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Review Article

Acute Management of Shoulder


Dislocations
Abstract
Thomas Youm, MD
Richelle Takemoto, MD
Brian Kyu-Hong Park, MD

The shoulder joint has the greatest range of motion of any joint in the
body. However, it relies on soft-tissue restraints, including the
capsule, ligaments, and musculature, for stability. Therefore, this joint
is at the highest risk for dislocation. Thorough knowledge of the
shoulders anatomy as well as classification of dislocations,
anesthetic techniques, and reduction maneuvers is crucial for early
management of acute shoulder dislocation. Given the lack of
comparative studies on various reduction techniques, the choice of
technique is based on physician preference. The orthopaedic
surgeon must be well versed in several reduction methods and
ascertain the best technique for each patient.

S
From the Department of Orthopaedic
Surgery, NYU Hospital for Joint
Diseases, New York, NY (Dr. Youm
and Dr. Park) and the Bone and Joint
Center at Kauai Medical Clinic, Wilcox
Memorial Hospital, Lihue, HI
(Dr. Takemoto).
Dr. Youm or an immediate family
member is a member of a speakers
bureau or has made paid presentations
on behalf of and serves as a paid
consultant to Arthrex. Neither of the
following authors nor any immediate
family member has received anything
of value from or has stock or stock
options held in a commercial company
or institution related directly or indirectly
to the subject of this article:
Dr. Takemoto and Dr. Park.
J Am Acad Orthop Surg 2014;22:
761-771
http://dx.doi.org/10.5435/
JAAOS-22-12-761
Copyright 2014 by the American
Academy of Orthopaedic Surgeons.

December 2014, Vol 22, No 12

everal shoulder dislocation reduction techniques have been described


in the modern literature, but little of
it synthesizes the early management
of acute shoulder dislocations. The
shoulder is the most commonly dislocated large joint.1 With the increasing activity level associated with
modern society, the incidence of
shoulder dislocation has risen to
24 per 100,000 person-years.2 The
highest percentage of primary dislocations occurs in males aged 10 to 20
years followed by the 50- to 60-year
age group.3,4 A thorough knowledge
of shoulder anatomy, classification of
dislocations, anesthetic techniques,
and a variety of reduction maneuvers
is essential for management of this
injury.

Pathoanatomy
The shoulder joint develops as an
appositional articulation and has the
greatest range of motion (ROM) of
any joint in the body due to a scarcity
of bony restraints and minimal
articular contact. Thus, the shoulder

is more reliant on soft-tissue restraints of the capsule, ligaments, and


musculature, placing this joint at high
risk for dislocation. The shoulder is
held reduced by static and dynamic
stabilizers (Table 1). Static stabilizers
maintain congruity of the shoulder
joint through buttressing support
and provide stability at the end
ranges of motion. Dynamic stabilizers function via the neuromuscular
system, actively stabilizing the moving joint at the mid ranges of motion.
Static constraints of the shoulder
consist of the coracoacromial arch,
glenoid fossa, labrum, capsule, and
glenohumeral ligaments (GHLs). The
coracoacromial arch is formed by the
coracoid, coracoacromial ligament,
acromioclavicular joint, and clavicle.
These structures collectively provide
anterosuperior stability. Moreover,
the articular surface of the glenoid is
angled anteriorly and superiorly,
providing posterior and inferior stability. In contrast to the acetabulum of
the hip joint, the glenoid has a smaller
articular surface, thereby rendering
the shoulder less stable. The articular
surface of the humeral head is three

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Acute Management of Shoulder Dislocations

Table 1
Static and Dynamic Glenohumeral Joint Stabilizing Structures
Structure
Static Stabilizers
Coracoacromial arch
Glenoid fossa
Labrum
Capsule/GHLs
Superior GHL
Middle GHL
Inferior GHL
Dynamic Stabilizers
Deltoid
Rotator cuff
Long head of biceps tendon
Periscapular musculature

Function

Anterosuperior stability
Posteroinferior stability
[ Articular surface area, vacuum seal
Multidirectional stability
Stability in adduction
Anterior and ER stability in 45 abduction
AP and ER/IR stability in 90 abduction
Inferior stability
Compresses humeral head against glenoid
Depresses humeral head in abduction
Stabilizes scapula, scapulohumeral rhythm

ER = external rotation, GHL = glenohumeral ligament, IR = internal rotation

times larger than that of the glenoid,


and only 25% to 30% of the humeral
head articulates with the glenoid at any
one time.5,6 For this reason, adhesioncohesion forces mediated by synovial
fluid are instrumental in centering the
humeral head on the glenoid.
Because of the lack of bony constraint of the glenoid fossa, which is
relatively flat and small, stability is
primarily conferred by soft-tissue
structures. The labrum increases
shoulder stability by contributing
50% of glenoid cavity depth and
increasing the total surface area.7
Along with the rotator cuff, the
labrum is integral to concavity compression and provides a seal around
the joint.8 Any disturbance in the
labrum can disrupt the intra-articular
vacuum and alter the mechanics of
the joint. Once the negative pressure
seal is lost, the humeral head typically
translates inferiorly.
Capsular lesions allow increased
translation of the humeral head and
instability in the opposing direction.
The superior GHL resists inferior
humeral translation and is the primary
restraint of the adducted shoulder. The
morphology and size of the middle

