What is the treatment for a shoulder dislocation?

Shoulder Dislocation Treatment

After confirming the diagnosis with mandatory pre-reduction radiographs (AP views in internal and external rotation PLUS axillary or scapula-Y view), perform prompt closed reduction using gentle techniques, followed by immobilization, early rehabilitation, and age-stratified decision-making regarding surgical stabilization—with arthroscopic repair strongly considered for patients under 25 years old who engage in high-demand activities due to recurrence rates exceeding 80% with conservative management alone. 1, 2

Immediate Diagnostic Requirements Before Reduction

• Never attempt reduction without radiographic confirmation, as AP views alone miss posterior dislocations in over 60% of cases and could worsen occult fracture-dislocations 1, 3
• Obtain anteroposterior views in internal and external rotation PLUS mandatory axillary or scapula-Y view to identify Hill-Sachs deformities and bony Bankart lesions 1, 3
• Assess for associated fractures before manipulation, particularly in elderly patients who have significantly higher rates of rotator cuff tears 1

Reduction Technique

• Perform reduction promptly, as delays increase neurovascular complications 1
• Consider procedural sedation with propofol or etomidate combined with opioid analgesia for patient comfort 1
• The scapulohumeral distraction technique demonstrates significantly less procedure time and pain compared to traditional Hippocratic methods, with comparable 95% success rates 4
• Gentle traction-based techniques performed by a single operator achieve 90.7% success with minimal premedication requirements 5

Post-Reduction Management

• Obtain mandatory post-reduction radiographs to confirm successful reduction and evaluate for previously obscured fractures 1, 3
• Perform thorough neurovascular assessment, particularly evaluating axillary nerve function and vascular integrity 1
• Consider CT angiography if vascular compromise is suspected, especially with proximal humeral fractures 1, 3

Immobilization and Initial Recovery

• Immobilize the shoulder following reduction 6
• Avoid overhead pulleys during initial recovery as they encourage uncontrolled abduction that may worsen injury 6
• Consider shoulder strapping or sling to prevent trauma during recovery 6

Pain Management Protocol

• Use acetaminophen or ibuprofen for pain relief when no contraindications exist 6
• Intra-articular corticosteroid injections demonstrate significant pain reduction effects 6
• Subacromial corticosteroid injections benefit pain related to subacromial region injury or inflammation 6
• For spasticity-related shoulder pain, botulinum toxin injections into subscapularis and pectoralis muscles may be beneficial 6

Rehabilitation Strategy

• Begin early physical therapy after the immobilization period to restore function and prevent complications 6
• Focus on gentle stretching and mobilization techniques, particularly increasing external rotation and abduction 6
• Progress to strengthening of shoulder muscles, especially the rotator cuff 6
• Implement neuromuscular re-education if nerve injury is present 6
• Consider functional electrical stimulation to improve shoulder lateral rotation 6

Age-Stratified Surgical Decision Making

Patients Under 25 Years Old

• Strongly consider arthroscopic stabilization for young, high-demand athletes unwilling to modify activity, as recurrence rates with conservative management exceed 80% in this population 2, 7
• The primary pathology is capsulolabral avulsion (Bankart lesion), present in 84% of cases, making acute arthroscopic repair ideal when tissue quality is excellent 8, 7
• Surgery reduces risk of recurrent instability and subsequent osteoarthritis development 2
• Delaying surgery makes stabilization more demanding due to capsular elongation, progressive labro-ligamentous injury, and increasing glenoid bone loss 2

Patients Over 25 Years Old

• Conservative management with immobilization and rehabilitation is appropriate for most patients, as recurrence rates are relatively low 2, 7
• Do not overlook rotator cuff tears, which are significantly more common in elderly patients and present with weakness in external rotation, abduction, or internal rotation 1

Advanced Imaging for Recurrence Risk Assessment

• For young patients, obtain MR arthrography (the gold standard with 9/9 appropriateness rating) to evaluate labral tears, capsular injuries, and bone loss that predict recurrence 1, 9
• MR arthrography outperforms non-contrast MRI in detecting glenohumeral ligament and anterior labral injuries 9
• Glenoid bone loss occurs in up to 10% of patients with recurrent instability and may require bone grafting to restore stability 9, 1

Critical Complications to Monitor

• Educate healthcare staff, patients, and family on correct positioning and handling to prevent further injury 6
• Monitor for complex regional pain syndrome (shoulder-hand syndrome), which may require early oral corticosteroid intervention 6
• Perform regular neurological assessments 6
• Surgical intervention should be considered for patients with neurological deficits suggesting nerve involvement 6

Follow-Up Imaging

• Limit follow-up imaging to what will change management decisions 6
• CT scan is indicated to better characterize associated fractures 6
• MRI should be considered for concerns about soft tissue injuries or neurological involvement 6