Reduction - Shoulder dislocation

Related Videos

Indications

Shoulder dislocation

Contraindications (absolute in bold)

Life or limb-threatening conditions

Prolonged dislocation over seven days (risk of vascular injury or fracture)

Fracture surgical neck of humerus (risk of avascular necrosis of humoral head)

Fracture dislocation with large fragments or fragment obstructing relocation

Posterior or inferior dislocation suspected

Alternatives

Closed reduction in theatre

Open reduction

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Written consent

More complex non-emergency procedure with higher risk of complications

Potential complications (of dislocation and reduction)

Failure to reduce (5%)

Fractures with clinical significance (25%)

Hill-Sach’s lesion (compression fracture of humeral head)

Bony Bankart’s lesion (fracture of glenoid rim)

Greater tuberosity avulsion fracture

Coracoid fracture (humeral head impact during dislocation)

Humeral shaft fracture (high impact trauma)

Ligamentous tears with shoulder instability (50%)

Bankart’s lesion (glenoid labrum avulsion)

Glenohumeral ligament injury

Musculotendinous Injury (more common in older patients)

Rotator cuff

Neurological injury (25%)

Axillary nerve

Brachial plexus injury

Vascular injury (more common in older patients)

Axillary artery rupture or damage

Frozen shoulder and joint stiffness (more common in older patient with >1 week immobilisation)

Recurrent dislocation(more common in younger patients)

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Any bed space

Staff

Procedural clinician and assistant

Equipment

A collar and cuff, sling and swathe, or a shoulder immobiliser

Medication

Consider lignocaine 1% 20ml intra-articular injection (maximum 3mg/kg, ultrasound-guided, 1cm below acromion)

Consider fentanyl 50-100mcg IV titrated to relief of pain

Consider nitrous oxide 50-70% titrated to pain relief (monitoring required)

Sequence

Administer pain relief

X-ray prior to reduction if: first dislocation, fracture suspected, traumatic mechanism, over 40 years old

Perform neurovascular assessment (including brachial plexus):

Brachial pulse

Axillary nerve: sensation over deltoid

Median nerve: sensation thenar eminence, opposition against resistance (tip of thumb to tip little finger)

Ulnar nerve: sensation hypothenar eminence, abduction/adduction of fingers against resistance

Radial nerve: sensation dorsal lateral palm, extension of the fingers and wrist

Sequence (Cunningham technique)

Position the patient sat upright in a chair or on a bed

Sit opposite and adjacent to the patient taking the weight and control of their arm

Take your time and advise the patient there will be no sudden movements or pulling

Rest the patient’s hand on your shoulder to flex elbow and offload pressure from the biceps

Rest one hand on the antecubital fossa and move the arm to an adducted position without shoulder flexion

With the other hand squeeze the trapezius, deltoid and bicep relaxing the muscle

Encourage patient to relax, puff the chest out and drop the shoulders back and down

Sequence (Kocher’s technique)

Position the patient sat upright or supine on a bed

Take your time and advise the patient there will be no sudden movements or pulling

Position with the arm adducted against the chest with the elbow flexed to 90 degrees

Slowly externally rotate to 80 degrees, then flex shoulder in sagittal plan

Internally rotate the shoulder by bringing the hand across to the opposite shoulder

Sequence (Fares technique)

Position the patient supine with affected arm at their side

Gentle traction without counter traction is applied to the arm

The arm is oscillated up and down about 10 degrees while slowly abducted to 90 degrees

At 90 degrees, add gradual external rotation (moving palms upwards) and continue to 120 degrees

Massaging tension in shoulder muscles may help

Post-procedure care

Check X-ray, circulation and limb function:

Re-assesses neurovascular status (axillary sensation over deltoid, brachial pulse)

Post-reduction X-ray assessing reduction and associated fractures (unless recurrent and non-traumatic)

Ongoing care:

Immobilise shoulder in adduction and internal rotation (three weeks <30 years old, one week >30 years old)

Orthopaedic follow-up arranged in one week, expect return to sporting activity by 16 weeks

Pain relief for discharge prescribed

Patient advice:

Immobiliser worn unless bathing or performing range of motion exercises (pendulum exercises)

Physio input for range of motion exercises recommended (pendulum exercises)

Tips

It may take 10-15 minutes to relax the patients and perform these techniques

Scapular stabilisation can release tension on the joint and aid reduction with these techniques

The ability to place the hand of the affected extremity on the opposite shoulder confirms reduction

Traction with arm abduction should be avoided in the elderly due to risk of fracture and neurovascular injury

Greater tuberosity fractures with dislocation can be reduced in the emergency department and require extended immobilisation

Discussion

Reduction can often be achieved without sedation. We outline a simple initial approach using analgesia and minimal traction techniques. For difficult reductions procedural sedation may be required.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Hendey GW. Managing anterior shoulder dislocation. Ann Emerg Med. 2016;67(1):76-80. doi:10.1016/j.annemergmed.2015.07.496

Alkaduhimi H, van der Linde JA, Willigenburg NW, van Deurzen DFP, van den Bekerom MPJ. A systematic comparison of the closed shoulder reduction techniques. Arch Orthop Trauma Surg. 2017;137(5):589-599. doi:10.1007/s00402-017-2648-4

Khiami F, GĂ©rometta A, Loriaut P. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol Surg Res. 2015;101(1 Suppl):S51-S57. doi:10.1016/j.otsr.2014.06.027

Cunningham NJ. Techniques for reduction of anteroinferior shoulder dislocation. Emerg Med Australas. 2005;17(5-6):463-471. doi:10.1111/j.1742-6723.2005.00778.x

Alkaduhimi H, van der Linde JA, Flipsen M, van Deurzen DF, van den Bekerom MP. A systematic and technical guide on how to reduce a shoulder dislocation. Turk J Emerg Med. 2016;16(4):155-168. Published 2016 Nov 18. doi:10.1016/j.tjem.2016.09.008

Youm T, Takemoto R, Park BK. Acute management of shoulder dislocations. J Am Acad Orthop Surg. 2014;22(12):761-771. doi:10.5435/JAAOS-22-12-761

Chitgopkar SD, Khan M. Painless reduction of anterior shoulder dislocation by Kocher's method. Injury. 2005;36(10):1182-1184. doi:10.1016/j.injury.2004.12.004

Janitzky AA, Akyol C, Kesapli M, Gungor F, Imak A, Hakbilir O. Anterior shoulder dislocations in busy emergency departments: the external rotation without sedation and analgesia (ERWOSA) method may be the first choice for reduction. Medicine (Baltimore). 2015;94(47):e1852. doi:10.1097/MD.0000000000001852

Wakai A, O'Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults. Cochrane Database Syst Rev. 2011;(4):CD004919. Published 2011 Apr 13. doi:10.1002/14651858.CD004919.pub2

Professor Lennard Funks’s educational website: www.shoulderdoc.co.uk

© Agency for Clinical Innovation 2021

Feedback