Shoulder dislocationMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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411 items

☷ Legend

01Approach to the Critical Patient/attcp39

Immediate threats and escalation

›Time critical risks

›Airway compromise from sedation risk

›Hemodynamic instability from polytrauma

›Limb threat from vascular injury

›Open dislocation

›Fracture dislocation

›Posterior dislocation after seizure or electrocution

›Immediate escalation triggers

›If absent distal pulses then emergent reduction attempt and vascular surgery

›If pulses not restored after reduction then CT angiography upper extremity

›If expanding hematoma then direct pressure and operative pathway

›If open injury then antibiotics and orthopedics

›If gross contamination then add gram negative coverage

›If suspected surgical neck fracture then avoid forceful reduction and orthopedics

›If neurovascular deficit then emergent ortho

›Analgesia and sedation readiness

›Dedicated monitoring personnel during PSA ACEP Level C

›Capnography adjunct to detect hypoventilation earlier ACEP Level B

›Fasting time not a reason to delay ED PSA ACEP Level B

Pre and post reduction safety checks

›Neurovascular baseline

›Radial pulse quality

›Capillary refill

›Hand color and temperature

›Sensation lateral deltoid axillary nerve

›Deltoid activation if tolerated

›Median nerve sensation index fingertip

›Ulnar nerve sensation small fingertip

›Radial nerve wrist and finger extension

›Reduction readiness

›Pain control plan

›Anticipated dislocation direction

›High fracture risk features

›Age 40 years or older

›First episode dislocation

›Humeral ecchymosis

›Equipment plan

›Sling and swathe

›Pulse oximetry and capnography if PSA

›Suction and airway equipment if PSA

02History/hx33

Core history elements

›Presentation pattern

›Sudden shoulder pain

›Loss of contour

›Inability to move shoulder

›Paresthesias

›Mechanism and context

›Abduction external rotation injury

›Fall on outstretched hand

›Direct blow

›Seizure

›Electrocution

›High energy trauma

›Prior instability

›First time dislocation

›Recurrent dislocation history

›Prior surgery stabilization

›Ability to self reduce

Risk factors and associated injuries

›Fracture risk features

›Age 40 years or older

›First time dislocation

›Substantial force mechanism

›Rotator cuff injury risk

›Age over 40 years

›Persistent weakness after reduction

›Night pain after reduction

›Nerve injury risk

›Older age

›First time dislocation

›Prolonged dislocation time

›Posterior dislocation clues

›Seizure or electrocution history

›Arm held in adduction and internal rotation

›Inability to externally rotate

03Physical Exam/exam26

Focused exam

›Inspection and deformity

›Loss of deltoid contour

›Prominent acromion

›Arm position

›Skin tenting or open wound

›Palpation

›Humeral head position

›Clavicle tenderness

›Proximal humerus tenderness

›AC joint tenderness

›Range of motion pattern

›Guarding

›Block to external rotation posterior concern

›Luxatio erecta posture inferior concern

Neurovascular and complications

›Axillary nerve assessment

›Lateral deltoid sensation deficit

›Deltoid weakness

›Axillary nerve injury described as high as 40 percent in some series

›Distal neurovascular assessment

›Radial pulse asymmetry

›Capillary refill delay

›Hand ischemia signs

›PITFALLS

›Normal frontal radiograph does not exclude posterior dislocation

›Missed posterior dislocation reported as high as 79 percent in some studies

›Persistent pain after reduction suggests fracture or cuff tear

04Differential Diagnosis/ddx23

Traumatic shoulder pain and deformity

›Shoulder dislocation ICD 10 S43.0

›Anterior glenohumeral dislocation

›Posterior glenohumeral dislocation

›Inferior dislocation luxatio erecta

›Fractures

›Proximal humerus fracture

›Greater tuberosity fracture

›Surgical neck fracture

›Glenoid rim fracture bony Bankart

›Clavicle fracture

›Scapular fracture

›Soft tissue injuries

›Rotator cuff tear

›Labral tear Bankart

›AC separation

›Neurovascular injuries

›Axillary nerve neuropraxia

›Brachial plexus injury

›Axillary artery injury

›Mimics

›Cervical radiculopathy with shoulder pain

›Septic arthritis if atraumatic fever

›Calcific tendinitis

05Laboratory Tests/lt19

Reduction and sedation safety labs

›PSA related tests when indicated

›Pregnancy test for patients with pregnancy potential

›Imaging and sedation medication risk mitigation

›Point of care glucose if seizure or altered mental status

›Hypoglycemia as seizure trigger

›Electrolytes if seizure evaluation planned

›Sodium abnormalities as seizure trigger

›Coagulation and bleeding risk when indicated

›INR if anticoagulant use

›Hematoma risk and procedural planning

›Platelets if thrombocytopenia concern

›Procedure bleeding risk

Trauma associated labs

›Multisystem trauma labs when indicated

›CBC for suspected hemorrhage

›Anemia baseline if major trauma

›Type and screen if high energy trauma

›Operative pathway readiness

›Creatinine for CT angiography planning

›Contrast safety context

06Diagnostic Tests/dt59

Scoring Systems

›Quebec shoulder dislocation decision rule for radiography

›Purpose

›Reduce unnecessary prereduction and postreduction radiographs

›Prereduction radiography indications

›Age 40 years or older and humeral ecchymosis

›Age 40 years or older and first episode dislocation

›Younger than 40 years and mechanism other than fall from standing height or atraumatic injury

