What is the management for a young to middle-aged adult with a history of trauma or sports injury and a right anterior infracoracoid glenohumeral dislocation, possibly with pre-existing shoulder instability?

Management of Right Anterior Infracoracoid Glenohumeral Dislocation

Confirm the dislocation with standard three-view radiography (AP in internal rotation, AP in external rotation, and axillary or scapular-Y view) before attempting reduction, then perform closed reduction under procedural sedation, followed by post-reduction radiographs and immobilization. 1, 2

Initial Diagnostic Imaging

• Obtain radiographs immediately with three mandatory views: anteroposterior in internal rotation, anteroposterior in external rotation, and axillary or scapular-Y view 1, 2
• The axillary or scapular-Y view is critical because glenohumeral dislocations are routinely misclassified on AP views alone, and attempting reduction without proper imaging could worsen occult fracture-dislocations 2, 3
• Radiographs will identify the infracoracoid position (humeral head displaced anteriorly and inferiorly to the glenoid) and detect associated injuries including Hill-Sachs deformity (posterolateral humeral head compression fracture) and bony Bankart lesion (anterior glenoid rim fracture) 2, 3

Procedural Sedation for Reduction

Use propofol with remifentanil for procedural sedation, as this combination provides superior recovery times (median 15 minutes) compared to traditional morphine/midazolam (median 45 minutes) while maintaining equivalent pain control and reduction success. 4

• Administer propofol 0.5 mg/kg with remifentanil 0.5 mcg/kg IV over 90 seconds, with additional doses of 0.25 mg/kg and 0.25 mcg/kg respectively if needed 5
• Provide oxygen via tight-fitting facemask with Mapleson C circuit to prevent hypocapnia and reduce apnea risk 4
• Alternative sedation with etomidate provides shorter procedural sedation duration (median 10 minutes) compared to midazolam (23 minutes) for shoulder reduction, though myoclonus occurs in 21% of patients 1
• All patients given propofol/remifentanil recover within 30 minutes, with mean reduction time of 1.6 minutes and mean pain score of 1.7/10 5, 4

Reduction Technique

• Perform closed reduction using the Milch technique or provider's preferred method while patient is adequately sedated 5
• Most reductions succeed within four minutes of sedation administration, with 64% requiring only one attempt 5
• Have a second practitioner perform the reduction while the sedating physician monitors the patient 4

Post-Reduction Management

• Obtain post-reduction radiographs to confirm successful reduction and evaluate for fractures that may have been obscured by the dislocation 2
• Perform thorough neurovascular examination post-reduction, as axillary nerve injury and vascular compromise can occur, particularly with associated proximal humeral fractures 2, 6
• Consider MRI without contrast for detailed soft tissue assessment if you need to evaluate for rotator cuff tears, labral injuries (Bankart lesions), or capsular tears, particularly in patients over 35 years or those with recurrent instability 1, 3

Advanced Imaging Considerations

• MRI without contrast is the preferred next study after successful reduction when soft tissue injury assessment is needed, as post-traumatic joint effusion provides sufficient visualization without requiring arthrography 1
• The inferior glenohumeral ligament complex is the most frequently injured structure in anterior dislocations and the most important stabilizer against anteroinferior dislocation 7
• CT without contrast is reserved for characterizing complex fracture patterns when surgical planning is needed, and is superior to MRI for evaluating fracture planes 1, 2

Critical Pitfalls to Avoid

• Never attempt reduction without radiographic confirmation, as this could worsen fracture-dislocations 2
• Delaying reduction increases risk of neurovascular complications 2
• Failure to obtain axillary or scapular-Y views leads to missed diagnoses in over 60% of posterior dislocations, though this is less relevant for confirmed anterior dislocations 2, 3
• In older patients, overlooking associated rotator cuff tears (which are common) can impact outcomes and requires specific evaluation 2

Recurrence Risk and Follow-up

• Younger patients under 35 years have substantially higher recurrence rates due to labroligamentous injury and persistent instability 3
• In pediatric patients (≤14 years), recurrent dislocation occurs in 44% at median 14.7 months post-injury, with 20% ultimately requiring surgical stabilization 8
• Skeletal maturity is associated with significantly higher recurrent instability rates 8
• Recurrent instability significantly worsens functional outcomes, with unstable patients scoring 71.4% versus 94.3% on WOSI scores 8