762

GHL is variable, poorly defined, and


absent in 30% of shoulders.9 When
present, this ligament resists anterior
translation and limits external rotation
at 45 of abduction. The inferior GHL
consists of three bands and is the
strongest of all the GHLs. It provides
the greatest stability by resisting anteroinferior translation. The anterior
band of the inferior GHL prevents
anterior dislocation by limiting external rotation at 45 to 90 of abduction.
The dynamic stabilizers include the
deltoid, biceps, rotator cuff, and scapular stabilizing muscles. The long head
of the biceps has been thought to
depress the humeral head during
abduction, resulting in further stability.
However, the biomechanical function
of the biceps tendon is confounded by
conflicting electromyelography studies; some show activity in the biceps
tendon during active abduction, and
others do not.10,11
The rotator cuff provides dynamic
compression of the humeral head into
the glenoid through a phenomenon
known as concavity compression.
Direct attachments to the capsule allow
the rotator cuff muscles to contribute
to stability by increasing articular

tension. During shoulder movement,


active compression of the humerus
against the glenolabral articular concavity provides additional support. In
addition, proprioceptive muscular reflexes counter capsular stretch and
shoulder motion detected by sense receptors, further increasing stability.8
The trapezius, rhomboids, latissimus dorsi, serratus anterior, and
levator scapulae muscles stabilize
the scapula and increase dynamic
stability. With active glenohumeral
abduction, the scapula rotates about
the thorax. This synchronous movement is referred to as scapulohumeral
rhythm. Patients with shoulder
instability have been found to have
excessive movement into protraction
or a delay in retraction with shoulder
elevation and increased spinal tilt,
thereby altering the normal scapulohumeral rhythm. Changes in
scapulohumeral rhythm were found
to be caused by decreased activity in
the lower portion of the trapezius and
serratus anterior muscles.12

Classification
Shoulder dislocations are classified as
atraumatic or traumatic. Atraumatic
glenohumeral dislocation presents as
multidirectional instability. Related to
generalized ligamentous laxity, multidirectional instability is often bilateral and responds well to nonsurgical
management. Underlying connective
tissue disease such as Ehlers-Danlos
syndrome or a bony abnormality such
as glenoid hypoplasia or excessive
glenoid retroversion should be considered when an atraumatic shoulder
dislocation occurs.
Up to 96% of shoulder dislocations
are traumatic in origin.3 Traumatic
dislocation is caused by a posteriorly
directed torque on an abducted and
externally rotated arm and is often
associated with contact sports or
a fall onto an outstretched arm.3,13
Subsequent unidirectional instability

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Thomas Youm, MD, et al

may occur after repeated traumatic


dislocations have damaged the capsule and ligaments.3
Glenohumeral dislocations are
further classified by the direction of
the humeral head dislocation: anterior, posterior and inferior.

Associated Injuries
In a study of 3,633 patients with
traumatic
shoulder
dislocation,
Robinson et al14 reported that 40% of
patients also had an associated
structural injury about the glenohumeral joint. Thirty-three percent of
patients sustained a rotator cuff tear
or fracture of the greater tuberosity.
The incidence of rotator cuff tear in
patients older than 40 years is especially high (20% to 54%15) secondary
to preexisting tendon degeneration.
Robinson et al14 also reported that
13% of patients sustained a neurologic injury associated with shoulder
dislocation. The axillary nerve, which
is the most commonly injured nerve, is
susceptible to traction injury because
it transverses the axilla adjacent to the
inferior capsule. Injury to this nerve
may manifest as deltoid weakness
or numbness over the anterolateral
shoulder. However, normal sensation
does not exclude axillary nerve injury.
Bankart lesions, detachments of the
anterior labrum from the glenoid rim,
are associated with 85% of traumatic
anterior dislocations.16 Patients with
recurrent shoulder dislocations have
a higher incidence of Bankart lesions.
Posterior dislocations can result in
reverse-Bankart lesions of the posteroinferior labrum.3,17 The HillSachs lesion, an impaction fracture
of the posterolateral humeral head
on the glenoid rim, is estimated to
occur in 40% to 90% of anterior
shoulder dislocations and 100% of
recurrent dislocations.18 Reverse
Hill-Sachs lesions affect the anterior
humeral head and occur in 86% of
posterior shoulder dislocations.18
December 2014, Vol 22, No 12

Radiographic Assessment
Radiography is essential for diagnosis
of shoulder dislocation. Radiographs
should be taken before and after
reduction to plan reduction maneuvers, ensure concentric reduction, and
evaluate for concomitant fractures. AP,
lateral, and axillary views are obtained
to identify the direction of the dislocation and any associated fractures.
The axillary view is critical to assess
the relationship between the humeral
head and the glenoid. To obtain this
view, the patients arm is abducted,
a cassette is placed superiorly on the
shoulder, and the beam is directed
superiorly into the axilla. Ideally, the
arm is abducted to 90; however, if
patients have difficulty tolerating that
position, less abduction is acceptable.
Alternatively, a Velpeau view can be
obtained. The arm is adducted and
internally rotated to the chest. The
patient stands or sits at the edge of
a roentgenographic table and leans
backward 30 to 45. The beam is
directed down through the shoulder
joint. The standard axillary view is
preferred over the Velpeau view
because the Velpeau view produces
a distorted, magnified projection.
However, either view is acceptable.
The West Point and Stryker notch
views have traditionally been used to
assess for bony Bankart and Hill-Sachs
lesions, respectively. CT and MRI
technology have largely replaced these
special views. CT can detect subtle
fractures not identified on radiography,
such as Hill-Sachs lesions and glenoid
rim fractures. MRI is used to identify
soft-tissue structural damage, particularly Bankart lesions, ligament/capsule
detachment, and rotator cuff tears.

