AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Shoulder dislocation is documented in Egyptian tomb murals as early as 3000 BC, with depiction of a manipulation for glenohumeral dislocation resembling the Kocher technique. Hippocrates detailed the oldest known reduction method still in use today and advocated treating chronic shoulder instability with cauterization of the deep tissues of the anterior shoulder. Historical techniques to reduce dislocated glenohumeral joints have been shown to be safe when applied correctly. Kocher's method as originally described in 1870 did not involve traction and fell into disfavor when complications occurred with the application of large forces. The majority of dislocations are anterior, but less frequently, posterior, inferior (luxatio erecta), superior, and intrathoracic dislocations are also possible.

Pathophysiology

The shoulder is the most frequently dislocated joint. It moves almost without restriction but pays the price of stability. The shoulder's integrity is maintained by the glenohumeral joint capsule, the cartilaginous glenoid labrum (which extends the shallow glenoid fossa), and muscles of the rotator cuff.

In a recent review, anterior dislocations occurred in up to 98% of cases. Anterior displacement of the humeral head is the most common dislocation seen by emergency physicians. Posterior displacement is the next most frequently occurring dislocation. Inferior (luxatio erecta), superior, and intrathoracic dislocations are rare and are usually associated with complications.

Frequency

United States

Shoulder dislocations affect approximately 1.7% of the population and are most frequently secondary to trauma. The incidence of all traumatic shoulder dislocations has been estimated at 11.2 cases per 100,000 person-years, with a cumulative incidence rate of 0.7% for men and 0.3% for women up to age 70 years.

International

A Danish study estimated the incidence of shoulder dislocation at 17 cases per 100,000.¹ In a random sample of people in Sweden, 1.7% reported a history of shoulder dislocation.² 

A more recent Greek study examined the demographic data and recurrence rates of shoulder dislocations of 308 patients (170 men and 138 women).³ Subjects were observed for approximately 6 years. The most frequent mechanism of injury was falling, and 92% of reductions were in the ED. The overall recurrence rate in all ages was 50%, but rose to almost 89% in the 14-20 year age group.

Sex

Gender distribution is bimodal, with peak incidence in men aged 20-30 years (with a male-to-female ratio of 9:1) and in women aged 61-80 years (with a female-to-male ratio of 3:1).

Age

Shoulder dislocation occurs more frequently in adolescents than in younger children because the weaker epiphyseal growth plates in children tend to fracture before dislocation occurs. 

In older adults, collagen fibers have fewer cross-links, making the joint capsule and supporting tendons and ligaments weaker and dislocation more likely.
 
Anterior dislocation is most commonly seen in those aged 18-25 years due to sporting injury. The second most common age group to sustain anterior dislocation is in elderly persons due to their susceptibility to falls.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Patients generally complain of severe shoulder pain and an associated decreased range of motion of the affected extremity. Mechanisms of injury are usually traumatic but may vary. Mechanisms may include sports, assaults, falls, seizures, throwing an object, reaching to catch an object, forceful pulling on the arm, reaching for an object, turning over in bed, or combing hair. It is not unusual for patients to have a history of recurrent ED visits for the same complaint. Specific mechanisms or historical facts may be suggestive of certain types of dislocations, such as lightning injuries, electrical injuries, and seizure with posterior dislocations; throwing a ball or a punch or forceful pulling of the arm with an anterior dislocation; and axial loading of an extremely abducted arm with inferior dislocation.

Physical

• Anterior shoulder dislocation (95-98% of ED dislocations)
• • Arm is held in slight abduction and external rotation.
  • Shoulder is "squared off" (ie, boxlike) with loss of deltoid contour compared with contralateral side.
  • Humeral head is palpable anteriorly (subcoracoid region, beneath the clavicle).
  • Patient resists abduction and internal rotation and is unable to touch the opposite shoulder.
  • Compare bilateral radial pulses to help rule out vascular injury.
  • In all cases, evaluate the axillary nerve before and after reduction by testing both pinprick sensation in the "regimental badge" area of the deltoid and palpable contraction of the deltoid during attempted abduction. Evaluate sensory and motor function of the musculocutaneous and radial nerves.
• Posterior shoulder dislocation (3% of ED shoulder dislocations)
• • Arm is held in adduction and internal rotation.
  • Anterior shoulder is "squared off" and flat with prominent coracoid process. Shoulders may look identical in bilateral dislocation, making it a commonly missed injury.
  • Posterior shoulder is full with humeral head palpable beneath the acromion process.
  • Patient resists external rotation and abduction.
  • Neurovascular deficits are infrequent.
• Inferior (luxatio erecta) shoulder dislocation (0.5% of ED dislocations)
• • Arm is fully abducted with elbow commonly flexed on or behind head.
  • Humeral head may be palpable on the lateral chest wall.

