What is the best approach to reduce an anterior shoulder dislocation in a patient?

Reducing an Anterior Shoulder Dislocation

Obtain pre-reduction radiographs (AP views in internal and external rotation plus axillary or scapular Y view) to confirm anterior dislocation and rule out fractures, then use procedural sedation with etomidate or propofol followed by gentle traction-based reduction techniques, and always obtain post-reduction imaging to confirm successful reduction. 1

Pre-Reduction Imaging Requirements

You must obtain radiographs before attempting reduction to avoid catastrophic complications from reducing an unrecognized posterior dislocation or fracture-dislocation. 1, 2

• Standard views include anteroposterior (AP) in internal rotation, AP in external rotation, and an axillary or scapular Y view 1, 2
• The axillary or Y view is critical because over 60% of posterior dislocations are missed on AP views alone, and attempting reduction on a posterior dislocation can worsen the injury 1, 2
• Look specifically for Hill-Sachs deformity (posterolateral humeral head compression fracture), bony Bankart lesion (anterior glenoid rim fracture), and proximal humerus fractures 1, 2

Procedural Sedation Protocol

Use etomidate as first-line sedation for reduction, with propofol as an alternative. 1

• Etomidate provides a median procedural sedation time of 10 minutes with a 90% success rate 1
• Propofol is an effective alternative with shorter recovery time but requires careful monitoring for respiratory depression and hypotension 1
• However, research shows that gentle traction techniques can achieve 90.7% success with only 16.3% requiring any premedication, suggesting sedation may not always be necessary 3, 4

Reduction Techniques

Gentle traction-based methods are highly effective and should be attempted first. Multiple techniques exist with comparable success rates:

Gentle Traction, Abduction, and External Rotation (TAE)

• Patient positioned supine, physician applies gentle traction on the affected limb while counter-holding against the acromion 5
• Maintain eye contact and instruct patient to relax, adjusting traction based on muscular tension 5
• Success rate of 100% in one series of 263 patients, with 74.5% requiring no medication 5
• Another study showed 90.63% success without sedation, with significantly higher patient satisfaction compared to traditional methods under sedation 4

Single-Person Axillary Technique

• Patient sits on chair with physician standing behind on affected side 3
• Place one fist in anterior axillary fossa for countertraction (avoiding direct pressure into axilla), other hand grasps patient's forearm for traction 3
• Maintain gentle traction until muscle relaxation achieved; reduction typically occurs at this moment 3
• If needed, slow external rotation of fist in axilla can facilitate reduction by pushing humeral head laterally 3
• Success rate of 90.7% with minimal premedication needed 3

Traditional Traction-Countertraction

• Remains a valid option when other techniques fail or sedation is already administered 6
• Multiple reduction techniques exist, and no single method is 100% successful 6
• Occasionally multiple attempts using different techniques are required 6

Post-Reduction Protocol

Mandatory post-reduction radiographs must be obtained to confirm successful reduction and identify fractures that may have been obscured by the dislocation. 1, 7

• Obtain AP and axillary or Y views 1, 7
• Repeat neurovascular examination and document findings, particularly axillary nerve function 1, 7
• Immobilize in internal rotation sling 1

Age-Specific Advanced Imaging

For patients under 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. 1, 7

For patients over 40 years old, consider MRI to evaluate for rotator cuff tears, which are commonly associated with dislocation in this age group. 1, 7

Pain Management

• Use acetaminophen or ibuprofen as first-line if no contraindications 1, 7
• Intra-articular corticosteroid injection provides significant pain reduction 1, 7
• Avoid prolonged opioid use 1

Rehabilitation

• Brief immobilization period of 1-2 weeks followed by early physical therapy 1, 7
• Focus on gentle mobilization and progressive strengthening 1, 7
• Avoid overhead pulleys during initial recovery as they encourage uncontrolled abduction that may worsen the injury 1, 7

Critical Pitfalls to Avoid

• Never attempt reduction without proper radiographic views including axillary or Y view, as this can worsen fracture-dislocations or miss posterior dislocations 1, 2, 7
• Do not delay reduction attempts, as delays increase neurovascular complications 7
• Never overlook associated rotator cuff tears, especially in patients over 40 years or with high-energy trauma mechanisms 7
• Failure to obtain axillary or scapular Y views leads to missed posterior dislocations in over 60% of cases 1, 2