Acute Management
A myriad of reduction maneuvers exists. Regardless of the maneuver used,
several general principles apply. Acute
dislocations should be reduced in

a timely manner to avoid muscular


spasm and neurovascular compromise
while ensuring gentle and technically
sound closed reduction. The ease of the
reduction partially depends on the
length of time since the dislocation and
the tone of the shoulder girdle musculature. If the injury is tended to
promptly, reduction without local pain
medication is feasible. However, if the
patient is unable to relax or if the
musculature is in spasm, reduction
may be more difficult and anesthesia
may be required.
In the office or emergency department setting, two anesthesia options
exist: intra-articular block or procedural sedation. Compared with
sedation, intra-articular block with
lidocaine has been shown to provide
the same degree of analgesia and similar success rates in reduction.19-22
Sedation is associated with more
complications, greater time in the
emergency department, and higher
costs.19-22 Therefore, intra-articular
block should be used first, with sedation reserved for difficult reductions.

Anterior Shoulder
Dislocation and Reduction
Maneuvers
Most shoulder dislocations (97%) are
anterior.3 The mechanism of injury is
typically forced abduction and external rotation of the arm. Alternatively,
a posterior-to-anterior force directed
on the proximal humerus may result in
anterior dislocation. Anterior shoulder
dislocations are further subdivided into
subcoracoid and subglenoid, with
subcoracoid dislocations occurring
most commonly.
The patient with an anterior
shoulder dislocation will often present with the arm held fixed, slightly
internally rotated, and abducted. A
flattened shoulder silhouette is present when the humeral head is located
anterior, inferior, and medial to its
anatomic position. Passive and active
movement is restricted, as well. Here,

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Acute Management of Shoulder Dislocations

Table 2
Reduction Techniques for Anterior Dislocations
Method

Patient
Position

Type

Hippocratic
Tractioncountertraction
Chair

Traction
Traction

Kocher

Levering

Stimson

Traction

Milch

Combination

External rotation

Levering

Spaso

Traction

Eskimo

Traction

Scapular
manipulation
FARES

Combination

Traction

Traction 1
oscillation

Description

Supine
Supine

Longitudinal traction to arm with foot in axilla


Longitudinal traction to arm with counter
traction applied via sheet around chest wall
Sitting to
With the arm held in place, patient applies
standing
traction by standing up from a seated
position.
Supine or sitting Elbow flexed to 90; adduction, external
rotation, and forward flexion of shoulder
Prone
Arm hangs over edge of stretcher and
downward traction applied with weights
Supine or sitting Humeral head stabilized, arm fully abducted,
traction applied then humeral head pushed
over glenoid rim
Supine or sitting Arm adducted then passively externally
rotated
Supine
Scapula stabilized against stretcher and
upward traction and external rotation
applied
Lateral
Upward traction applied to abducted arm
decubitus
and torso lifted off floor
Prone
Stimson technique 1 manual internal
rotation and medialization of scapula
Supine
Arm adducted, vertical oscillating
movement, gradual abduction with gentle
traction

Success Rate
(%)
NR
NR
739723,24

8110025,26
NR
7010027-29

789030-33
688834-36

NR
799637-38
889526,33

FARES = fast, reliable, and safe; NR = not reported

we describe 11 reduction techniques


for management of anterior shoulder
dislocations (Table 2).
Hippocratic
Hippocrates described the earliest
reduction technique. The physician
places a foot in the patients axilla
while applying traction to the
affected arm with alternating internal and external rotation to disengage the humeral head. This method
is largely historical and has been
abandoned because of the high rate
of traction injury to the brachial
plexus.
Traction-Countertraction
The traction-countertraction method
uses longitudinal traction to disengage the humeral head. The patient is

764

placed supine. A sheet wrapped


around the patients chest and within
the axilla is pulled away from the
affected side by an assistant while the
affected limb is pulled inferiorly and
laterally at a 45 angle (Figure 1).
Alternatively, the sheet may be tied to
the railing of the stretcher if no
assistant is available. Slight external
rotation of the humerus may aid the
humeral head in clearing the anterior
glenoid rim. Once the humerus is
disengaged, slight lateral traction on
the proximal humerus may be
necessary.
Chair
In another traction-based maneuver,
the patient is seated sideways in a chair
with the affected arm hanging over
the backrest. The clinician holds the

supinated forearm stationary and the


patient slowly stands (Figure 2). A
73% success rate was reported in the
original description of this technique.23 Westin et al24 modified the
technique by tying a loop of stockinette about the forearm, flexing the
elbow 90, and using the loop as
a pedal. The authors reported a success rate of 97%, and anesthesia was
not required in 110 of 118 reductions
(93%).
Kocher
The Kocher technique was first
described in 1870.25 With the patient
supine or seated, the operator grasps
the patients forearm on the affected
side and flexes the elbow 90. The
patient adducts the affected arm and
actively externally rotates to 70 to

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Thomas Youm, MD, et al

Figure 1

Photograph demonstrating the


traction-countertraction reduction
technique. A sheet is placed across
the patients torso and held by an
assistant or tied to the bed railing
while axial traction is applied to the
dislocated shoulder.