Causes

• Anterior shoulder dislocations usually result from abduction, extension, and external rotation, such as when preparing for a volleyball spike. Falls on an outstretched hand are a common cause in older adults. The humeral head is forced out of the glenohumeral joint, rupturing or detaching the anterior capsule from its attachment to the head of the humerus or from its insertion to the edge of the glenoid fossa. This occurs with or without lateral detachment.
• Posterior dislocations are caused by severe internal rotation and adduction. This type of dislocation usually occurs during a seizure, a fall on an outstretched arm, or electrocution. Occasionally, a severe direct blow may cause a posterior dislocation. Bilateral posterior dislocation is rare and almost always results from seizure activity. Misinterpretation of the radiograph appearance of a posterior dislocation may result in misdiagnosis as a soft tissue injury in up to 79% of cases.
• Rare, but serious, inferior dislocations (luxatio erecta) may be due to axial force applied to an arm raised overhead, such as when a motorcycle collision victim tumbles to the ground. More commonly, the shoulder is dislocated inferiorly by indirect forces hyperabducting the arm. The neck of the humerus is levered against the acromion and the inferior capsule tears as the humeral head is forced out inferiorly. Luxatio erecta almost always has an associated fracture or soft-tissue injury. One series found 80% of patients to have fracture of the greater tuberosity or tear of the rotator cuff. Neurologic compromise was found in 60% of patients, with the axillary nerve the most commonly injured nerve. Inferior dislocations have the highest incidence (3.3%) of vascular compromise.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Associated fractures occur in approximately 30% of dislocations. The most common fractures include the Hill Sachs lesion, which is a compression fracture that results in the formation of a groove in the posterolateral aspect of the humeral head. This lesion is seen in 54-76% of dislocations. The Bankart lesion is a fracture of the anterior rim of the glenoid fossa. This lesion results from impaction of the humeral head against the anteroinferior glenoid labrum. It is associated with rupture of the joint capsule and inferior glenohumeral ligament injury. Avulsion fractures of the greater tuberosity are seen in 10-16% of cases. Humeral shaft and coracoid process fractures are rare. (See Complications.)

The rotator cuff is injured in 35-86% of dislocations and is more commonly seen in elderly patients. Glenohumeral ligament injury occurs in approximately 55% of cases and is most common in young patients. The axillary nerve is injured in 3% of anteroinferior dislocations. It is the most frequently injured, but brachial plexus, radial, and other nerve injury can occur. (See Complications.)

If a brachial plexus injury is diagnosed, axillary artery injury, though rare, should be considered. Patients with axillary artery rupture present with axillary hematoma, a cool limb, and absent pulses. However, patients with collateral blood flow may have distal pulses. Luxatio erecta has the highest incidence (3.3%) of vascular compromise. Evaluation of vascular injury should include Doppler blood flow studies, angiography, and arteriography. (See Complications.)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• No lab studies are specifically indicated for evaluation of shoulder dislocation.

Imaging Studies

• Shoulder trauma series - Anteroposterior (AP) and axillary or scapular "Y" views  
• • Anterior dislocation is characterized by subcoracoid position of the humeral head in the AP view. The dislocation is often more obvious in a scapular "Y" view, where the humeral head lies anterior to the "Y." In an axillary view, the "golf ball" (ie, humeral head) is said to have fallen anterior to the "tee" (ie, glenoid).
  • In posterior dislocation, the AP view may show a normal walking stick contour of the humeral head, or it may resemble a light bulb or ice cream cone, depending upon the degree of rotation. The scapular "Y" view reveals the humeral head behind the glenoid (the center of the "Y"). In an axillary view, the "golf ball" falls posteriorly off the "tee."
  • In inferior dislocation (luxatio erecta), the AP view may show the arm raised over the head with the radial head inferior to the glenoid.
• Pre-reduction films are commonly performed to document the nature of the dislocation and to establish the existence of any associated pathology, such as a Hill-Sachs lesion or other humeral fractures. In cases where patients have experienced repeated anterior dislocations, pre-reduction films may not be necessary prior to attempts at reduction.
• Post-reduction films confirm relocation of the humerus and may reveal new or previously obscured pathology. Post-reduction immobilization is imperative. A recent prospective observational study examined whether post-reduction radiographs add clinically important information to what is seen on pre-reduction radiographs in patients with anterior shoulder dislocations who are seen in the ED. The authors found that, even though the majority (62.5%) of fractures were seen on pre-reduction radiographs, more than one third (37.5%) were only visible on post-reduction films. None of the missed fractures changed ED management, and no persistent dislocations were found on post-reduction films.⁴

