The Approach to Shoulder Dislocation in the Emergency Setting
This article will help emergency physicians decide which technique for relocation of a shoulder best fits their patient. Specifically, this article will review the pertinent anatomy, types of dislocation, relocation techniques (including use with and without analgesia), as well as injuries commonly associated with a shoulder dislocation.
Shoulder dislocations are a common occurrence in the emergency department (ED). It has been estimated that 1-2% of people will have a shoulder dislocation, mostly from traumatic sources, in their lifetime.1,2 The incidence of shoulder dislocations in the United States has been estimated to be 11.2 per 100,000 person-years in a rural county3 to 23.9 per 100,000 person-years in a national sample.4 The later study of nearly 9000 patients estimated that approximately 70,000 shoulder dislocations required emergency care in the United States each year, with 72% occurring in males.4 Approximately half of these occurred in the context of athletic activity, notably football and basketball.4 The shoulder is the most commonly dislocated joint in the body, capable of dislocating in multiple directions, most commonly anteriorly.
Posterior glenohumeral dislocation is much less common than anterior dislocation, with a prevalence of 1.1 per 100,000 population per year. This type of dislocation is most prominently associated with seizures and falls, but rarely may be caused by electrocution.5
The shoulder is a ball and socket joint consisting of the humeral head and glenoid fossa of the scapula. It is held in place by both ligaments and muscles. The labrum, glenohumeral, and coracohumeral ligaments and joint capsule hold the joint in place at rest. The shoulder muscles, specifically the rotator cuff muscles supraspinatus, infraspinatus, teres minor, and subscapularis, provide support for the joint while it is in motion via balancing rotatory and in-line force. This is done with assistance from the deltoid, long head of the biceps, and pectoralis muscles.
Structures providing support against dislocation have been categorized by location. Anterior support for the shoulder is comprised of the following: anterior labrum, subscapularis, and anterior rim of the glenoid cavity. Posterior support is comprised of the greater tuberosity of the humerus, along with the supraspinatus and infraspinatus muscles.6
Anatomy of Dislocation
The most typical mechanism for dislocation entails forceful external rotation with the shoulder in abduction, dislodging the humerus anterior from the glenoid fossa. Contraction of the biceps and subscapularis muscles provides counter forces that prevent dislocation. The tendon of the long head of the biceps traverses the joint capsule and humeral head. When the biceps muscle contracts, it prevents anterior movement of the humeral head and may also restrict lateral movement, which is required for the humeral head to move past the glenoid rim. The subscapularis inserts on the lesser tubercle, producing internal rotation and medial movement of the humeral head. Contraction of the subscapularis prevents external rotation and maintains the large articular surface of the humeral head in contact with the glenoid fossa.7
Types of Shoulder Dislocations
The shoulder most commonly dislocates anteriorly, with the humeral head ending up in a subcoracoid and subglenoid position approximately 70% and 30% of the of time, respectively.8,9 In these dislocations, the humeral head sits anterior and medial to the glenoid, with the greater tuberosity sitting on the anterior or anteroinferior rim of the glenoid. (See Figures 1 and 2.) Anterior dislocations occur when the arm is in abduction, externally rotated, and in extension, such as can be seen with a fall onto an outstretched arm10 or onto the point of the shoulder.11 Such falls transmit forces through the glenohumeral joint. While anterior dislocations are most common in young male athletes following direct-contact trauma, repeat dislocations can produce a chronically unstable joint that may dislocate after minimal trauma. (See Table 1.)
|Table 1: Recurrence Rates by Age and Mechanism|
|Age||Recurrence Rate||Usual Mechanism|
Younger than 20 years
Bankart lesion and inferior glenohumeral head dislocation
Disruption of the labral attachment of the glenohumeral ligament
Older than 40 years
Rotator cuff tears
Figure 1: Anterior Shoulder Dislocation with Humeral Head in Subcoracoid Position on AP View
Other types of dislocations are uncommon (see Table 2), but of these, posterior dislocation in which the humeral head is posterior to the glenoid is the next most frequent. (See Figure 4.) It is caused by forced adduction, internal rotation, and flexion of the humerus. While the traditional teaching has been that these dislocations are caused by electrocution or seizures, the most frequent causes are trauma and seizures, in that order. Posterior dislocations may be bilateral, classically described with seizures or electrocution.5
|Table 2: Types of Dislocations|
Figure 2: Anterior Shoulder Dislocation with Humeral Head in Subglenoid Position on AP View
Figure 3: Anterior Shoulder Dislocation with Humeral Head Anterior to Glenoid on Scapular Y View
The true inferior (luxation erecta) dislocation occurs when the humerus is inferior to and not intact with the glenoid rim. It is caused by sudden hyperextension and is associated with severe injuries. Superior dislocations occur when the humeral head is above the glenoid. This type of dislocation is caused when the fully adducted arm receives sudden upward axial pressure. It is associated with tears of the supraspinatus and subscapularis. Lastly, the subclavicular and intrathoracic dislocations are both caused by a large lateral to medial force on the abducted humerus. The intrathoracic dislocation is associated with a fracture of the proximal humerus pulling the head of the humerus into the chest wall.
