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Management of Acute

Shoulder Dislocation
An overview

Heather Campion
Sports Medicine Conference
Shoulder is the most commonly dislocated joint
Traumatic Dislocations
Anterior 96%
Posterior 2-4%
Diverse group of patients experience dislocations;
M and F
young and old
active and inactive
Anatomic Consideration
Glenohumeral stabilization mechanisms
Passive: joint conformity, vacuum effect, ligamentous and
capsular restraints, labrum
Active: long head of Biceps and Rotator Cuff
Pathoanatomy of shoulder dislocations
Bankart Lesion: avulsion of anteroinferior labrum
Hill-Sachs Lesion: posterolateral humeral head defect
Assoc. RCT: more common in older patients
Clinical Evaluation
Prominent acromion, sulcus
sign, palpable humeral head
Neuro integrity of axillary
and musculcutaneous nerves
Apprehension Test:
reproduces sense of
instability and pain in
shoulder reduced prior to
Radiographic Evaluation
AP vs true AP
Axillary vs Valpeau
Special Views:
West Point axillary: for
visualization of glenoid rim
Hill-Sach view: internal
rotation view
Stryker Notch: view 90% of
posterolateral humeral head

Reduction Maneuvers

Methods of Premedication
prior to Reduction
Intraarticular Lidocaine
IV Sedation
Supraclavicular Block
Suprascapular Block
IV Sedation vs Intraarticular
Lidocaine Injection
Level 1 RCT: Miller et al JBJS 2002
Prospective Randomized study put isolated shoulder
dislocation patients (#30) into 2 groups
Variety of Outcome Measures:
Reduction Success


Time to reduce/Time in the ER

IV Sedation vs Intraarticular
Lidocaine Injection
No significant difference between:
Reduction Success
Reduction Time
Pain Score
Statistical Significance:
Pts tx with intraarticular Lidocaine
left the ER earlier
Fewer Complications
Lower Cost with Lidocaine
IV Sedation vs Intraarticular
Lidocaine Injection

Intra-articular Lidocaine
Injection is Preferred over
IV Sedation
Reduction Maneuvers
Is there an Ideal Method for Reduction?
Over 24 Techniques Described
Most Common Techniques
Kocher (71-100%)
External Rotation (78-90%)
Milch (70-89%)
Stimson (91-96%)
Scapular Manipulation (79-96%)
Kocher Maneuver
Arm is adducted and
flexed at the elbow
Externally rotate arm
until resistance is felt
The ER arm is flexed
forward as far as
The arm is internally
External Rotation
Arm aducted to body
Forearm flexed to 90
Traction on forearm
Gentle and gradual
external rotation until
Milcher Technique
Patient is supine
One hand on shoulder,
with thumb on
dislocated humeral head
Other arm slowly
abducts shoulder to
overhead position
Head is gently pushed
over glenoid rim to
reduce dislocated
Stimson Technique
Patient is supine
Affected arm hanging
down over the edge
10 lbs weight applied to
Wait for relaxation and
Arm in some abduction

Traction applied to arm

Assistant applies firm

counter-traction with
sheet across the body
Scapular Manipulation
Patient is prone
Shoulder flexed to 90
degrees hanging with
elbow flexed and humerus
in external rotation
5-15lbs of traction on arm
One hand on superior
scapula pushing laterally
Other hand on inferior
angle pushing medially
Milch vs Kocher
RCT (Beattie 1986)
Randomization by date
111 patients

No premedication

Outcome: Successful Reduction

Results: No difference in manuever for successful

Is there a best Reduction Maneuver?
Unknown: More Research Needed
Recommend learning three techniques and gaining
experience with them each
Post-Reduction Immobilization
Is immobilization

What Method
is Best?
Does immobilization
reduce recurrence?
Level I RCT: Hovelius JBJS 2008
Prospective multi-center study
257 primary anterior shoulder dislocations

25 year follow up


Immobilization for 3-4 weeks after shoulder

dislocation does NOT change the prognosis
compared with immediate mobilization
Internal vs External Rotation
Level II RCT: Itoi JBJS 2007
Basis: MRI has shown that coaptation of the Bankart
lesion is better with the arm in ER than in IR
Thought: If the Bankart heals recurrence is less likely

198 primary shoulder dislocations randomized to ER

or IR immobilization for 3 weeks
Followed for a minimum of 2 years

Level 2: low compliance, instructional bias, short f/u

Internal vs External Rotation
Level II RCT: Itoi JBJS 2007
ER for 3 weeks
Recurrence rate: 32%
IR for 3 weeks
Recurrence rate: 60%
P = 0.007
Premedicate with Intraarticular Lidocaine

Learn multiple reduction maneuvers

If you decide to immobilize, immobilize in ER