80 until resistance is felt. The physician forward flexes the arm and
reduction of the humeral head occurs. This technique has a reported
success rate of 81% to 100%.
Stimson
Initially described in 1900, the Stimson
technique is performed with the
patient prone on the stretcher, and the
affected arm hanging over the edge.39
Downward traction is applied with
weights, starting with 5 lbs (2.27 kg;
Figure 3). Alternatively, the elbow
may be flexed 90 to relax the biceps
tendon, and the physician may apply
manual traction with a gentle rocking
motion. Reduction should occur
within 15 to 20 minutes. Advantages
of this method include the relative
ease of reduction and avoidance of
large amounts of force. One disadvantage is the difficulty providing
sedation with the patient in the prone
position.
Milch
The Milch technique was first
described in 1938 and is based on the
principle of recreating the injury.40
The patient can be positioned supine
December 2014, Vol 22, No 12

Figure 2

Photograph demonstrating the chair


technique for reduction of an anterior
shoulder dislocation. The patient
initially sits with the affected arm
hanging over a chair back and then
stands while the physician holds the
arm. The patient reduces the
shoulder using his own power.

or seated, with the physician on the


affected side. The physician places
a hand on the superior aspect of the
injured shoulder and uses a thumb
to stabilize the humeral head in
a fixed position while the arm is
abducted. Once the arm is fully abducted, gentle longitudinal traction is
applied, and the humeral head is
manipulated with the thumb over the
glenoid rim. This technique can be
modified by rotating the arm externally to allow the greater tuberosity to
tilt posteriorly and the thinnest profile
to pass over the glenoid rim.27-29
Success rates ranging from 70% to
100% have been reported.27-29 In
a study of 76 acute anterior shoulder
dislocations reduced with the Milch
technique, all shoulders were reduced
on the first attempt without anesthesia
or complications.28
External Rotation
In 1957, a self-reduction technique
was devised whereby the patient
would sit on a swiveling stool and
grasp a stationary object such as the

Figure 3

Photograph demonstrating the


Stimson technique for reducing
anterior shoulder dislocation. With
the patient in the prone position,
weights are hung from the wrist or
elbow.

leg of a table.41 The patient rotates the


body, passively externally rotating
the shoulder until reduction occurs.
This method has been modified to be
performed with the patient supine or
seated, with the arm fully adducted
and external rotation performed by
a clinician (Figure 4). Reduction
should occur at 70 to 110 of
external rotation. This method is
atraumatic and easy to perform, with
reported success rates ranging from
78% to 90% and .80% of patients
requiring no anesthesia.30-32
Spaso
The Spaso technique, which was initially described in 1998, is performed
with the patient positioned supine.42
The physician stands adjacent to the
affected arm, holding it in 90 of forward flexion. Gentle vertical traction
is applied to the arm, followed by
slight external rotation (Figure 5). The
medial border of the scapula must be
kept in contact with the bed to stabilize
the glenoid. Reduction should occur
spontaneously after several minutes of
traction or the humeral head may be
manually pushed toward the glenoid

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Acute Management of Shoulder Dislocations

Figure 4

Figure 5

Figure 6

Photograph demonstrating the external


rotation technique for reduction of
anterior shoulder dislocation. While the
arm is held adducted, slow, gentle,
passive external rotation is applied until
reduction occurs.

fossa. Success rates ranging from 68%


to 88% have been reported.34-36
Eskimo
This technique was originally developed in Greenland and was first
described in 1988.43 The patient lies
on the ground in the lateral decubitus
position. The clinician grips the dislocated arm and applies a vertically
oriented force, lifting the contralateral
shoulder several centimeters off the
ground. The patient is held in this
position for several minutes until
reduction occurs. Although this technique is easy to perform, it may place
undue stretch on the brachial plexus.
There are no reported data on the
safety of the Eskimo technique.
Scapular Manipulation
Scapular manipulation is performed
by internally rotating and medializing the scapula. The patient is placed
prone, with the arm hanging over the
edge of the stretcher, as in the Stimson technique. Once gentle traction
is applied, the clinician stabilizes the
superior aspect of the scapula with
the thumb and applies medial force
on the inferior angle of the scapula
with the other thumb (Figure 6).
Reduction is often extremely subtle
and may be missed. Success rates

766

Photograph demonstrating the


Spaso shoulder reduction technique
in which vertically oriented traction is
applied with slight external rotation.
Contact between the scapula and the
stretcher must be maintained.

ranging from 79% to 96% have


been reported, and the major disadvantage of this technique is the
steep learning curve.37,38

Fast, Reliable and Safe


Sayegh et al26 described the Fast,
Reliable, and Safe (FARES) method
for reduction of anterior shoulder
dislocation. In this method, the
patient lies supine with the physician
standing on the affected side (Figure
7). The patient holds the arm adducted, with the elbow extended and
the forearm in neutral rotation. Axial
traction is applied without countertraction. A short-range oscillating,
vertical movement is rapidly performed throughout the reduction
maneuver. The arm is slowly abducted. At 90 of abduction, the arm
is gradually externally rotated while
continuing abduction and vertical
oscillation. Reduction typically occurs at 120 of abduction. The authors claim that this technique is
easier to perform than traditional
methods.

Photograph demonstrating scapular


manipulation. The scapula is reduced
to the humeral head by applying
medially directed pressure on the
inferior angle of the scapula with one
thumb and stabilizing the superior edge
of the scapula with the other thumb.

