What are the guidelines for reducing a shoulder dislocation that has been dislocated for more than 3 days?

Guidelines for Reducing Shoulder Dislocations After 3+ Days

For shoulder dislocations that have been present for more than 3 days, closed reduction should not be attempted in the emergency department setting but instead requires surgical consultation for potential open reduction due to increased risk of neurovascular complications and soft tissue contracture. 1

Assessment of Chronic Dislocations

When evaluating a shoulder that has been dislocated for more than 3 days:

• Imaging requirements:

  • Plain radiographs from multiple angles to assess joint position, associated fractures, and humeral head defects 1
  • MRI without contrast is preferred for evaluating soft tissue damage, including rotator cuff and labral tears 1

• Key clinical considerations:

  • Neurovascular status assessment is critical - check axillary nerve function (deltoid sensation)
  • Evaluate for muscle contractures and soft tissue adaptations
  • Assess for humeral head defects or fractures that may have occurred during initial trauma

Management Algorithm

1. Duration 3-7 days:

   • Surgical consultation is required
   • Closed reduction under general anesthesia may be attempted in the operating room with muscle relaxation
   • Have surgical backup ready for immediate open reduction if closed methods fail

2. Duration >7 days:

   • Open reduction is typically required
   • Soft tissue contractures and potential bone defects make closed reduction increasingly difficult and risky
   • Higher risk of iatrogenic fracture, neurovascular injury, and unsuccessful reduction 2

Procedural Considerations

• Anesthesia requirements:

  • General anesthesia with complete muscle relaxation is necessary for chronic dislocations 3
  • Regional blocks alone are insufficient due to muscle contractures

• Surgical approach:

  • May require capsular release
  • Potential need for subscapularis lengthening
  • Possible bone grafting for humeral head defects

Post-Reduction Management

• Immobilization:

  • External rotation immobilization has not been shown to reduce recurrence rates compared to internal rotation (24.7% vs 30.8%, p=0.36) 4
  • Immobilization period may need to be extended in chronic cases to allow soft tissue healing

• Rehabilitation phases:

  • Phase 1: Pain control, gentle ROM exercises, proper positioning education 1
  • Phase 2: Progressive ROM exercises, light strengthening for rotator cuff and periscapular muscles 1
  • Phase 3: Progressive resistance training and activity-specific rehabilitation 1

Complications of Chronic Dislocations

• Higher risk of recurrent instability
• Increased likelihood of rotator cuff tears
• Greater tuberosity fractures (if present) may heal in non-anatomic position in 35% of cases 5
• Potential for avascular necrosis of humeral head
• Permanent functional limitations

Special Considerations

• Elderly patients with chronic dislocations may develop surprisingly good function despite persistent dislocation 2
• Patients with greater tuberosity fractures have lower recurrence rates (5.5%) but may experience decreased range of motion 5
• Multiple reduction techniques exist (23 different techniques with 17 modifications), but most are designed for acute dislocations and are contraindicated in chronic cases 6

Pitfalls to Avoid

• Attempting forceful closed reduction after 3 days without adequate anesthesia
• Failing to obtain adequate imaging before reduction attempts
• Neglecting to assess neurovascular status before and after reduction
• Underestimating the force required, which increases risk of iatrogenic fracture
• Inadequate post-reduction rehabilitation leading to stiffness or recurrent instability