Typically, the patient with an anterior shoulder dislocation holds his or her arm in adduction close to the body, in slight external rotation. Associated nerve injury with anterior dislocations is reported as occurring in 5% and 55% of patients, usually affecting the axillary nerve and manifested by decreased sensation over the deltoid muscle.
Shoulder Reduction Techniques
The premise of all shoulder relocation techniques is that the shoulder wants to return to its anatomical position; however, it is being kept from doing so by a combination of muscle spasms, pain, and broken bones. There are three general mechanisms for achieving shoulder relocation: leverage, scapular manipulation, and traction.12 (See Table 3.)
|Table 3: Summary of Shoulder Relocation Techniques|
Patient’s arm close to body and elbow flexed to 90 degrees, gently rotated back and forth, and then the arm is raised vertically
Patient’s arm fully extended and close to body. Slowly abduct and externally rotate until at zero position
Patient’s arm adducted and elbow flexed to 90 degrees, arm resting on physician’s shoulder; patient shrugs shoulders while physician performs mid-biceps massage
Physician pushes inferior tip of scapula inward and superior-lateral portion downward while an assistant applies gentle traction and external rotation
Physician places foot in axilla and uses foot as fulcrum by pulling distal portion of affected arm medially
Patient lies prone and provider hangs 10 lb weight from affected arm.
Assistant wraps sheet under affected axilla and pulls while physician applies counter-traction and external rotation
Physician holds wrist of affected arm, lifts it in sagittal plane while applying gentle traction and external rotation
Patient sits up straight, a stockinette is tied to the proximal forearm, and physician pulls down with foot in stockinette while using hands for rotation
Patient lies lateral decubitus with affected arm up and physician abducts arm and lifts patient off the ground until shoulder relocates
Leverage manipulation techniques (Kocher, Milch, and Cunningham) are based on the concept of the "zero position," the point at which all shoulder muscles are in line and there is no rotator or transverse force applied to the shoulder. When the scapula is pulled back toward the spine, zero position is acquired at approximately 100 degrees of abduction. When the scapula is rotated and pulled forward, the zero position is achieved with the shoulder elevated 45 degrees above the horizontal plane (described as 135 degrees of forward flexion) and abducted 165 degrees.13 The position looks as if the patient is pointing to something in the sky, with the arm halfway between pointing straight out front and due laterally. At this location, the articular surfaces of the humeral head and the glenoid fossa are opposed, making it easier for them to relocate. Achieving this position is the goal of the Kocher, Milch, and scapular manipulation methods. A useful website is www.shoulderdislocation.net, which has useful information on positioning and techniques.