Other Tests

• Arteriography, angiography, and Doppler flow studies may be used to evaluate suspected vascular injury.
• Electromyography (EMG) may be used later to evaluate nerve injuries.

Procedures

• The key to a successful reduction is slow and steady application of a maneuver with adequate analgesia and relaxation.
• Procedural sedation and analgesia (PSA) protocols in the ED assist in relaxing the musculature of the shoulder and make reduction a more comfortable and easier procedure. (For further information, see Procedural Sedation.)
• Other adjuncts to facilitate reduction for patients who are high risk or may not be candidates for PSA include intra-articular lidocaine and ultrasound-guided interscalene (lidocaine) block of the brachial plexus.  
• • Successful reduction is evidenced by marked reduction in pain and increased range of motion. A palpable or audible relocation ("clunk") may also be noted.
  • The patient may be asked to touch the uninjured shoulder to safely demonstrate a successful reduction.
• Some authors recommend an orthopedic consultation prior to reduction of posterior and inferior dislocations.
• After the completion of all reductions, apply a shoulder immobilizer with a sling and swathe. A careful neurovascular examination must be performed pre- and post-reduction.
• Post-reduction radiography is still recommended, especially if the procedure was difficult.
• Reduction of an anterior dislocation (For further information, see Joint Reduction, Shoulder Dislocation, Anterior.)
• • Inappropriate traction and poor technique can result in complications with otherwise safe methods of reduction. The Kocher method has been discouraged because of the increased incidence of complications. When performed correctly, it does not involve traction and has been demonstrated to be a safe technique.
  • Kocher's original method: Bend the arm at the elbow, press it against the body, rotate outwards until resistance is felt. Lift the externally rotated upper part of the arm in the sagittal plane as far as possible forwards and finally turn inwards slowly.
  • Stimson technique: The patient lies prone on the bed with the dislocated arm hanging over the side. Traction is provided by up to 10 kg of weight attached to the wrist or above the elbow. Apply gentle internal/external humeral rotation. Reduction may take 20-30 minutes.
  • External rotation method: While the patient lies supine, adduct the arm and flex it to 90° at the elbow. Slowly rotate the arm externally, pausing for pain. Reduce the shoulder before reaching the coronal plane. Often successful, this procedure requires only one physician and little force (see Special Concerns).
  • Traction-countertraction: While the patient lies supine, apply axial traction to the arm with a sheet wrapped around the forearm and the elbow bent at 90°. An assistant should apply countertraction using a sheet wrapped under the arm and across the chest while the shoulder is gently rotated internally and externally to disengage the humeral head from the glenoid.
  • Scapular rotation: This less traumatic technique has success rates of more than 90% in experienced hands, often without sedation. With the patient lying prone, apply manual traction or 5-15 lb of hanging weight to the wrist. After relaxation, rotate the inferior tip of the scapula medially and the superior aspect laterally. Alternatively, the patient can be seated while an assistant provides traction-countertraction by pulling on the wrist with one hand and bracing the upper chest with the other. The same scapular rotation is then performed.
• Reduction of a posterior dislocation: Apply gentle, prolonged axial traction on the humerus. Then, add gentle anterior pressure while coaxing the humeral head over the glenoid rim. Slow external rotation may be needed.
• Reduction of an inferior dislocation: Maintain gentle axial traction on the humerus while gentle abduction is applied. Apply countertraction across the ipsilateral shoulder. Following reduction, slowly adduct the arm. Buttonholing of the humeral head through the capsule usually requires open reduction.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Stabilize and treat associated trauma as indicated.
• Allow the patient to assume a position of comfort while maintaining cervical spine immobilization if necessary.
• A pillow between the patient's arm and torso may increase comfort.