Posterior Shoulder
Dislocation and Reduction
Maneuver
Posterior dislocations comprise ,3%
of dislocations.17 Posterior dislocations
are often unrecognized or incorrectly
recognized; therefore, careful examination is required. Posterior shoulder
dislocations most commonly occur in
men aged 35 to 55 years.17 Traumatic
dislocations are responsible for about
half of posterior shoulder instability
cases.44 In a systematic review of the
literature on posterior shoulder dislocations, 34% were associated with
seizures.45
Posterior dislocations are often
difficult to diagnose. However,
posterior shoulder prominence
may be observed with the arm held
fixed, internally rotated, and adducted (Figure 8). Both passive and
active movements are restricted, as
well.
Closed reduction is often difficult
and may require sedation. It should be
attempted only within 3 weeks of the
injury and in patients with humeral
head defects that comprise ,20% of
the articular surface.17,46 Two operators are needed for the reduction

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Figure 7

Photograph demonstrating the Fast,


Reliable, and Safe (FARES)
technique. While the clinician
maintains traction, short, vertical,
oscillating movements (orange
arrow) are performed during gradual
abduction and external rotation of the
arm (blue arrow). Note there is no
sheet across the torso to provide
countertraction.

maneuver. The physician forward


flexes the shoulder to 90 then adducts and internally rotates the arm
to disengage the humeral head from
the glenoid rim. The assistant maintains cross-body traction while the
physician applies gentle, anteriorly
directed pressure to the posterior
humeral head. Finally, external rotation can be attempted to complete
and confirm reduction.17,45,46

Inferior Shoulder Dislocation


and Reduction Maneuvers
Inferior shoulder dislocation is
exceedingly rare, comprising ,1% of
all shoulder dislocations.47,48 These
injuries are also known as luxatio
erecta humeri because of the resultant fixed, abducted position of the
arm following dislocation. These
dislocations are high-energy injuries
that occur when a hyperabduction
force applied to the arm levers the
proximal humerus onto the acromion.
Subsequently, the inferior capsule and
labrum are injured and the humeral
head disengages inferiorly from the
glenoid. The humeral head is then
December 2014, Vol 22, No 12

Figure 8

AP (A) and axillary (B) radiographs of the shoulder demonstrating a posterior


dislocation. On the AP view, the humerus is held in internal rotation, and the
proximal humerus demonstrates the light bulb sign, which is characteristic of
a posterior shoulder dislocation.

lodged in the infraglenoid region, resulting in the characteristic fixed, abducted position of the arm47 (Figure 9).
Bony, soft-tissue, or neurovascular
injuries about the shoulder are commonly associated with inferior dislocation. The reported incidence of
concomitant fractures of the greater
tuberosity and rotator cuff tears is as
high as 80%.49 Additionally, the incidence of neurologic injury is as high as
60% and vascular compromise is as
high as 39%.48,49 Although the incidence of these associated injuries is
based on a small case series, a high
suspicion for associated structural and
neurovascular injury must be maintained when evaluating a patient who
presents with luxatio erecta.
Traction-Countertraction
As with anterior dislocations, the
application of axial traction to the arm
aids in reduction of an inferior shoulder dislocation. A sheet is wrapped
around the upper torso and held in
place by an assistant for countertraction. Superiorly directed traction

is applied to the arm, and shoulder


abduction is gradually decreased.50
Two-step
The two-step technique converts an
inferior dislocation to an anterior
dislocation. Once converted, any
maneuver for reducing an anterior
dislocation can be used. The examiner stands at the patients head and
pushes laterally on the abducted
humeral shaft with one hand, while
simultaneously pulling superiorly on
the medial epicondyle with the other
hand (Figure 10). This maneuver
will move the humeral head out of
the infraglenoid position and rotate
it anteriorly around the glenoid rim.
If conversion is successful, the arm
may be adducted against the chest
wall. External rotation, tractioncountertraction, or any other anterior dislocation reduction technique
may then be performed.50

Comparison of Techniques
Few studies have compared different
methods of closed reduction (Table 3).

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Acute Management of Shoulder Dislocations

Figure 9

Figure 10

AP (A) and axillary (B) radiographs of the shoulder demonstrating an inferior


dislocation with associated greater tuberosity fracture. This patient was unable to
adduct her arm.

In a study of 111 patients, Beattie


et al51 compared the Milch and
Kocher techniques. Overall, there
was no difference between the two
methods in terms of success rate.
However, the Milch technique was
found to be more successful in patients aged ,40 years when performed within 4 hours of dislocation.
The authors recommended the technique as a first-line treatment. For
obese patients, the authors recommended the Kocher technique,
despite the lack of statistical significance. In a recent randomized study,
60 patients with anterior shoulder
dislocations were treated with either
the Milch or Stimson technique. The
success rate on the first reduction
attempt was 82% with the Milch
technique versus only 28% for the
Stimson technique.52
In a randomized control trial, 154
patients with acute anterior shoulder
dislocations were treated with the
FARES method, the Hippocratic
technique, or the Kocher technique.26
The FARES method was found to be
more successful, quicker, and less
painful than the Hippocratic and
Kocher techniques. In another randomized control trial, the FARES
method was compared with the

768

external rotation technique in 160


patients with acute anterior shoulder
dislocation.33 Again, the FARES
method was found to be more successful, quicker, and less painful.

Postreduction
Rehabilitation
Following successful reduction, the goal
of rehabilitation is to regain maximum ROM while retaining stability.
The affected arm is immobilized for
a minimum of 3 to 4 weeks, and limited physical rehabilitation is recommended. The program should begin
with passive ROM exercises. In patients
with anterior shoulder dislocations, restrictions include no external rotation
past neutral and no abduction past 90
for the first 4 to 6 weeks after injury.
Conversely, in patients with posterior
dislocations, internal rotation is limited for 4 to 6 weeks. Isometric contractions for muscle rehabilitation can
begin immediately after the injury to
strengthen the stabilizing musculature.
Return to athletic activities can occur
after the patient regains full strength
and ROM without pain. The timing of
return to contact sports has not been
well established in current literature,

Photograph demonstrating the twostep technique for converting an


inferior dislocation to an anterior
dislocation. The first step consists of
applying a force over the lateral
humeral shaft. while the medial
elbow is pulled in the opposite
direction. This will direct the humeral
head anteriorly, converting the
inferior dislocation to an anterior
dislocation.

but we restrict patients from returning


to contact sports for a minimum of 2
months.
In patients with limited active
ROM, weakness, or persistent pain 2
to 3 weeks after closed reduction,
rotator cuff pathology is suspected,
and MRI should be obtained.15 This
is especially true for patients older
than 40 years who are at higher risk
for rotator cuff tear. MRI should
also be obtained in cases of recurrent
dislocation to evaluate for underlying pathoanatomy. CT is reserved
for suspected bone loss or further
evaluation of fractures (eg, bony
Bankart lesions) that may be seen on
radiography or MRI.