Kocher Method. The patient starts with the affected arm flexed at 90 degrees at the elbow and the arm fully adducted against the body. The physician holds the affected elbow and wrist while slowly externally rotating the humerus between 70-85 degrees, stopping when resistance of pain is felt. It is helpful to distract the patient with conversation. With the arm externally rotated and adducted, gently push (or lift) the mid-humerus anteriorly in the sagittal plane as far as possible. Then the arm is rotated internally until the hand on the affected arm points toward the opposite shoulder.14 No traction is applied.15-17 This method has been associated with complications when used with traction,18-20 which are not seen when using the original technique.21
Milch Technique. The patient starts with the arm extended. The physician stands in front of the patient facing him or her. One hand is placed with the fingers bracing the superior portion of the scapula and the thumb bracing the dislocated humeral head. The physician grasps the distal portion of the affected arm and slowly abducts and externally rotates the arm until at zero position. It is important that the humeral head only rotates and does not otherwise move, as that will be painful and require force to complete the movement. Once in zero position, the physician can use his or her thumb to gently push the humeral head into place.7 Multiple variations of this technique exist, and several include an element of traction.9,19,22
Cunningham Technique. The procedure starts with the physician standing next to patient’s affected arm while the patient’s arm is fully adducted and flexed at the elbow. Keeping the patient’s elbow flexed, rest his or her hand on the physician’s shoulder (if the patient’s right arm is affected, the patient’s right hand should rest on physician’s right shoulder), and the physician places his or her wrist on the affected forearm. Relax the patient by performing mild massage of the affected arm’s trapezius and deltoid muscles and with conversation. Then have the patient shrug his or her shoulders posteriorly and superiorly in order to stabilize the scapula while the physician performs mild massage of the biceps at mid-humerus level.23
This technique was originally described by Bosely in 1979 using the prone position in which the affected arm is allowed to hang free from the examiner’s table and is attached to a 10-pound weight.24,25 The physician then manipulates the inferior tip of the scapula medially and the superior portion of the scapula laterally. This has also been described with the patient upright or sitting using an assistant to apply gentle, firm traction on the affected arm while it is somewhat externally rotated and elevated in the sagittal position. The physician then makes the same scapular manipulation.12 Scapular manipulation with traction has also been described in the supine position.26
Hippocratic Method. The Hippocratic method starts with the patient supine. The physician places his or her foot in the axilla of the affected arm while holding the distal portion of the affected arm with his or her hand. Relocation is achieved using the inserted foot as a fulcrum by adducting the distal portion of the dislocated arm and using mild traction.27-29
Stimson Method. The Stimson method starts with the patient in the prone position. The affected arm is allowed to hang downward in forward flexion with the wrist attached to a 10-pound weight. Over time, the muscles fatigue and relax, and the shoulder joint spontaneously reduces.30-32
Traction/Counter-traction. The traction/counter-traction method starts with the patient prone or supine. An assistant wraps a sheet under the axilla of the affected arm and applies firm, steady traction. Meanwhile, the physician applies counter-traction to the affected arm while flexing the elbow 90 degrees and alternating between external and internal rotation until the humeral head relocates.10,16,29,33
Spaso Technique. The Spaso technique starts with the patient supine. The physician holds the wrist of the affected arm and lifts it in the sagittal plane to 90 degrees of flexion at the shoulder while applying gentle traction and then rotating externally.20
Snowbird Technique. The snowbird technique starts with the patient sitting up very straight. An assistant can help to ensure that the patient’s back is straight. The affected elbow is flexed 90 degrees and a stockinette is tied to the proximal forearm and connected to the foot of the physician. This allows the physician to continue to apply downward traction while using both hands to rotate the shoulder as needed.34
Eskimo Technique. In the Eskimo technique, the patient lies supine in lateral decubitus with the affected arm upward. The physician and an assistant hold the affected wrist, abduct the arm until it is above the level of the shoulder, and gently lift the patient off the ground a couple of centimeters and hold until the shoulder is relocated. This technique may require the assistance of a third person to apply direct pressure on the humeral head in the axilla.34
Other Traction Techniques. There are several techniques similar to the Hippocratic one that use a fulcrum and traction to reduce the shoulder. One is the Manes technique, in which the physician places his or her forearm, bent 90 degrees, into the axilla of the affected arm. The other arm grasps the patient’s wrist on the affected arm and adducts the arm using the physician’s own arm as a fulcrum over which the reduction occurs. The arm grasping the patient’s wrist can also apply gentle downward traction.35 Similar techniques using a chair as the fulcrum are described by Nordeen and White.36,37 The slump technique also uses an examiner’s forearm in the axilla as a fulcrum, along with longitudinal traction.38
Associated Orthopedic Injuries
Fractures occur in approximately 30% of shoulder dislocations. (See Table 4.) The most common injuries are the Hill-Sachs lesion and Bankart lesion.39,40
|Table 4: Associated Injuries|
Figure 4: Posterior Shoulder Dislocation with Humeral Head Posterior to Glenoid on Scapular Y View
The Hill-Sachs lesion, also called the hatchet deformity, occurs in 54-76% of cases. It is due to a compression fracture or impaction injury to the posterolateral aspect of the humeral head, resulting in a groove. This can be viewed best with internal rotation on the post-reduction X-ray.39-42 (See Figures 5 and 6.) This lesion results from collision of the humeral head with the anterior glenoid rim as it dislocates. The clinical significance of a Hill-Sachs injury is that it may predispose the patient to recurrent instability of the joint.43
Figure 5: Chronic Hill-Sachs Deformity
Figure 6: CT Showing Large Hill-Sachs Lesion
For posterior dislocations, an anterior humeral head defect, generally referred to as a reverse Hill-Sachs lesion, may be noted. (See Figure 7.) Large reverse Hill-Sachs lesions are predictive of recurrent instability.5
Figure 7: CT of Posterior Shoulder Dislocation with Reverse Hill-Sachs Lesion
The Bankart lesion is due to impact of the humeral head against the antero-lateral inferior glenoid labrum during dislocation. It is associated with joint capsule rupture and inferior glenohumeral ligament damage.30,44 (See Figure 8.) It is more common in younger patients and has a high associated dislocation recurrence rate of 85-87%.30,41,45
Figure 8: MR Image of Hill-Sachs and Bankart Lesion
Other less common injuries include SLAP (Superior Labral tear, Anterior to Posterior) and avulsion of the greater tuberosity (10-16%).8,39,40,46,47 Coracoid fracture can result in painful non-union with dislocation of the shoulder and humeral shaft fracture and is associated with high-impact trauma.
