What is the recommended treatment plan for an acute shoulder dislocation?

Treatment Plan for Acute Shoulder Dislocation

For acute shoulder dislocation, immediate closed reduction is the priority, followed by immobilization in external rotation (especially for patients aged 21-30 years), pain management, and early physical therapy after the immobilization period. 1, 2

Immediate Management

Initial Imaging

• Obtain radiographs before reduction attempts with minimum 3 views: anteroposterior (AP) in internal and external rotation, plus axillary or scapula-Y view to confirm dislocation and rule out fractures 3
• The axillary or scapula-Y views are critical as glenohumeral dislocations can be misclassified on AP views alone 3
• Perform radiographs upright when possible, as malalignment can be underrepresented on supine imaging 4

Reduction

• Perform immediate closed reduction to minimize neurovascular complications and soft tissue damage 5, 6
• The longer reduction is delayed, the higher the risk of permanent axillary nerve injury, deltoid weakness, and progressive labro-ligamentous damage 5
• Multiple gentle reduction techniques exist; physician preference determines the specific method, but avoid techniques causing additional pain 6, 7
• One effective single-person technique involves the patient sitting with the physician behind them, using gentle traction on the forearm with countertraction via a fist in the anterior axilla, achieving 90.7% success with minimal premedication 7

Post-Reduction Imaging

• Obtain post-reduction radiographs to confirm successful glenohumeral joint reduction 3
• Consider CT without contrast if fractures are present or suspected to characterize fracture morphology, as this changes management in up to 41% of proximal humeral fracture cases 3
• Order MRI without contrast if there are concerns about rotator cuff tears (especially in patients >40 years), labral tears, or neurological deficits 3, 4

Immobilization Strategy

Immobilize in external rotation rather than traditional internal rotation, particularly for patients aged 21-30 years 2

• External rotation immobilization reduces recurrence rates from 29.4% to 6.3% overall 2
• In the 21-30 age subgroup, external rotation prevents recurrence entirely (0% vs 29.4% with internal rotation) 2
• Duration of immobilization should be followed by early physical therapy 1

Pain Management

• Use acetaminophen or ibuprofen as first-line analgesics if no contraindications exist 1
• Intra-articular corticosteroid injections provide significant pain reduction 1
• Subacromial corticosteroid injections are beneficial when pain relates to subacromial region injury or inflammation 1
• For spasticity-related shoulder pain, consider botulinum toxin injections into subscapularis and pectoralis muscles 1

Rehabilitation Protocol

Avoid overhead pulleys during initial recovery as they encourage uncontrolled abduction that may worsen injury 1

Early Phase (Post-Immobilization)

• Begin early physical therapy after immobilization period to restore function and prevent complications 1
• Focus on gentle stretching and mobilization techniques, emphasizing external rotation and abduction 1

Progressive Phase

• Advance to progressive strengthening of shoulder muscles, particularly rotator cuff 1
• Include neuromuscular re-education if nerve injury is present 1
• Consider functional electrical stimulation (FES) to improve shoulder lateral rotation 1

Prevention of Complications

• Educate healthcare staff, patients, and family on correct positioning and handling of the affected arm 1
• Use shoulder strapping or sling to prevent trauma during recovery 1
• Monitor for complex regional pain syndrome (shoulder-hand syndrome), which may require early oral corticosteroids 1
• Perform regular neurological assessments, particularly for axillary nerve function (deltoid strength and lateral shoulder sensation) 1, 5

Surgical Considerations

Consider surgical intervention in specific populations:

• Patients with neurological deficits suggesting axillary nerve involvement require surgical exploration 1, 4
• Young athletes <25 years with high activity demands who are unwilling to modify lifestyle have recurrence rates justifying primary surgical stabilization 8, 9
• Surgical treatment reduces recurrence rates significantly compared to conservative management (odds ratio 12.71) 9
• The presence of associated fractures with neurological deficits mandates surgical approach 4

Follow-Up Monitoring

• Limit follow-up imaging to only what will change management decisions 1, 4
• Monitor closely for recurrent instability, particularly in patients <25 years where recurrence rates are highest 8, 9
• Assess for development of rotator cuff tears, especially in patients over 40 years 5

Critical Pitfalls to Avoid

• Never delay reduction waiting for "ideal" conditions—even layperson reduction attempts in wilderness settings achieve 70.8% success, emphasizing that delayed reduction causes worse outcomes 5
• Do not miss associated fractures by obtaining inadequate radiographic views (AP views alone are insufficient) 3, 4
• Avoid traditional internal rotation immobilization in young patients (21-30 years) as this significantly increases recurrence risk 2
• Do not underestimate neurological injury—decreased deltoid sensation indicates axillary nerve involvement requiring different management 4