What is the recommended technique for reducing a shoulder dislocation in an emergency department setting?

Shoulder Reduction Technique in the Emergency Department

Primary Recommendation

For acute anterior shoulder dislocations in the ED, use the external rotation method as your first-line technique—it achieves 78-95% success rates without requiring sedation or analgesia in most patients, significantly reducing ED length of stay and eliminating sedation-related complications. 1, 2, 3, 4

Pre-Reduction Requirements

Mandatory Imaging Before Reduction Attempts

• Obtain standard radiographs before attempting reduction: anteroposterior (AP) views in internal and external rotation PLUS an axillary or scapular Y view to confirm dislocation type and identify associated fractures 5, 6
• The axillary or Y view is absolutely critical—over 60% of posterior dislocations are missed on AP views alone, and attempting reduction on an unrecognized posterior dislocation or fracture-dislocation can worsen the injury 5, 6
• Look specifically for Hill-Sachs deformity (posterolateral humeral head compression fracture), bony Bankart lesion (anterior glenoid rim fracture), and proximal humerus fractures 5

Neurovascular Assessment

• Document axillary nerve function (sensation over lateral deltoid) and distal pulses before any reduction attempt 6
• Vascular compromise is particularly concerning with associated proximal humeral fractures—if suspected, obtain CT angiography 5, 6

Reduction Technique: External Rotation Method (First-Line)

Why This Method First

• Success rate of 78-95% without sedation or analgesia when performed slowly and gently 1, 2, 3, 4
• Average reduction time under 2 minutes in successful cases 2, 3
• Particularly effective in male patients (83% success rate) 3
• Eliminates sedation-related complications and reduces ED length of stay from 118 minutes to 55 minutes compared to sedation-based approaches 3

Step-by-Step Technique

Patient positioning: Patient sits upright in a chair or on the stretcher 1, 2

Physician positioning: Stand beside the affected shoulder 1, 2

The maneuver:

• Flex the patient's elbow to 90 degrees with the arm adducted against the body 2, 4
• Gently and slowly externally rotate the shoulder, taking 2-3 minutes to reach 90 degrees of external rotation 2, 3
• The key is slow, gentle rotation—this allows muscle relaxation without triggering protective spasm 3, 4
• Reduction typically occurs spontaneously during the slow external rotation process 2, 4
• If reduction doesn't occur at 90 degrees of external rotation, gently abduct the arm while maintaining external rotation 2

Critical Technical Points

• Speed is everything: Rapid movements increase muscle resistance and pain, leading to failure 3, 4
• No traction-countertraction is required with this method 2, 4
• The technique works by gradually overcoming muscle spasm through slow, sustained positioning rather than force 3

When Sedation Is Needed

Indications for Procedural Sedation

If the external rotation method fails after one careful attempt, proceed to sedation-assisted reduction 3, 7

Sedation Agent Selection

For anterior shoulder dislocation reduction specifically, use etomidate as first-line sedative agent 8:

• Median procedural sedation time of 10 minutes (versus 23 minutes for midazolam) 8
• 90% success rate for shoulder reduction 8
• Comparable safety profile to midazolam with shorter recovery time 8
• Dose: Standard induction doses per institutional protocol 8

Alternative: Propofol 8:

• Provides effective sedation with shorter recovery time (15 minutes) compared to midazolam (76 minutes) 8
• Initial dose 1 mg/kg followed by 0.5 mg/kg supplements as needed 8
• Requires careful monitoring for respiratory depression and hypotension 8

Critical Sedation Safety Points

• Always administer opioids first, then titrate benzodiazepines—this sequence reduces respiratory depression risk 8
• Combined benzodiazepine-opioid use increases respiratory compromise risk 8
• Maintain continuous monitoring with pulse oximetry and have bag-mask ventilation immediately available 8
• Brief episodes of oxygen desaturation (responding to stimulation or jaw thrust) occur in 5-30% of cases but rarely require intervention beyond basic airway maneuvers 8

Alternative Reduction Techniques

When to Use Alternative Methods

If external rotation fails and you need to attempt reduction before sedation is available, or if patient anatomy/injury pattern makes external rotation unsuitable 7

Key Alternative Approaches

Scapular manipulation: Particularly useful when performed simultaneously with traction methods; can be done with patient prone or sitting 7

Stimson technique: Patient prone with affected arm hanging off stretcher with 5-10 lb weight; allows gravity-assisted reduction over 15-30 minutes 7

Traction-countertraction: Traditional method but requires assistant and often needs sedation; higher force application increases soft tissue injury risk 7

Post-Reduction Protocol

Immediate Post-Reduction Steps

• Obtain mandatory post-reduction radiographs (AP plus axillary or Y view) to confirm successful reduction and identify any fractures obscured by the dislocation 5, 6
• Repeat neurovascular examination and document findings 6
• Immobilize in internal rotation sling 6

Advanced Imaging Considerations

For patients <35 years old: Obtain MRI without contrast or MR arthrography within 1-2 weeks to evaluate for labral tears, capsular injuries, and bone loss that predict recurrence 6

For patients >40 years old: Consider MRI to evaluate for rotator cuff tears, which are commonly associated with dislocation in this age group 5, 6

Pain Management

• First-line: Acetaminophen or ibuprofen if no contraindications 6
• Intra-articular corticosteroid injection provides significant pain reduction 6
• Avoid prolonged opioid use 6

Rehabilitation

• Brief immobilization period (typically 1-2 weeks) followed by early physical therapy 6
• Focus on gentle mobilization and progressive strengthening 6
• Avoid overhead pulleys during initial recovery—they encourage uncontrolled abduction that may worsen injury 6

Critical Pitfalls to Avoid

Imaging Errors

• Never attempt reduction without proper radiographs—you will miss posterior dislocations and fracture-dislocations that require different management 5, 6
• Never rely on AP views alone—always obtain axillary or Y view 5, 6

Timing Errors

• Do not delay reduction attempts—every hour of delay increases neurovascular complication risk and makes reduction technically more difficult due to progressive soft tissue damage 9, 6
• Even in wilderness settings, layperson reduction attempts show 70.8% success rates, emphasizing that timely reduction trumps waiting for ideal conditions 9

Technical Errors

• Do not use excessive force with any technique—this increases fracture risk and soft tissue injury 7
• Do not rush the external rotation method—rapid movement defeats the entire mechanism of action 3, 4

Assessment Errors

• Never overlook associated rotator cuff tears, especially in patients >40 years or with high-energy mechanisms 6
• Do not miss axillary nerve injury (present in up to 40% of anterior dislocations)—always document pre- and post-reduction neurological status 6

Algorithm Summary

1. Confirm diagnosis: Standard radiographs (AP + axillary/Y view) + neurovascular exam 5, 6
2. First attempt: External rotation method without sedation (slow, gentle, 2-3 minutes to 90° external rotation) 1, 2, 3, 4
3. If unsuccessful: Procedural sedation with etomidate, then repeat reduction attempt 8
4. Post-reduction: Radiographs, neurovascular exam, immobilization 6
5. Follow-up imaging: MRI for patients <35 years or >40 years to assess for recurrence risk factors and rotator cuff tears 6