›Derived rule performance

›Sensitivity 100 percent for clinically important fracture dislocation

›Specificity 34.2 percent

›Negative likelihood ratio 0.04

›Postreduction radiography indications in refined approach

›Clinically significant fracture on initial radiography

›Uncertain reduction

MRI

›MRI shoulder

›Indications

›Suspected labral tear in recurrent instability

›Suspected rotator cuff tear with persistent weakness

›Persistent pain despite normal radiographs

›Technique considerations

›MR arthrogram for labral pathology

›Standard MRI for rotator cuff evaluation

›Limitations

›Not required for acute ED reduction success

›Availability and timing constraints

›CT shoulder

›Indications

›Suspected glenoid fracture

›Suspected humeral head impaction defect evaluation

›Preoperative planning for recurrent instability

›CT angiography upper extremity

›Indications

›Persistent pulse deficit after reduction

›Expanding hematoma

›Interpretation focus

›Axillary artery injury

›Distal runoff compromise

Ultrasound

›Point of care ultrasound applications

›Dislocation confirmation when radiography delayed

›Humeral head position relative to glenoid

›Post reduction confirmation adjunct

›Rapid confirmation prior to post reduction radiographs in select settings

›Rotator cuff screening

›Full thickness tear concern in older patients

›Limitations

›Operator dependence

›Glenoid rim fractures not reliably excluded

Plain radiography

›Radiograph views

›AP shoulder

›Scapular Y view

›Axillary view or Velpeau axillary if pain limits abduction

›Radiographic clues

›Anterior dislocation subcoracoid position

›Posterior dislocation lightbulb sign

›Hill Sachs defect on humeral head

›Bony Bankart glenoid rim fragment

›Timing

›Prereduction imaging when fracture risk high

›Postreduction imaging for alignment and associated fractures

07Disposition/dispo20

Discharge criteria and follow up

›Discharge after successful reduction

›Pain controlled with oral medications

›Neurovascular exam normal or baseline unchanged

›Stable postreduction imaging or clear clinical confirmation pathway

›Follow up planning

›Orthopedics or sports medicine within 1 week for first time dislocation

›Earlier follow up for high risk recurrence

›Physical therapy referral timing after immobilization period

›Activity restrictions

›Sling and swathe use

›Avoid abduction external rotation until cleared

Admission or transfer indications

›Admission considerations

›Irreducible dislocation in ED

›Vascular injury concern

›Significant fracture dislocation

›Uncontrolled pain

›Unsafe discharge environment after sedation

›Transfer considerations

›Need for emergent orthopedic surgery capability

›Suspected axillary artery injury

08Treatment/t90

Analgesia and anesthesia options

›Multimodal pain control

›Acetaminophen PO 1000 mg once

›Maximum 4000 mg per 24 hours typical adult

›Ibuprofen PO 600 mg once

›Avoid in pregnancy third trimester

›Ketorolac IV 15 mg once

›Avoid if renal impairment or bleeding risk

›Fentanyl IV 0.5 mcg per kg

›Repeat 0.5 mcg per kg every 5 minutes as needed

›Morphine IV 0.05 mg per kg

›Repeat 0.05 mg per kg every 10 minutes as needed

›Intra articular lidocaine option

›Lidocaine 1 percent 20 mL intra articular

›Aspirate joint fluid first if possible

›Onset 5 to 10 minutes

›Similar effectiveness to IV sedation with fewer adverse events in meta analysis

Procedural sedation and analgesia

›PSA safety framework

›ASA classification and airway risk assessment

›High risk comorbidities cardiopulmonary disease

›OSA history

›Monitoring

›Pulse oximetry continuous

›Blood pressure cycling

›ECG monitoring

