What is the highest priority intervention for a patient with a shoulder dislocation after a traumatic injury?

Highest Priority Intervention for Traumatic Shoulder Dislocation

The highest priority intervention for a patient with a shoulder dislocation after a traumatic motorcycle accident is immediate reduction of the dislocated shoulder to restore proper alignment and minimize neurovascular complications.

Assessment of Traumatic Shoulder Dislocation

When evaluating a patient with suspected shoulder dislocation after trauma:

• Radiography is the preferred initial diagnostic modality to confirm dislocation and identify associated fractures before attempting reduction 1
• A standard set of shoulder radiographs should include anteroposterior (AP) views in internal and external rotation, plus an axillary or scapula-Y view 1
• Axillary or scapula-Y views are vital as acromioclavicular and glenohumeral dislocations can be misclassified on AP views alone 1

Management Algorithm

1. Immediate Reduction:

   • Prompt reduction of the dislocated shoulder is the highest priority intervention after confirming dislocation 2
   • Reduction should be performed using gentle traction techniques to minimize pain and prevent additional injury 2

2. Post-Reduction Assessment:

   • Post-reduction radiographs to confirm successful reduction and evaluate for any fractures that may have been obscured by the dislocation 1
   • Assessment for neurovascular compromise following reduction 1

3. Immobilization:

   • After successful reduction, immobilization is typically recommended 3
   • Some evidence suggests immobilization in external rotation may reduce recurrence rates compared to traditional internal rotation positioning (relative risk reduction of 38.2%) 3, 4

Important Clinical Considerations

• Young patients (under 30 years) have significantly higher recurrence rates (up to 88.9% in the 14-20 year age group) following initial dislocation 5, 3
• Vascular assessment is critical in traumatic dislocations, especially with associated proximal humeral fractures, as axillary artery injury can occur 1
• CT angiography (CTA) is the preferred examination if vascular compromise is suspected following shoulder trauma 1

Reduction Techniques

• Various reduction techniques exist, with success rates around 90% when performed properly 2
• Many reductions can be performed without sedation or general anesthesia (92.1% in one study) 5
• A single-person technique with the patient sitting and the physician applying gentle traction has shown high success rates (90.7%) with minimal need for premedication 2

Pitfalls to Avoid

• Failure to obtain proper radiographic views (especially axillary or scapula-Y views) may lead to missed diagnosis of dislocation 1
• Attempting reduction without radiographic confirmation could worsen fracture-dislocations 1
• Delaying reduction increases risk of complications including neurovascular compromise 1
• Overlooking associated injuries such as rotator cuff tears, which are more common in older patients with shoulder dislocation 1