II. Contraindications

  1. Do not attempt to reduce a chronic Shoulder Dislocation present for >3-4 weeks
    1. Prolonged dislocations form adhesions between Humerus and axillary artery
    2. Risk of axillary artery rupture on relocation maneuvers
    3. Relocation should be by orthopedic surgery typically in the operating room
  2. References
    1. Herbert and Webley in Herbert (2015) EM:RAP 15(3): 1
    2. Verhaegen (2012) Acta Orthop Belg 78(3): 291-5 [PubMed]
    3. Sahajpal (2008) J Am Acad Orthop Surg 16(7): 385-98 [PubMed]

III. Management: Premedications

  1. Consider Intra-articular Injection
    1. Inject 20 ml of Lidocaine 1% into the glenohumeral joint
      1. Consider using 20 gauge spinal needle for adequate length
      2. Inject over 20-30 seconds and expect maximal effect at 15 minutes
    2. Approaches (lateral approach preferred)
      1. See Glenohumeral Joint Injection
      2. Posterior Shoulder intraarticular injection or
      3. Lateral Shoulder intraarticular injection
    3. As effective as analgesia, Sedation for pain relief and successful Shoulder reduction
      1. Wakai (2011) Cochrane Database Syst Rev (4):CD004919 [PubMed]
      2. Jiang (2014) J Clin Anesth 26(5): 350-9 [PubMed]
  2. Anxiolytic alone (consider for Cunningham Technique)
    1. Ativan 0.5 to 1 mg IV
  3. Conscious Sedation
    1. Sedation
      1. Propofol or
      2. Ketamine or
      3. Versed 0.5 to 2 mg IV
    2. Analgesia
      1. Morphine Sulfate 1 to 6 mg IV or
      2. Fentanyl 100 mcg IV over 1 minute
        1. May repeat q5 min to total maximum of 3 mg/kg
    3. Precautions during Conscious Sedation
      1. See Procedural Sedation
      2. Supplemental Oxygen
      3. Capnography and Oxygen Saturation monitoring
      4. Naloxone at bedside
  4. General anesthesia
    1. Indicated for failed reduction under Sedation

IV. Management: Post-Reduction

  1. Immobilize Shoulder with sling
    1. Age under 40 years old
      1. Sling for 1 week
    2. Age over 40 years old
      1. Sling for only 2 to 3 days (no longer than 1 week)
      2. Risk of Frozen Shoulder
  2. Consider orthopedic referral
    1. Indicated for young or athletic patients
    2. Stabilization surgery prevents recurrent injury
      1. Bottoni (2002) Am J Sports Med 30:576-80 [PubMed]
  3. Shoulder Range of Motion Exercises as symptoms allow
    1. Pendulum Exercises and Circumduction at 5-10 days
      1. Start with arm in sling
        1. Bend at waist
        2. Allow arm to fall toward floor
        3. Rotate arm in circle
      2. Advance Exercise
        1. Arm out of sling
        2. Circles of greater diameter
    2. Advanced range of motion at 2-3 weeks
      1. Abduction via wall walking with fingers
      2. Internal rotation
        1. Start by touching hip
        2. Progress to touching mid-back
      3. Flex and extend elbow out of sling as tolerated
    3. Additional Exercises
      1. See Shoulder Strengthening Exercises
      2. Consider physical therapy starting at 2-4 weeks after dislocation
    4. Return to activity
      1. Shoulder strength and range of motion equal to the opposite side

V. Precautions

  1. Reduction becomes more difficult as muscles tighten
    1. Do not delay reduction
    2. Reduce on sideline in field if possible
  2. Check neurovascular exam before and after reduction
  3. Obtain AP and Axillary XRay prior to reduction

VI. Procedure: Reduction by Self-Reduction Method (Anterior and Posterior Dislocation)

  1. Known as Davos reduction maneuver or Boss-Holzach-Matter Technique
  2. Efficacy
    1. Very effective for reduction, even in the emergency department without Sedation
  3. Position
    1. Sit on floor with knees flexed
    2. Wrap both arms around ipsilateral knee
      1. Interlace fingers of each hand with one another
      2. Ace wrap wrists together
  4. Traction
    1. Lean backward, extend arm at elbow and extend head and neck backward
    2. Applies traction at Shoulder for reduction
  5. Resources
    1. Instructional Video
      1. https://www.youtube.com/watch?v=u2MsnjVNoPM
  6. References
    1. Stafylakis (2016) J Emerg Med 50(4):656-9 +PMID:26899512 [PubMed]

VII. Procedure: Reduction by Cunningham Technique (Anterior Dislocation)

  1. Preferred method for Anterior Shoulder Dislocation
    1. Requires no Conscious Sedation (in fact, requires an awake patient)
    2. Consider Ativan 0.5 to 1 mg prior to procedure
  2. Patient position
    1. Performed in awake, sitting patient
    2. Patient and examiner sit opposite one another eye to eye
    3. Patients arm position (Analgesic position, most comfortable)
      1. Held adducted at side
        1. Critical to success (may be difficult in Obesity)
      2. Elbow flexed to 90 degrees
      3. Patients palm rests against examiners Shoulder
    4. Examiner position
      1. Examiner's hand rests firmly on top of the patient's dorsal Forearm, applying downward pressure
  3. Technique
    1. Examiner applies gentle, steady pressure downward on dorsal Forearm (2-5 pounds of pressure)
    2. With free hand, examiner massages upper extremity proximal muscles
      1. Start at deltoid
      2. Move distally to biceps and triceps
    3. As patient begins to feel relaxation (expect some apprehension at this point)
      1. Premedication with Ativan prior to procedure may facilitate this transition
      2. Patient shrugs Shoulders up and back
      3. Patient pushes chest outward
    4. Anticipate Shoulder to spontaneously relocate
      1. May take as long as 15 minutes to relocate
  4. References
    1. Orman (2011) EMRap.tv, EMRAPTV-122-Cunningham-Technique
    2. Shoulder Dislocation Site
      1. http://shoulderdislocation.net/relocation/cunningham

