What is the appropriate management for an adult patient with a history of trauma and potential underlying conditions such as osteoporosis presenting with a dislocated shoulder?

Management of Shoulder Dislocation

Obtain pre-reduction radiographs (AP in internal and external rotation PLUS axillary or scapula-Y view) to confirm the dislocation and identify fractures before attempting any reduction, then proceed with closed reduction under procedural sedation for simple anterior dislocations without complex fractures. 1

Pre-Reduction Imaging Protocol

Never attempt reduction without radiographic confirmation, as this could worsen occult fracture-dislocations and lead to catastrophic complications. 1

• Mandatory three-view series: anteroposterior views in both internal and external rotation, PLUS either axillary or scapula-Y view 1
• The axillary or scapula-Y view is absolutely critical—over 60% of posterior dislocations are missed on AP views alone, leading to misdiagnosis and inappropriate treatment 2
• Radiographs identify associated fractures (Hill-Sachs lesions, bony Bankart lesions, greater tuberosity fractures, surgical neck fractures) that fundamentally alter your reduction approach 3, 1

Reduction Decision Algorithm

Type I: Anterior Dislocation with Isolated Greater Tuberosity Fracture

• Proceed with closed reduction under procedural sedation in the emergency department 4
• Success rate is 94% with no fracture propagation reported 4
• This is the safest fracture-dislocation pattern for ED reduction 4

Type II: Surgical Neck Fracture (With or Without Greater Tuberosity Involvement)

• Do NOT attempt reduction under sedation—these patients require general anesthesia in the operating room 4
• Attempted ED reduction resulted in significant displacement of the humeral head in relation to the shaft in multiple cases 4
• The fracture pattern makes controlled reduction under sedation unsafe 4

Posterior Dislocation with Any Fracture

• All posterior dislocations require reduction under general anesthesia, regardless of fracture pattern 4
• These are high-risk reductions that should not be attempted under procedural sedation 4

Simple Anterior Dislocation (No Fracture or Isolated Greater Tuberosity)

• Perform closed reduction under procedural sedation in the emergency department 1, 4
• Multiple reduction techniques are effective—your skill and experience matter more than the specific method chosen 5

Post-Reduction Management

Immediate Post-Reduction Steps

• Obtain post-reduction radiographs to confirm successful reduction and reassess for fractures that may have been obscured by the dislocation 1
• Perform thorough neurovascular examination, documenting axillary nerve function (deltoid sensation over lateral shoulder) and distal pulses 1
• If vascular compromise is suspected, obtain CT angiography immediately—axillary artery injury can occur, especially with proximal humeral fractures 1

Age-Specific Considerations for Advanced Imaging

Older patients (>40 years) require MRI without contrast after reduction to evaluate for rotator cuff tears, which are extremely common in this population and will determine definitive management. 3, 1

• MRI has high sensitivity and specificity for full-thickness rotator cuff tears 3
• Rotator cuff pathology is frequently missed in older patients with dislocation, leading to poor functional outcomes 1
• MRI also assesses labral injuries and capsular tears that influence recurrence risk 3

Younger patients (<35 years) have 80% recurrence rates with non-operative management and should be counseled about arthroscopic stabilization to prevent recurrent instability and subsequent osteoarthritis. 6

Critical Pitfalls to Avoid

• Attempting reduction without proper radiographic views leads to missed posterior dislocations and worsened fracture-dislocations 1
• Delaying reduction increases risk of neurovascular compromise and makes subsequent reduction more difficult 1
• Failing to obtain axillary or scapula-Y views results in missed diagnosis in the majority of posterior dislocations 2
• Overlooking rotator cuff tears in older patients leads to persistent pain and dysfunction despite successful reduction 1
• Attempting ED reduction of surgical neck fractures risks catastrophic humeral head displacement 4