Where to Send a Patient for Shoulder Reduction
A patient with an acute shoulder dislocation should be sent to the emergency department for immediate reduction under procedural sedation, with the critical exception that posterior dislocations and anterior dislocations with surgical neck fractures require reduction under general anesthesia in the operating room. 1, 2
Initial Triage Decision Algorithm
Imaging Requirements Before Any Reduction Attempt
- Never attempt reduction without proper imaging first - obtain anteroposterior views in internal and external rotation PLUS an axillary or scapula-Y view, as AP views alone will miss the dislocation 1, 3
- Perform radiographs upright rather than supine to avoid underestimating malalignment 1, 3
Decision Tree for Reduction Location
Send to Operating Room for General Anesthesia if:
- Any posterior dislocation - all posterior dislocations should be reduced under general anesthesia regardless of associated fractures 2
- Anterior dislocation with surgical neck fracture (Type II injury) - attempting reduction under sedation risks significant displacement of the humeral head from the shaft 2
- Neurological deficit present (decreased sensation, motor weakness) - requires surgical exploration of potentially injured nerves 1
Send to Emergency Department for Reduction Under Sedation if:
- Anterior dislocation without fracture - standard ED reduction is appropriate 2, 4, 5
- Anterior dislocation with isolated greater tuberosity fracture (Type I injury) - 94% success rate with sedation, no fracture propagation risk 2
Procedural Sedation Considerations in the ED
When reduction under sedation is appropriate, the emergency physician should consider:
- Propofol has the lowest rate of respiratory depression compared to methohexital, fentanyl/midazolam, and etomidate for procedural sedation 6
- Etomidate provides approximately 90% procedural success for shoulder reduction with minimal respiratory complications 6
- When combining benzodiazepines and opioids, give the opioid first and carefully titrate the benzodiazepine to reduce respiratory depression risk 6
Effective Reduction Techniques
Multiple techniques are available with high success rates:
- Scapular manipulation is effective and safe, with 92% success rate (47/51 patients) when properly executed 4
- Scapulohumeral distraction technique shows 95.3% success with significantly less pain and higher patient satisfaction compared to traditional traction methods 5
- Boss-Holzach-Matter method achieves 60% success without premedication, useful when rapid discharge is desired 7
Critical Pitfalls to Avoid
- Do not skip the axillary or scapula-Y view - this is the most common imaging error that leads to missed diagnoses 1, 3
- Do not attempt ED reduction of posterior dislocations - all cases in one series required general anesthesia 2
- Do not attempt ED reduction when surgical neck is involved - 5 of 8 failed ED reductions showed significant humeral head displacement 2
- Do not use overhead pulley exercises during initial recovery as they encourage uncontrolled abduction that may worsen injury 8