VIII. Procedure: Reduction by Hennepin Maneuver (Anterior Dislocation)

  1. Premedication
    1. May be attempted without premedication
    2. Typically requires good muscle relaxation (e.g. Ativan 0.5 to 1 mg IV)
    3. Consider Opioid Analgesics or Conscious Sedation
  2. Patient position
    1. Patient supine
  3. Technique
    1. Examiner flexes patient's elbow to 90 degrees
    2. Examiner externally rotates Shoulder to 90 degrees (relocates the humeral head under glenoid)
      1. Relocation may occur spontaneously at this time
      2. Consider maintaining this position until muscles Fatigue and ultimately relax
    3. Milch Technique (added to above technique)
      1. Indicated if external rotation alone does not relocate Shoulder
      2. Continue to maintain 90 degrees of external rotation
      3. Examiner slowly abducts arm
  4. References
    1. Simon (1984) Ann Emerg Med 13:981 [PubMed]
    2. Garnavos (1992) J Trauma 32:801 [PubMed]

IX. Procedure: Reduction by Stimson's Method (Anterior dislocation)

  1. Patient position
    1. Patient lies prone on table
    2. Affected arm hangs over side of table
  2. Downward traction applied
    1. Assistant applies downward traction on arm or
    2. Attach 5 to 10 kg weight (10 to 15 pounds) to wrist
      1. Weight should hang freely and not touch floor
  3. Reduction
    1. Spontaneous reduction as Shoulder muscles relax
    2. Pushing humeral head in caudal direction may assist

X. Procedure: Reduction by Traction (Anterior and Posterior Dislocation)

  1. Patient sitting or prone
  2. Traction at wrist by one provider
    1. Gentle, slight straight (parallel to body) traction
    2. Apply from patient's wrist
  3. Countertraction by second provider
    1. Apply with 4-5 inch sling (e.g. sheet) under axilla
    2. Pull transverse across patient's chest
    3. Consider pulling upward at 30 degrees

XI. Procedure: Reduction by Hippocratic Method (Anterior Dislocation)

  1. Patient lies supine
  2. Single provider reduction method
    1. Counter-traction
      1. Place one foot on patient's chest wall
    2. Traction
      1. Grasp patient's wrist
      2. Apply traction at 45 degree angle

XII. Procedure: Reduction by Modified Traction (Anterior dislocation)

  1. Patient prone, arm at side with elbow flexed 90 degrees
  2. Technique
    1. Traction toward patient's feet (parallel to body)
    2. Externally rotate Shoulder by moving wrist laterally

XIII. Procedure: Reduction by Strap Method (Anterior dislocation)

  1. Patient in sitting position
  2. Countertraction
    1. Second strap placed under axilla and across chest
    2. Assistant pulls strap across chest
  3. Traction
    1. Patient's elbow flexed at 90 degrees
    2. Strap placed around patient's Forearm
    3. Other end of strap placed under examiner's foot
    4. Downward traction applied to Forearm via strap
    5. Examiner externally rotates arm 20 degrees
    6. Spontaneous reduction often occurs

XIV. References

  1. Wirth in Greene (2001) Musculoskeletal Care, p.151-2
  2. Burra (2002) Orthop Clin North Am 33:479-95 [PubMed]

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Ontology: Dislocated shoulder reduction (C0558632)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 150631003, 274450004
Dutch schouderontwrichtingreductie, repositie van ontwrichte schouder
French Réduction d'une épaule luxée, Réduction d'une luxation de l'épaule
German Schulterluxation, Reposition der Luxation, Reposition einer luxierten Schulter
Italian Riduzione di lussazione della spalla
Portuguese Redução de luxação do ombro
Spanish Reducción de dislocación de hombro, Reducción de hombro dislocado, reducción de luxación de hombro (procedimiento), reducción de luxación de hombro
Japanese 脱臼肩関節整復, 肩関節脱臼整復, カタカンセツダッキュウセイフク, ダッキュウカタカンセツセイフク
Czech Repozice luxace ramene, Repozice ramene
English Reduction of dislocated shoulder, dislocated shoulder reduction, shoulder dislocation reduction, Shoulder dislocation reduction, Dislocated shoulder reduction, Dislocated shoulder reduction (procedure)
Hungarian Vállficam repozíció, Vállficam repozíciója

Ontology: Closed treatment of shoulder dislocation with manipulation (C2067342)

Concepts Therapeutic or Preventive Procedure (T061)
CPT 23650, 1004260
English closed treatment of shoulder dislocation with manipulation, closed treatment of shoulder dislocation with manipulation (treatment), Closed treatment of shoulder dislocation with manipulation, Closed treatment of shoulder dislocation, with manipulation