The glenohumeral ligaments are damaged in approximately 55% of shoulder dislocations and are more common in younger patients.41,47 Rotator cuff tears are more commonly associated with shoulder dislocations in the older patient population.48
Up to about one-half of shoulder dislocations may be associated with nerve damage,46 with axillary nerve damage being the most frequent, and with brachial plexus injury reported but less common. Axillary nerve damage is manifested as weakness on elevation and abduction, with numbness or paresthesias along the lateral aspect of the arm, as the nerve innervates the posterior deltoid and the teres minor.
If the brachial plexus is injured, clinicians must look for signs of axillary artery damage, including pain in the axilla, axillary hematoma, or cool limbs with diminished or no pulses. Arterial injuries are rare, but are more common in the older patient population.
Opiates and benzodiazepines have long been the staple medications for shoulder dislocations, and some believe they should always be used.9,16,49 However, many of the techniques mentioned here have been described without the need for additional analgesia.15,18,34,38,39,50 While there will still remain a subset of patients who benefit from the use of opiates, benzodiazepines, or sedation, there are new techniques for analgesia using local anesthetics.
The first entails intra-articular injections of local anesthetic. The generally described approach is using 4 mg/kg (up to 200 mg) of 1% lidocaine and injecting into the joint using the lateral approach. While this is potentially beneficial in that it can be done quickly and allow for reduction without the need for sedation, it has had mixed results in the literature with regard to success and patient satisfaction.51 There is also the risk of joint infection.
Another option is an interscalene block. Few studies have looked at this, but one notes less time spent in the ED and no difference in pain or patient satisfaction. The drawback to this technique is that it is ultrasound-guided and, therefore, it is provider-dependent and comes with the risk of paralyzing the phrenic nerve. Some consultants prefer that the patient be rendered completely unresponsive, making propofol or etomidate treatment options.
Not all shoulder dislocations require a pre-procedural X-ray; however, most do. The exceptions to this are those that frequently dislocate with atraumatic or minor trauma mechanisms, as there is a very low likelihood that these patients have an associated spiral humeral fracture or a bone fragment in the way of relocating the shoulder. All others would benefit from a pre-procedural X-ray. Pre-reduction X-rays may identify any fracture fragments that may impede reduction. Posterior dislocations have been missed historically during the initial medical evaluation, perhaps because orthogonal views were not used during the initial assessment.5 Radiography typically consists of internal/external anteroposterior (AP), scapular Y, and axillary views of the affected shoulder. A Stryker notch view may be obtained to specifically look for a Hill-Sachs lesion.
All patients, except those who have recurrent dislocations from minor trauma, should also receive post-reduction imaging. One study looking at the prevalence of post-reduction iatrogenic fractures in first-time dislocations in those patients older than 40 years noted a significant association between those who had a humeral head fracture on initial imaging and then had a humeral neck fracture on follow-up imaging.52
Point-of-care ultrasound is a new technique being used to diagnose shoulder dislocation in the emergency department. With normal anatomy, the humeral head is viewed just below the acromion, whereas when dislocation exists, there is widened space between the acromion and the humeral head. Ultrasound may also reveal an empty glenoid fossa, disappearance of the humeral head, or visualization of the humeral head below the coracoid process.53 The drawback to this modality is the user-dependent nature of ultrasound and the difficulty with identifying associated fractures. The benefits to the use of this bedside imaging include quicker diagnosis and treatment of a painful condition, decreased wait, and avoidance of ionizing radiation without the patient going to and from X-ray. In one recent report of 69 shoulder dislocations, two of which were posterior, the sensitivity and specificity for assessment of complete shoulder reduction were 100%.53 An earlier report had confirmed ultrasound diagnosis in two cases of posterior shoulder dislocation.54 A potential advantage of ultrasound is the identification of posterior shoulder dislocations when the plain radiographs are not clearly diagnostic. (See Figures 9 and 10.)