›Capnography adjunct ACEP Level B

›Fasting

›Do not delay ED PSA based on fasting time ACEP Level B

›Propofol ACEP Level A

›Propofol IV 0.5 mg per kg bolus

›Repeat 0.25 mg per kg every 1 to 3 minutes

›Hypotension monitoring

›Propofol IV infusion 25 mcgg per kg per minute

›Titrate 10 to 20 mcg per kg per minute to effect

›Ketamine ACEP Level A children

›Ketamine IV 1 mg per kg

›Repeat 0.5 mg per kg every 5 to 10 minutes

›Emergence reaction risk in adolescents

›Ketamine IM 4 mg per kg

›Repeat 2 mg per kg after 10 minutes if needed

›Etomidate ACEP Level B adults

›Etomidate IV 0.1 mg per kg

›Repeat 0.05 mg per kg once if needed

›Myoclonus consideration

›Ketamine propofol combination ACEP Level B

›Ketamine IV 0.5 mg per kg

›Pair with propofol IV 0.5 mg per kg

›Repeat small propofol boluses to effect

Reduction techniques

›General reduction principles

›Gentle technique with muscle relaxation

›Stop if mechanical block or severe pain

›Repeat neurovascular exam after each attempt

›Anterior dislocation options

›Scapular manipulation

›Prone or seated position

›Downward medial pressure on scapular tip

›External rotation method

›Elbow flexed 90 degrees

›Slow external rotation without traction

›Milch technique

›Abduction with gentle external rotation

›Humeral head guidance if needed

›Stimson technique

›Prone with arm hanging

›Gradual traction with weights

›Traction countertraction

›Sheet countertraction

›Steady longitudinal traction

›Posterior dislocation reduction

›Gentle traction in line with humerus

›Gradual external rotation to neutral

›Anterior pressure on humeral head as needed

›Avoid forceful rotation

›Risk of iatrogenic fracture

›Inferior dislocation luxatio erecta

›Traction and gradual adduction

›Convert to anterior then reduce

›High neurovascular injury risk pathway

Post reduction care

›Immobilization

›Sling and swathe internal rotation

›Typical immobilization 1 to 3 weeks for simple reduction

›Early pendulum exercises when cleared

›Post reduction reassessment

›Pain relief improvement

›Full neurovascular recheck

›Post reduction imaging when indicated

›Recurrence counseling

›High recurrence in young patients

›Under 20 years recurrence 72 to 100 percent

›Age 20 to 30 years recurrence 70 to 82 percent

›Over 50 years recurrence 14 to 22 percent

09Special Populations/sp27

Pregnancy

›Pregnancy specific considerations

›Radiation minimization

›Shielding and lowest necessary views

›Ultrasound adjunct when feasible

›Analgesia choices

›Acetaminophen preferred

›Avoid NSAIDs in third trimester

›PSA considerations

›Aspiration risk awareness

›Left lateral tilt in late pregnancy

Geriatric

›Older adult considerations

›Higher fracture dislocation risk

›Low energy falls still high risk

›Prereduction radiography threshold lower

›Higher rotator cuff tear risk

›Persistent weakness prompts early imaging and referral

›Sedation risk

›Lower dosing

›Delirium risk with benzodiazepines

Pediatrics

›Pediatric considerations

›Physeal injury mimic

›Proximal humerus epiphyseal injury consideration

›Recurrence risk high in adolescents

›Early sports medicine referral

›PSA options

›Ketamine safe for children ACEP Level A

›Weight based dosing strict

10Background/b32

Epidemiology

›Epidemiology basics

›Traumatic anterior dislocation common

›Incidence near 24 per 100000 person years

›Male predominance 2 to 5 times

›Nearly half occur before age 30

›Direction distribution

›Anterior dislocations about 90 percent of cases

›Posterior dislocations less than 4 percent of cases

›Miss rate and diagnostic difficulty

›Missed posterior dislocation reported as high as 79 percent