Emergency Department Care

• Administer analgesics to decrease pain.
• Pre-reduction and post-reduction radiographs are recommended. Patients with frequent recurrent dislocations can safely avoid radiographs.
• Procedural sedation and analgesia (PSA) protocols, intra-articular lidocaine, and ultrasound-guided brachial plexus nerve block assist in making reduction an easier and more comfortable procedure.
• Immobilize the shoulder after reduction. 
• Perform careful pre- and post-reduction neurovascular examinations.

Consultations

Orthopedic consultation may be helpful for dislocations with concomitant fractures, for posterior or inferior dislocations, and for cases in which the patient's shoulder cannot be reduced in a timely fashion.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Opiate analgesia should be given as needed for pain. Intravenous or intramuscular medications, intra-articular injections, and regional anesthetic techniques have been reported as successful aides for reduction of shoulder dislocations. Procedural sedation and analgesia (PSA) is commonly used to achieve adequate pain control and muscle relaxation for reduction. A randomized, controlled trial of 30 patients compared intra-articular lidocaine with PSA (morphine and midazolam).⁵ All patients who received intra-articular injections obtained adequate analgesia and muscle relaxation, were free of complications, and had significantly shorter emergency department stays (78 min vs 186 min; p=0.004).⁵

Etomidate, fentanyl/midazolam, ketamine, or propofol is commonly used for PSA. Some ED physicians prefer etomidate because of its rapid onset (<30 sec), short duration (about 5 min), and excellent muscle relaxation. Other physicians consider propofol superior in terms of side effects and duration. Propofol's high lipid solubility results in a rapid onset (30-60 sec) and a short plasma half-life (1.3-4.1 min). The result is a rapid decline of propofol concentrations, rapid awakening, and shorter recovery times.

A recent ED-based study evaluated the combination of propofol and remifentanil for sedation to reduce anterior shoulder dislocations.⁶ Eleven patients were given propofol 0.5 mg/kg and remifentanil 0.5 mcg/kg, IV over 90 seconds. Further doses of propofol 0.25 mg/kg and remifentanil 0.25 mcg/kg were administered if needed. All patients had adequate sedation and analgesia within 3 minutes. Mean time to achieve reduction after dosage was 1.6 minutes, and mean time to being clinically alert was 3 minutes. However, post-reduction time in the ED ranged from 30-312 minutes. Rapid recovery was a marked feature of this study. All subjects became alert quickly and were ambulatory without assistance in less than 30 minutes.

Drug Category: Analgesics

These agents may be used for the relief of pain and relaxation of shoulder muscles. Pain control is essential to quality patient care. It ensures patient comfort, improves likelihood of successful reduction, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with injuries.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• After procedural sedation with longer-acting sedating agents (eg, midazolam), the patient should be observed for the necessary period and then discharged in the care of family or friends.
• Patients who require operative reduction and repair should be admitted by the orthopedic surgery service.

Further Outpatient Care

• Arrange orthopedic follow-up in 5-7 days.
• The patient's shoulder should remain in the immobilizer until his or her orthopedic clinic appointment.
• Primary surgical repair of initial acute traumatic shoulder dislocations in young adults engaged in highly demanding physical activities (eg, sports, military) is supported by a Cochrane Database Systematic Reviews of 5 randomized, controlled studies.⁷ Subsequent shoulder instability was significantly less frequent in the surgical group (relative risk, 0.20; 95% CI, 0.11-0.33), with half of the conservatively treated patients opting for subsequent surgery. Functional assessment measures of the shoulder were also more favorable in those treated surgically. Since this demographic group is at far greater risk of recurrent dislocation, these results cannot be generalized to other groups.

In/Out Patient Meds

• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be taken as needed for pain and inflammation.
• A few days of narcotic analgesia, with an agent such as hydrocodone or oxycodone, is often helpful.

Deterrence/Prevention

• The patient should remain in the immobilizer until under the care of an orthopedic surgeon.
• To prevent recurrent dislocation, patients should avoid immediate participation in contact or sporting activities. Simple activities that involve abduction and external rotation of the arm, such as combing their hair should also be avoided.

