical neck of humerus (requires general anesthesia) 2

Procedural Sedation Preparation

1. Medication options:

   • Etomidate: Provides rapid sedation with shorter recovery time (10 min vs 23 min for midazolam)
   • Propofol: Effective alternative with rapid recovery
   • Consider fentanyl for analgesia prior to sedation 3

2. Monitoring requirements:

   • Continuous pulse oximetry
   • Blood pressure monitoring
   • Cardiac monitoring
   • Availability of resuscitation equipment 3

Reduction Technique

Traction-Countertraction Method:

1. Place patient supine on stretcher
2. Apply a sheet around patient's chest for countertraction
3. Apply gentle, steady inline traction to the affected arm at 30-45° abduction
4. Maintain traction for 5-10 minutes while encouraging muscle relaxation
5. Apply gentle external rotation once muscles relax
6. Feel for the characteristic "clunk" as humeral head reduces 4

Alternative Gentle Reduction Technique:

1. Position patient supine
2. Grasp patient's hand of injured limb with one hand
3. Place other hand against acromion for counter pressure
4. Gradually increase traction using your trunk as a fulcrum
5. Maintain eye contact with patient and encourage relaxation
6. Adjust traction based on muscle tension 5

Post-Reduction Care

1. Immediate post-reduction assessment:

   • Confirm successful reduction clinically
   • Verify with post-reduction radiographs
   • Assess neurovascular status (particularly axillary nerve function) 1

2. Initial immobilization:

   • Apply sling for comfort
   • Temporary immobilization for 1-2 weeks 1

3. Rehabilitation protocol:

   • Phase 1 (Weeks 1-2): Pain control, gentle ROM exercises
   • Phase 2 (Weeks 3-6): Progressive ROM, light strengthening of rotator cuff
   • Phase 3 (Weeks 7+): Progressive resistance training, advanced stabilization 1

Follow-up Care

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

Common Pitfalls and Caveats

• Avoid forceful manipulation which can cause iatrogenic fractures or nerve injury
• Never attempt sedation reduction with Type II injuries (surgical neck fractures)
• Posterior dislocations should not be reduced under sedation in the emergency department 2
• Beware of recurrence risk which is significantly higher in patients under 25 years old 6
• Monitor for respiratory depression during procedural sedation, especially when combining benzodiazepines and opioids 3

This systematic approach ensures safe and effective management of anterior shoulder dislocations while minimizing complications and optimizing outcomes.