Pathophysiology

›Mechanism and lesion patterns

›Anterior dislocation mechanism

›Abduction and external rotation lever out of glenoid

›Associated bony lesions in anterior instability

›Bony lesions reported in 96 percent in pooled studies of recurrent instability

›Hill Sachs lesion prevalence 69 percent in pooled sample

›Bony Bankart lesion prevalence 13 percent in pooled sample

›Neurovascular injury mechanisms

›Axillary nerve stretch across humeral head

›Axillary artery tethering in older patients

Therapeutic Considerations

›Reduction timing and outcomes

›Earlier reduction improves pain control and muscle spasm

›Prolonged dislocation increases difficulty and complications

›Analgesia strategy evidence

›Intra articular lidocaine similar success to IV sedation in RCT meta analysis

›Intra articular lidocaine associated with fewer adverse events and shorter ED length of stay

›Immobilization strategy

›Internal rotation sling commonly recommended

›Immobilization duration commonly 1 to 3 weeks after simple reduction

›Surgical consultation rationale

›High recurrence in young active patients

›Large bony defects increase instability recurrence

11Patient Discharge Instructions/pdi19

Copy discharge instructions

›Discharge care after shoulder reduction

›Sling and swathe continuously except hygiene

›Ice 15 minutes up to 4 times daily for 48 hours

›Acetaminophen as directed on label

›NSAID use only if safe for kidneys stomach and pregnancy status

›Keep elbow wrist and hand moving several times daily

›No lifting pushing pulling with injured arm

›Avoid shoulder abduction and external rotation

›Follow up

›Orthopedics or sports medicine within 1 week

›Earlier follow up for first time dislocation age under 30 or athlete

›Physical therapy referral after immobilization period

›Return to ED immediately

›New numbness or weakness in arm or hand

›Fingers cold blue or very swollen

›Severe increasing pain not controlled with medication

›Shoulder looks out of place again

›Fever or redness around any wound

›Chest pain or shortness of breath after sedation

12References/r24

Clinical guidelines and policies

›ACEP Clinical Policy Procedural Sedation and Analgesia in the ED 2014

›Fasting time should not delay ED sedation ACEP Level B

›Capnography may be used as adjunct to detect apnea earlier ACEP Level B

›Propofol can be safely administered for ED PSA ACEP Level A

›Ketamine can be safely administered to children for ED PSA ACEP Level A

›Etomidate can be safely administered to adults for ED PSA ACEP Level B

›Quebec decision rule refinement for radiography in anterior shoulder dislocation CJEM 2009

›Sensitivity 100 percent for clinically important fracture dislocation

›Negative likelihood ratio 0.04

›AAOS OrthoInfo Dislocated Shoulder patient guidance

›Immediate goal return to normal alignment

Evidence based sources

›Systematic review and meta analysis intra articular lidocaine vs IV sedation 2022

›Similar reduction success

›Fewer adverse events

›Shorter ED length of stay

›Review traumatic first time anterior dislocation recurrence by age 2016

›Under 20 years recurrence 72 to 100 percent

›Age 20 to 30 years recurrence 70 to 82 percent

›Over 50 years recurrence 14 to 22 percent

›Systematic review bony lesion prevalence in traumatic anterior dislocation 2022

›Hill Sachs lesion prevalence 69 percent

›Bony Bankart lesion prevalence 13 percent

›Review posterior shoulder dislocation missed diagnosis 2018

›Missed initial diagnosis reported as high as 79 percent

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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