Shoulder Dislocation: Immediate Reduction Protocol
Yes, your shoulder should be reduced promptly in the emergency department after obtaining appropriate radiographs to confirm the dislocation and rule out associated fractures. 1, 2
Pre-Reduction Imaging Requirements
Before attempting any reduction, you must obtain three specific radiographic views 3, 2:
- Anteroposterior (AP) views in both internal and external rotation
- Axillary view OR scapular Y-view (this is non-negotiable)
Critical pitfall: Relying on AP views alone will miss the dislocation and associated fractures—the axillary or scapular Y-view is essential and represents the most common imaging error leading to missed diagnoses. 2
Reduction Procedure
Sedation Options
For procedural sedation during reduction 2:
- Propofol has the lowest rate of respiratory depression compared to other agents
- Etomidate provides approximately 90% procedural success with minimal respiratory complications
- If combining benzodiazepines and opioids, give the opioid first and carefully titrate the benzodiazepine to reduce respiratory depression risk
Post-Reduction Confirmation
Mandatory post-reduction radiographs must be obtained to verify successful joint relocation. 1
Immediate Post-Reduction Management
Immobilization Position
Do not use a traditional sling in internal rotation. 4 The evidence suggests that internal rotation worsens the detachment of anterior shoulder structures, while external rotation realigns them. 4 Consider using a splint or pillow to maintain the arm in external rotation. 4
Duration of Immobilization
For patients under 30 years old, immobilization beyond one week provides no additional benefit—the recurrence rate is 41% with ≤1 week immobilization versus 37% with ≥3 weeks (not statistically significant). 5 External rotation bracing may reduce recurrence from 40% to 25% compared to traditional sling immobilization, though this difference did not reach statistical significance. 5
Critical Complications to Monitor
Age-Specific Risks
Older patients (>60 years) have fundamentally different injury patterns than younger patients: 6
- Rotator cuff tears are significantly more common than nerve injuries in older patients
- Rotator cuff tears can be mistaken for nerve palsies
- Recurrent dislocation is much less likely in older patients compared to younger patients
Neurological Assessment
If you have any neurological deficits (decreased sensation, motor weakness), you require immediate surgical exploration. 2 Injuries to the axillary nerve or brachial plexus are more common in older patients and require prompt recognition. 6
Advanced Imaging Indications
Order additional imaging based on specific concerns 1:
- Non-contrast CT scan: If fracture is suspected or identified on plain films (alters management in 41% of proximal humeral fracture cases)
- Non-contrast MRI: For patients >40 years old with suspected rotator cuff pathology, labral injury, or neurological deficits
Post-Reduction Rehabilitation
What to Avoid
Absolutely avoid overhead pulley exercises during initial recovery—they encourage uncontrolled abduction that worsens injury. 1, 2
Rehabilitation Protocol
Begin early physical therapy after immobilization 1:
- Focus on gentle stretching and mobilization, especially increasing external rotation and abduction
- Progress to strengthening of rotator cuff muscles
- Consider functional electrical stimulation for improving shoulder lateral rotation
Pain Management
If no contraindications exist 1:
- Acetaminophen or ibuprofen for initial pain relief
- Intra-articular corticosteroid injections show significant pain reduction effects
- Subacromial corticosteroid injections for subacromial region inflammation
Follow-Up Considerations
Persistent shoulder pain and dysfunction after dislocation, especially in older patients, requires careful evaluation for rotator cuff pathology—these injuries are often missed. 6 Limit follow-up imaging to what will actually change management decisions. 1
Monitor for complex regional pain syndrome (shoulder-hand syndrome), which may require early intervention with oral corticosteroids. 1