Reducing Anterior Shoulder Dislocations

 

Written by: Megan Wong, DO; Edited by: Timothy Khowong, MD, MSEd

 

Teaching Goals

  1. Recognize the anatomy and classification of shoulder dislocations

  2. Understand what must be assessed before attempting a reduction

  3. Compare analgesia and procedural sedation options 

  4. Learn five closed reduction techniques

 

Classification

**Because anterior dislocations make up the overwhelming majority of what we see in the ED, the rest of this post focuses on closed reduction of anterior shoulder dislocations.

Pre-reduction Assessment Checklist

History - For every patient, ask about

  • Mechanism and timing of injury

  • First-time vs. recurrent dislocation

  • Prior shoulder surgery

Neurovascular Exam — before and after every attempt

  • Axillary nerve: sensation over the lateral deltoid, deltoid contraction

  • Radial, median, and ulnar nerve function

  • Distal pulses and capillary refill

Imaging

  • X-ray (AP + axillary or scapular-Y view) to confirm direction and rule out an associated fracture

Contraindication to worry about: a suspected associated fracture that needs orthopedic input before you pull on anything.

Analgesia & Procedural Sedation

Pain control is arguably the single biggest lever you have for first-pass success — a relaxed patient means relaxed muscles, and relaxed muscles mean the humeral head reduces more easily.

 

Five Closed Reduction Techniques

 

1. Traction–Countertraction

  • Apply folded sheet across patient’s chest/ axilla, anchor by an assistant for countertraction

  • Tie folded sheet around yourself

  • You apply steady, longitudinal traction at ~20-70 degrees of ABDuction

  • Maintain constant force for several minutes as muscles fatigue and relax

  • Massage glenohumeral joint to promote reduction

  • Wait for the clunk

 

2. External Rotation

  • ADDuct arm, elbow flexed to 90deg

  • SLOWLY externally rotate forearm

  • Pause at resistance or spasm

  • Go past restrictive barrier

  • Reduction usually occurs before full rotation

 

3. Scapular Manipulation

  • Stabilize scapula with one hand

  • Other hand rotates the inferior tip of scapula medially while stabilizing superior border

  • Rotate glenoid to re-engage with humeral head

 

4. FARES Method

  • Apply longitudinal traction to extended arm

  • Gently oscillate arm up and down ~2-3 cycles per second (handshake motion)

  • Slowly ABDuct while oscillation

  • Continue past 90deg ABDuction

  • Bring into external reduction as reduction occurs

 

5. Stimson (gravity)

  • Attach 5-10lb weights to wrist

  • Gravity slowly fatigues and stretches shoulder, ~15-20 min

  • Reduction may happen spontaneously, or with gentle manual assistance

 

Post-reduction checklist 

  • Repeat neurovascular and ROM exam

  • Post-reduction film

  • Immobilize

 

Take Home Points

  • Neurovascular exam pre AND post reduction are non-negotiable!! Document these!

  • Adequate analgesia improves first-pass success rate and patient comfort

  • No single method is best, you may combine methods if needed

  • Gentle, slow technique >> force

  • Pre and post X-rays are also non-negotiable!!

 

References

  1. Alkaduhimi H, van der Linde JA, Willigenburg NW, et al. A systematic comparison of the closed shoulder reduction techniques. Arch Orthop Trauma Surg. 2017;137(5):589-599.

  2. Sayegh FE, Kenanidis EI, Papavasiliou KA, et al. Reduction of acute anterior dislocations: a prospective randomized study comparing the FARES method with the Hippocratic and Kocher methods. J Bone Joint Surg Am. 2009;91(12):2775-2782.

  3. Yuen MC, Yap PG, Chan YT, Tung WK. An easy method to reduce anterior shoulder dislocation: the Spaso technique. Emerg Med J. 2001;18(5):370-372.

  4. Baykal B, Sener S, Turkan H. Scapular manipulation technique for reduction of traumatic anterior shoulder dislocations: experiences of an academic emergency department. Emerg Med J. 2005;22(5):336-338.

  5. Anderson D, Zvirbulis R, Ciullo J. Scapular manipulation for reduction of anterior shoulder dislocations. Clin Orthop Relat Res. 1982;(164):181-183.

  6. Sithamparapillai A, Grewal K, Thompson C, Walsh C, McLeod S. Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis. CJEM. 2022;24(8):809-819.

  7. Ziang N, Hu YJ, Zhang KR, et al. Intra-articular lidocaine versus intravenous analgesia and sedation for manual closed reduction of acute anterior shoulder dislocation: an updated meta-analysis. J Clin Anesth. 2014;26(5):350-359.

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

  9. Medscape/eMedicine. Shoulder Dislocation: Practice Essentials, Epidemiology, and Treatment. emedicine.medscape.com/article/93323-overview.

  10. Merck Manual Professional Edition. Shoulder Dislocations. merckmanuals.com/professional/injuries-poisoning/dislocations/shoulder-dislocations.

  11. Baden DN, Roetman MH, Boeije T, et al. BRASD trial: biomechanical reposition techniques in anterior shoulder dislocation — a randomized multicenter clinical trial. Int J Emerg Med. 2023;16(1):14.

  12. https://radiopaedia.org/articles/anterior-shoulder-dislocation?lang=us

  13. https://radiopaedia.org/articles/posterior-shoulder-dislocation?lang=us

  14. https://radiopaedia.org/articles/inferior-shoulder-dislocation?lang=us

 
NYPQ