Complications

• Recurrent shoulder dislocation (See Prognosis).
• Fractures and soft-tissue injuries (See Other Problems to be Considered.)  
• • Hill-Sachs lesions occur when the edge of the glenoid causes an impaction fracture in the posterolateral aspect of the humeral head during anterior dislocation and in the anterolateral aspect in posterior dislocation (referred to as a "reverse Hill-Sachs" lesion).
  • A Bankart lesion is fracture of the anterior rim of the glenoid labrum associated with joint capsule rupture and inferior glenohumeral ligament injury. Significantly displaced anterior or posterior glenoid rim fractures require operative management. Most initial shoulder dislocations produce a Bankart lesion, particularly in younger patients.
  • Fracture of the greater tuberosity, acromion, coracoid, clavicle, and humeral neck also occur.
  • Rotator cuff traction injury is most common in elderly patients and in association with inferior dislocations. This is a commonly missed injury, with an average time of 7 months from injury to diagnosis of rotator cuff rupture in patients older than 40 years.
• Nerve injury (See Other Problems to be Considered.)
• • Approximately 3% (and higher in some series) of dislocations involve injury to the axillary nerve. Injury may resolve spontaneously or require surgical exploration and possible nerve grafting.
  • Patients exhibit numbness in the area of the deltoid muscle and weakness with abduction and external rotation.
  • Axillary nerve injury does not change initial treatment, but pre-reduction and post-reduction neurologic examinations are important.
  • Radial nerve injury should also be determined. The axillary and radial nerves both arise from the posterior cord. The thumb, wrist, and elbow will be weak on extension, and the dorsal hand will be numb.
• Vascular injury (See Other Problems to be Considered.)
• • Axillary artery injuries are rare but have been reported to occur with anterior, inferior, and intra-thoracic dislocations. Especially susceptible are older adults with atherosclerotic axillary arteries. Arterial injury may be associated with decreased radial pulse.
  • Lateral chest wall ecchymosis with associated axillary hematoma and bruit may be noted on physical examination.
  • Angiography should be considered with any brachial plexus injury.

Prognosis

• Age is a major factor in the likelihood of sustaining a recurrent shoulder dislocation.
• Approximately 80-94% of patients younger than 20 years at the time of the initial dislocation have a recurrence. The major pathology in this age group is thought to be a Bankart lesion with associated inferior glenohumeral ligament injury.
• Of patients younger than 40 years, 26-48% develop recurrent dislocation. The major pathology for this age group is thought to be disruption of the labral attachment of the glenohumeral ligaments.
• Dislocation recurs in only 0-10% of patients older than 40 years. Rotator cuff tear is the major pathology.
• Minor trauma that results in a dislocation is associated with an 86% recurrence rate. Many orthopedic surgeons believe that more than one complete anterior dislocation justifies considering surgical repair.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Shoulder Dislocation.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to diagnosis posterior dislocations: This type of dislocation can be missed, especially in elderly or cognitively impaired individuals. A careful physical examination, 3 views of the shoulder (ie, a Y-view or an axillary view in addition to the standard AP and lateral views) and proper interpretation of the radiographs are important. One study found an average interval of 1 year between injury and diagnosis of posterior dislocation in a series of 40 patients.⁸
• Failure to find and document associated fractures or neurovascular injuries
• Complications secondary to the reduction technique such as iatrogenic fracture, nerve injury, or vascular injury
• Complications secondary to use of benzodiazepines, opiates, PSA, or regional anesthesia techniques such as cardiovascular and respiratory depression, or the theoretical risk of joint infection

Special Concerns

• Pregnant patients  
• • Patients in the third trimester should be placed in the left lateral decubitus position to avoid compression of the inferior vena cava by the uterus.
  • The abdomen should be shielded during radiography.
  • Relocation techniques that require placement of the patient in a prone position may be problematic.
• Pediatric patients: The epiphyseal plate is prone to fracture, so use a gentle relocation technique.
• Geriatric patients: Because fractures can occur easily with vigorous manipulation, choose a gentle relocation technique that does not require excessive force or traction. The Kocher and external rotation methods, when appropriately performed without traction or leverage, have recently been demonstrated to be safe and relatively painless procedures. Towels or sheets used for traction or counter-traction can cause friction injury to the fragile skin of older adults. This age group is at higher risk for benzodiazepine, opiate, and PSA-related complications.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Feb 27, 2008