Clinical Outcomes
The primary end point in outcome
assessment is redislocation. Recurrent anterior dislocations are most
likely to occur 2 years after the initial
injury.13 Thus, 2 years can be used as
an end point in treatment.

Journal of the American Academy of Orthopaedic Surgeons

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Thomas Youm, MD, et al

Table 3
Comparison of Reduction Maneuvers
Study (Design)

No. of
Patients

Sayegh et al26
(RCT level I)

154

Maity et al33
(RCT level I)

160

Beattie et al51
(RCT level II)

111

Amar et al52
(RCT level I)

60

Maneuver

Outcomes (P Value)

Comments

FARES method is more


FARES versus Hippocratic Reduction on first or second
effective, faster, and less
versus Kocher
attempt: FARES 88%,
painful than Hippocratic or
Hippocratic 72.5%, Kocher
Kocher methods.
68% (P = 0.033) Time to
reduction: FARES 2.3 min,
Hippocratic 5.5 min, Kocher
4.3 min (P ,0.001 )
FARES method is faster, less
FARES vs ER
Reduction on first or second
painful and requires fewer
attempt: FARES 95%, ER
attempts than ER. It is an
91% (P = 0.53) Number of
ideal first-line method.
reduction attempts: FARES
1.14, ER 1.46 (P ,0.0001)
Time to reduction: FARES
2.1 min, ER 3.2 min
(P ,0.0001)
Milch versus Kocher
Reduction on first attempt:
No difference overall. Milch
Milch 70%, Kocher 72% (NP) may be better for patients
aged ,40 years. Kocher may
be better in obese patients.
Milch technique superior to
Milch versus Stimson
Reduction on first attempt:
Stimson technique in terms of
Milch 82%, Stimson: 28%
success rate and speed of
(P ,0.001)
reduction.
Time to reduction: Milch
4.6 min, Stimson 8.8 min
(P 0.007)

ER = external rotation, FARES = fast, reliable, and safe; NP = not published, RCT = randomized control trial

Age and sex are predictive factors for


recurrent shoulder dislocation after
primary traumatic anterior dislocation.
Recurrent dislocations are most common in patients aged #20 years.3 The
incidence of recurrent shoulder dislocation decreases precipitously after
age 50 years.3 In a study of 252 patients treated for primary anterior
shoulder dislocation, 56% of younger
patients developed instability over 2
years and 66.8% developed instability
over 5 years.13 Men were found to
have a greater risk of recurrent instability than women.
The degree of trauma associated
with the initial dislocation also affects
outcome. Mechanism of injury, associated fractures, nerve injury, and the
difficulty of reduction are all determinants of outcome. Relative risk for
redislocation after primary anterior
December 2014, Vol 22, No 12

dislocation is highest in patients who


sustained significant rotator cuff tear
and/or associated fracture resulting in
severe damage to the dynamic and/or
static stabilizers.53
Traditionally, participation in athletics has been thought to predispose the
patient to recurrent dislocation. However, conflicting evidence has been reported on this point. Robinson et al13
found that, among patients younger
than 25 years, participation in athletics
did not yield a significant difference in
the rate of recurrence. In contrast,
Sachs et al54 found that participation
in contact sports or occupational use of
overhead motion increases the frequency of recurrent dislocation after
acute traumatic anterior dislocation.
Many surgeons consider recurrent
dislocation an indication for surgery.
However, the patient may consider

recurrent dislocations as only a nuisance. Although recurrent dislocations


in highly competitive athletes or laborers may threaten the patients livelihood, in lower demand patients,
surgery may not be indicated. Sachs
et al54 reported that, over a 4-year
follow-up period after initial acute
traumatic anterior shoulder dislocation, 18 of 37 patients (49%) in the
highest risk group for redislocation
requested surgery.

Summary
Dislocations should be tended to
promptly for the easiest possible
reduction and to minimize damage
to surrounding neurovascular structures. For anterior dislocations, we
recommend the use of an intra-

769

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Acute Management of Shoulder Dislocations

articular block as a first-line method


of analgesia and reserve sedation for
failed awake reductions. Because of
the high success rates reported for
many reduction techniques and the
lack of comparative studies, the choice
of reduction technique depends on
the patient as well as physician familiarity with each technique. Following
reduction, every patient should be
immobilized for a 3- to 4-week period,
followed by a gradual return to ROM
and activity. Methods for acute management of shoulder dislocation vary,
and the orthopaedic surgeon must be
well versed in several methods to best
ascertain the appropriate approach
for each patient.

