Shoulder Dislocation

Stepwise Protocol:

Reduction Without Procedural Sedation

Identify Anterior Dislocation

Intra-articular Xylocaine Analgesia

Stimson Method

Scapular Rotation Method

External Rotation Method

Procedural Sedation if this Fails

References

About this Document

Anterior Dislocation

· 97% of dislocations are anterior. Confirmed by X-ray.

· Check sensation in “Chevron” area over deltoid before and after reduction to detect possible axillary nerve injury. Deltoid paresis can occasionally accompany this.

· Shoulder usually slightly abducted and extended, supported by opposite hand

· Concavity or flattening of deltoid area.

Intra-articular Lidocaine

· Glenoid easily accessible as a depression below the acromion

· Sterile technique

· Use #22 x 3.5 cm. needle

· Enter skin 2 cm inferior and lateral to the acromion directed slightly caudad Fig 1.

· Aspirate any blood

· Use 20 ml. 1% xylocaine without epinephrine max. 200 mg. or 4 mg/kg.

· Demonstrated to reduce time and costs in the ED for this procedure compared with IV sedation.

Stimson Method

· Once xylocaine administered, patient lies prone with the affected shoulder on a soft pad and protruding free of the edge of the stretcher.

· The arm is allowed to hang in forward flexion at 90 degrees, and a 10 lb. weight attached at the wrist by a loop of fabric Fig 2.

· The weight must not be grasped by the hand.

· Allow up to 25 min. for reduction to take place.

· The patient will usually sense when reduction has taken place.

Scapular Rotation

· Can be used initially or if the Stimson method fails.

· Can be done easily in prone position or sitting.

· Similar position to Stimson with traction maintained to stabilize the humerus

· Mild external rotation is helpful

· The tip of the scapula is pushed medially and cephalad.

· The superior and medial aspect of the scapula is stabilized or pushed laterally Fig 3.

· A small amount of dorsal displacement of the scapular tip can be done if possible.

· The scapula rotates to accept the humeral head.

External Rotation Method

· This method utilizes the initial modalities of the Kocher maneuver (traction, external rotation, adduction, internal rotation) but is less traumatic.

· With the patient supine, adduct the humerus against the trunk and flex the elbow to 90 degrees.

· No traction is used.

· Place the shoulder in 20 degrees of forward flexion.

· Stabilize the elbow and, using the wrist, gently externally rotate the forearm until it lies in the coronal plane Fig 4.

· Reduction will often occur during external rotation.

· If done by the patient, similar to placing the hands behind the head

· Self-reduction of recurrent dislocations can be very empowering for the patient.

Consider Procedural Sedation

· Failure of above measures may call for improved muscle relaxation, sedation and analgesia.

References

1. Sokransky SJ, et al. Intra-articular lidocaine for the reduction of posterior shoulder dislocation. Can J Emerg Med 2005; 7(6): 423-426

2. Miller SL, et al. Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations: A randomized, prospective study. J Bone Joint Surg Am 2002; 84: 2135-2139.

3. Eachempati KK, et al. The external rotation method for reduction of anterior shoulder dislocations and fracture-dislocations of the shoulder. J Bone Joint Surg 2004; 86A(11): 2431-2434.

4. Baycal B, et al. Scapular manipulation technique for reduction of traumatic anterior shoulder dislocations: experiences of an academic emergency department. Emerg Med J 2005; 22: 336-338.

5. Schubert H. Reducing anterior shoulder dislocation: easy is good. Canadian Family Physician 2002; 48: 469-472.