Figure 9A: Posterior Shoulder Dislocation (difficult to discern on AP view)
Figure 9B: Posterior Shoulder Dislocation Visible on Scapular Y View
Figure 10: Bedside Ultrasound of Posterior Shoulder Dislocation
Magnetic resonance imaging (MRI) is typically ordered in the setting of recurrent dislocations, rather than in the ED. It is, however, the gold standard to image injuries to the labrum/joint capsule and rotator cuff, and for gauging the size of Hill-Sachs deformities and glenoid bone loss. (See Figure 8.) MRI can visualize tearing of the anterior labrum and disruption of the scapular attachment of the anterior band of the inferior glenohumeral ligament (soft tissue Bankart injury), as well as an avulsed anterior labrum that remains attached to the glenoid (Perthes lesion). Injuries to the rotator cuff, especially the subscapularis tendon, may be seen in the setting of dislocation, but do not affect emergency management.43
Recurrence and Follow-up Care
One study estimates that 1-2% of people will have a shoulder dislocation, mostly from traumatic sources, in their lifetime. (See Table 1.) The rate of recurrence of shoulder dislocation is higher in those whose first dislocation occurred at a younger age.55
After reduction, the traditional method of treatment has been to keep the shoulder immobilized in a sling or brace for 2-3 weeks in internal rotation. There have been immobilization techniques that keep the arm in external rotation, based on MRI evidence for better coaptation of the humerus on the glenoid neck,50 but it was shown that external rotation did not lower the incidence of recurrence in a follow-up study.57
All shoulder dislocations without fracture would benefit from shoulder rehabilitation, including early range of motion, followed by rotator cuff muscle strengthening. However, if the dislocation is associated with a fracture, the patient should be referred to follow up with an orthopedist to determine the length of time to heal and whether it is a stable fracture. Surgical intervention is more effective than non-operative treatment for prevention of recurrent dislocations after a primary dislocation.58-61
For patients who have relapsing dislocations, a home relocation technique has been described by Boss-Holzach-Matter.8 With this maneuver, the patient sits on a hard surface, bends the knee on the ipsilateral side of the affected arm to 90 degrees, and interlocks the fingers of both hands behind the knee. The patient then shrugs his or her shoulders forward, mindful of relaxing the shoulders, while slowly leaning backward. This requires patience by the patient and careful technique. It is recommended that before prescribing it, the physician should monitor the patient performing this technique. As a rule, earlier surgical intervention may be favored in younger patients, those with a large glenoid defect, and highly active athletes who participate in sports that involve overhead throwing or contact.43
With a multitude of techniques available, the physician must determine which technique fits the respective patient’s scenario the best. The authors suggest starting with the position in which the patient presents. In other words, if the patient presents with the arm adducted and internally rotated, then the patient is already in the starting position for the Cunningham or Kocher technique. Conversely, if the patient presents with the arm fully extended and slightly abducted, he or she is already in the starting position for the Milch technique, scapular manipulation, or one of the traction techniques.
As noted previously, up to 30% of dislocations involve a fracture,39,40 and other injuries to the soft tissue, nerves, and vessels have been described.46,48 To reduce the chances of causing or worsening a complication, the authors favor the less traumatic techniques — those using leverage and scapular manipulation — as first-line. These can be done with or without analgesia. Cunningham proposed a similar recommendation and went further by arguing that the use of techniques primarily relying on traction should no longer be used.11
There is no consensus as to whether immobilization is helpful or, if so, what the optimal duration of immobilization is. Immobilization has not been shown to affect the rate of recurrence, and is performed mainly for comfort.
A variety of techniques exist for the relocation of dislocated shoulders. Often, the patient will present in a manner that favors one method, but if the first attempt is unsuccessful, the physician may try a different technique and/or add a type of analgesia to improve the likelihood of success. Both pre- and post-reduction X-rays are recommended for most patients. All patients should follow up with qualified personnel for either range of motion and strengthening or further surgical evaluation.
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