References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references
13, 19-21, 26, 33, and 52 are level I
studies. References 14, 22, 25, 45,
and 51 are level II studies. References
2, 3, 15, and 53 are level III studies.
References 23, 24, 28-32, 34, 35, 37,
38, 43, 47, 48, 50, and 54 are level
IV studies. Reference 27 is level V
expert opinion.
References printed in bold type are
those published within the past 5
years.
1. Egol KA, Koval KJ, Zuckerman JD, eds:
Handbook of fractures, 4th ed.
Philadelphia, PA, Lippincott Williams &
Wilkins, 2010.
2. Zacchilli MA, Owens BD: Epidemiology of
shoulder dislocations presenting to
emergency departments in the United States.
J Bone Joint Surg Am 2010;92(3):542-549.
3. Rowe CR: Prognosis in dislocations of the
shoulder. J Bone Joint Surg Am 1956;38(5):
957-977.
4. Leroux T, Wasserstein D, Veillette C, et al:
Epidemiology of primary anterior shoulder
dislocation requiring closed reduction in
Ontario, Canada. Am J Sports Med 2014;
42(2): p. 442-450.
5. Bost FC, Inman VC: The pathological changes
in recurrent dislocation of the shoulder: A
report of Bankarts operative procedure.
J Bone Joint Surg Am 1942;23:596-613.

770

with narcotics and benzodiazepines for


reduction of the dislocated shoulder: A
systematic review. Acad Emerg Med 2008;
15(8):703-708.

6. Soslowsky LJ, Flatow EL, Bigliani LU,


Mow VC: Articular geometry of the
glenohumeral joint. Clin Orthop Relat Res
1992;(285):181-190.
7. Howell SM, Galinat BJ: The glenoid-labral
socket: A constrained articular surface. Clin
Orthop Relat Res 1989;(243):122-125.
8. Halder AM, Kuhl SG, Zobitz ME,
Larson D, An KN: Effects of the glenoid
labrum and glenohumeral abduction on
stability of the shoulder joint through
concavity-compression: An in vitro study.
J Bone Joint Surg Am 2001;83(7):
1062-1069.
9. DePalma AF, Callery G, Bennett GA:
Variational anatomy and degenerative lesions
of the shoulder joint, in Blount WP, Banks SW,
eds: Instructional Course Lectures. Chicago,
IL, American Academy of Orthopaedic
Surgeons, 1949, vol 6, pp 255-281.
10. Yamaguchi K, Riew KD, Galatz LM,
Syme JA, Neviaser RJ: Biceps activity
during shoulder motion: An
electromyographic analysis. Clin Orthop
Relat Res 1997;336:122-129.
11. Youm T, ElAttrache NS, Tibone JE,
McGarry MH, Lee TQ: The effect of the
long head of the biceps on glenohumeral
kinematics. J Shoulder Elbow Surg 2009;18
(1):122-129.
12. Matias R, Pascoal AG: The unstable
shoulder in arm elevation: A threedimensional and electromyographic study
in subjects with glenohumeral instability.
Clin Biomech (Bristol, Avon) 2006;21
(suppl 1):S52-S58.
13. Robinson CM, Howes J, Murdoch H,
Will E, Graham C: Functional outcome and
risk of recurrent instability after primary
traumatic anterior shoulder dislocation in
young patients. J Bone Joint Surg Am 2006;
88(11):2326-2336.
14. Robinson CM, Shur N, Sharpe T, Ray A,
Murray IR: Injuries associated with
traumatic anterior glenohumeral
dislocations. J Bone Joint Surg Am 2012;94
(1):18-26.
15. Gomberawalla MM, Sekiya JK: Rotator
cuff tear and glenohumeral instability: A
systematic review. Clin Orthop Relat Res
2014;472(8):2448-2456.
16. Rowe CR, Patel D, Southmayd WW: The
Bankart procedure: A long-term end-result
study. J Bone Joint Surg Am 1978;60(1):1-16.
17. Robinson CM, Aderinto J: Posterior
shoulder dislocations and fracturedislocations. J Bone Joint Surg Am 2005;87
(3):639-650.
18. Provencher MT, Frank RM, Leclere LE,
et al: The Hill-Sachs lesion: Diagnosis,
classification, and management. J Am Acad
Orthop Surg 2012;20(4):242-252.
19. Fitch RW, Kuhn JE: Intraarticular lidocaine
versus intravenous procedural sedation

20. Miller SL, Cleeman E, Auerbach J,


Flatow EL: Comparison of intra-articular
lidocaine and intravenous sedation for
reduction of shoulder dislocations: A
randomized, prospective study. J Bone
Joint Surg Am 2002;84(12):2135-2139.
21. Matthews DE, Roberts T: Intraarticular
lidocaine versus intravenous analgesic for
reduction of acute anterior shoulder
dislocations: A prospective randomized
study. Am J Sports Med 1995;23(1):54-58.
22. Suder PA, Mikkelsen JB, Hougaard K,
Jensen PE: Reduction of traumatic, primary
anterior shoulder dislocations with local
anesthesia. J Shoulder Elbow Surg 1994;3
(5):288-294.
23. Noordeen MH, Bacarese-Hamilton IH,
Belham GJ, Kirwan EO: Anterior dislocation
of the shoulder: A simple method of
reduction. Injury 1992;23(7):479-480.
24. Westin CD, Gill EA, Noyes ME,
Hubbard M: Anterior shoulder dislocation:
A simple and rapid method for reduction.
Am J Sports Med 1995;23(3):369-371.
25. Uglow MG: Kochers painless reduction of
anterior dislocation of the shoulder: A
prospective randomised trial. Injury 1998;
29(2):135-137.
26.

Sayegh FE, Kenanidis EI, Papavasiliou KA,


Potoupnis ME, Kirkos JM, Kapetanos GA:
Reduction of acute anterior dislocations: A
prospective randomized study comparing
a new technique with the Hippocratic and
Kocher methods. J Bone Joint Surg Am
2009;91(12):2775-2782.

27. Milch H: The treatment of recent


dislocations and fracture-dislocations of the
shoulder. J Bone Joint Surg Am 1949;31(1):
173-180.
28. OConnor DR, Schwarze D, Fragomen AT,
Perdomo M: Painless reduction of acute
anterior shoulder dislocations without
anesthesia. Orthopedics 2006;29(6):528-532.
29. Garnavos C: Technical note: Modifications
and improvements of the Milch technique
for the reduction of anterior dislocation of
the shoulder without premedication.
J Trauma 1992;32(6):801-803.
30. Danzl DF, Vicario SJ, Gleis GL, Yates JR,
Parks DL: Closed reduction of anterior
subcoracoid shoulder dislocation:
Evaluation of an external rotation method.
Orthop Rev 1986;15(5):311-315.
31. Mirick MJ, Clinton JE, Ruiz E: External
rotation method of shoulder dislocation
reduction. JACEP 1979;8(12):528-531.
32. Eachempati KK, Dua A, Malhotra R,
Bhan S, Bera JR: The external rotation
method for reduction of acute anterior
dislocations and fracture-dislocations of the

Journal of the American Academy of Orthopaedic Surgeons

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Thomas Youm, MD, et al


shoulder. J Bone Joint Surg Am 2004;86
(11):2431-2434.

40. Milch H: Treatment of dislocation of the


shoulder. Surgery 1938;3:732-740.

33. Maity A, Roy DS, Mondal BC:


A prospective randomised clinical trial
comparing FARES method with the
Eachempati external rotation method
for reduction of acute anterior
dislocation of shoulder. Injury 2012;43
(7):1066-1070.

41. Parvin RW: Closed reduction of common


shoulder and elbow dislocations without
anesthesia. AMA Arch Surg 1957;75(6):
972-975.

34. Ugras AA, Mahirogullari M, Kural C,


Erturk AH, Cakmak S: Reduction of
anterior shoulder dislocations by Spaso
technique: Clinical results. J Emerg Med
2008;34(4):383-387.

42. Miljesic S, Kelly AM: Reductions of


anterior shoulder dislocations of the
shoulder: The Spaso technique. Emergency
Medicine 1998;10:173-175.
43. Poulsen SR: Reduction of acute shoulder
dislocations using the Eskimo technique:
A study of 23 consecutive cases. J Trauma
1988;28(9):1382-1383.

35. 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.

44. Matsen FA III, Chebli CM, Lippitt SB:


Principles for the evaluation and
management of shoulder instability. Instr
Course Lect 2007;56:23-34.

36. Fernndez-Valencia JA, Cue J, Casulleres JM,


Carreo A, Prat S: The Spaso technique:
A prospective study of 34 dislocations. Am J
Emerg Med 2009; 27(4):466-469.

45. Rouleau DM, Hebert-Davies J: Incidence of


associated injury in posterior shoulder
dislocation: Systematic review of the literature.
J Orthop Trauma 2012;26(4):246-251.

37. McNamara RM: Reduction of anterior


shoulder dislocations by scapular
manipulation. Ann Emerg Med 1993;22(7):
1140-1144.

46. Su B, Levine WN: Arthroscopic Bankart


repair. J Am Acad Orthop Surg 2005;13(7):
487-490.

38. Kothari RU, Dronen SC: Prospective


evaluation of the scapular manipulation
technique in reducing anterior shoulder
dislocations. Ann Emerg Med 1992;21(11):
1349-1352.
39. Stimson LA: An easy method of reducing
dislocations of the shoulder and hip. Med
Record 1900;57:356.

December 2014, Vol 22, No 12

47. Patel DN, Zuckerman JD, Egol KA:


Luxatio erecta: Case series with review of
diagnostic and management principles. Am
J Orthop (Belle Mead NJ) 2011;40(11):
566-570.
48. Groh GI, Wirth MA, Rockwood CA Jr:
Results of treatment of luxatio erecta
(inferior shoulder dislocation). J Shoulder
Elbow Surg 2010;19(3):423-426.

49. Mallon WJ, Bassett FH III, Goldner RD:


Luxatio erecta: The inferior glenohumeral
dislocation. J Orthop Trauma 1990;4(1):
19-24.
50. Nho SJ, Dodson CC, Bardzik KF,
Brophy RH, Domb BG,
MacGillivray JD: The two-step
maneuver for closed reduction of
inferior glenohumeral dislocation
(luxatio erecta to anterior dislocation to
reduction). J Orthop Trauma 2006;20
(5):354-357.
51. Beattie TF, Steedman DJ, McGowan A,
Robertson CE: A comparison of the Milch
and Kocher techniques for acute anterior
dislocation of the shoulder. Injury 1986;17
(5):349-352.
52.

Amar E, Maman E, Khashan M,


Kauffman E, Rath E, Chechik O: Milch
versus Stimson technique for nonsedated
reduction of anterior shoulder dislocation:
A prospective randomized trial and
analysis of factors affecting success.
J Shoulder Elbow Surg 2012;21(11):
1443-1449.

53. Robinson CM, Kelly M, Wakefield AE:


Redislocation of the shoulder during the
first six weeks after a primary anterior
dislocation: Risk factors and results of
treatment. J Bone Joint Surg Am 2002;84
(9):1552-1559.
54. Sachs RA, Lin D, Stone ML, Paxton E,
Kuney M: Can the need for future
surgery for acute traumatic anterior shoulder
dislocation be predicted? J Bone Joint Surg
Am 2007;89(8):1665-1674.

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