Anterior Shoulder Dislocation – Causes, Symptoms, Treatment

Anterior Shoulder Dislocation

Anterior shoulder dislocation may be defined as a soft-tissue or bony insult of the shoulder joints that causes the humeral head to subluxation or dislocate from the glenoid fossa. The lifetime risk of suffering from anterior shoulder dislocation or instability is 1 to 2%. The young Football, cricket player, active, the athletic population is at high risk to shoulder dislocation and instability of the shoulder joints.

Shoulder dislocation is one of the most common dislocation disorders in the upper extremity and encounters the second most common injury that is caused by the injury in shoulder joints, road traffic accident, sudden forceful thrust, outstretching hand, fall from the height, and rotational abnormality. The most common symptoms are pain, swelling, tenderness, reduce and restricted movement, joints stiffness are found frequently.

Types of Dislocation

The Types of shoulder dislocation are following

Anterior dislocation is the most common, and frequently found with accounting for up to 97% of all shoulder dislocations.

  • The mechanism of injury is usually a blowdown to an abducted movement, externally rotated movement, and extended injury in extremity.
  • It may also occur or happen with the posterior humerus forceful or fall down on an outstretched forearm and causes pain, swelling, tenderness.
  • On examination immediately, the arm is usually abducted movement and externally rotated movement, and the acromion appears the most prominent injury
  • There are founded mostly associated injuries in up 40% of anterior dislocations injury including nerve damage permanently, or tears, and fractures associated with the labrum injury, glenoid fossa, and/or humeral head fracture.

Posterior dislocations account for 2% to 4% of shoulder dislocations injury.

  • Usually, the injury is caused by a hit to the anterior shoulder joint and axial loading of the adducted movement internally rotated movement in the arm.
  • It may also be a result of forceful violent muscle contractions in seizures, electrocution movement.
  • On examination of shoulder joints, the arm is usually held in adduction movement, and internal rotation movement disorders and the patient is unable to rotational movement externally.
  • The most higher risk factors of associated injuries such as fractures of surgical neck fossa or tuberosity in the upper shoulder, reverse Hill-Sachs lesions that are also called a McLaughlin lesion which is an impaction fracture of anteromedial aspect of the humeral head, body, and injuries of the labrum or rotator cuff muscle.

Inferior dislocations (also known as luxation erecta) are the most uncommon and rare type of dislocation(less than 1%).

  • It is usually caused by hyperabduction movement or axial loading on the abducted movement of the arm.
  • On exam, the arm is held above is painful and behind the head and the patient is unable to adductory movement arm.
  • It is often associated with pinch nerve injury, rotator cuff muscle injury, tearing synovium, bursa in the internal capsule, and the highest causing incidence of the axillary nerve and artery injury that passage around the shoulder joints of all shoulder injuries and dislocations.

shoulder discation

Causes of Anterior Shoulder Dislocation

The Causes of Anterior Shoulder Dislocation are following

  • The acromioclavicular joint injury that also causes shoulder dislocation
  • Bicipital tendonitis problem
  • Clavicle fractures in acute or chronic injury
  • Rotator cuff muscle injury may also cause a shoulder dislocation
  • Shoulder subluxation also causes shoulder dislocation
  • Swimmer’s shoulder joints injury most often causes shoulder dislocation
  • Traumatic injury, unilateral or by lateral, bankart lesion in most commonly, surgical abnormal.
  • Atraumatic injury, multidirectional movement injury, bilateral disorder,
  • Proper or lake of rehabilitation timely also causes shoulder dislocation,
  • Inferior capsular shift injury also causes shoulder dislocation
  • Unilateral- or multi-directional instability injury
  • Atraumatic injury cases are often multidirectional with the associated hyperlaxity problems.
  • Traumatic injury in most cases is often unidirectional injury with an associated capsulolabral injury.
  • Lake of presence or absence of accompanying soft-tissue hyperlaxity problem may also cause a shoulder dislocation
  • In most cases of soft tissue hyperlaxity, including patulous capsular laxity injury,
  • It can be congenital or secondary to repeated micro traumatic injury also causes shoulder dislocation,
  • The major trauma, multiple instability events problem, recurrences, or a combination of all of these factors.
  • An acute, low-energy, compression fracture in most cases.
  • Chronic or recurrent, low-energy, attritional deficiency, and erosive changes can be over time
  • Suprascapular nerve entrapment injury also causes shoulder dislocation
  • Quadrilateral space syndrome may lead to shoulder dislocation
  • Posterior glenoid spur (Bennett lesion) also causes shoulder dislocation
  • Early osteoarthritis
  • Tumor

Symptoms of Anterior Shoulder Dislocation

The Symptoms of Anterior Shoulder Dislocation are following

  • The first symptom of frozen shoulder is pain and progressive stiffness, limited range of motion, fibrous tissue formation,
  • Restriction of movement in the glenohumeral joint capsule, ligaments, tendons, and muscle may also cause a shoulder dislocation
  • The second symptom of also causes shoulder dislocation is impossible to get dressed up and out, cooking, clean, reach a back pocket, or shift gears while driving a car, putting the arm up and back.
  • Fractures of the tuberosity, surgical neck fractures may occur in most cases and should not be reduced in the emergency department in acute cases.
  • Bankart lesion is one of the most common problems that may develop when the glenoid labrum is disrupted with or without the addition of an avulsed bone fragment (bony Bankart).
  • The soft Bankart lesions involving in most cases and the inferior anterior labrum are more common.
  • The Hill-Sachs deformity is a compression fracture of the posterolateral humeral joints and head primarily with anterior dislocations disorders are found
  • A feeling of pain and tightness in the whole shoulder area causes pain for shoulder dislocation
  • A feeling of tightness especially when you are throwing a ball overarm in cricket-playing, golf
  • Decrease range of motion is lost in the following direction such as external rotation, abduction, internal rotation, forward flexion.
  • Pain on the back and decrease the range of motion.
  • Dull, aching pain with paresthesia, itching, numbness
  • The referred pain and may felt in whole shoulder joints to the arms, forearms
  • The sleep disturbance and the problem with deprivation
  • Severe sharp pain and with rapid movement (eg. trying to catch mobile phone)
  • The difficulty with activities of daily living such as dressing, driving, and personal care.
  • Lack of movement in all directions of your hand
  • Symptoms will worsen at night and morning stiffness may be felt.
  • Muscle contraction of the coracohumeral ligament limits external rotation of the arm and forearms
  • Muscle contracture and tendinopathy and capsulitis may be felt.
  • Dull” or “deep-seated pain in the rotator cuff muscle and spread into the biceps muscles.
  • The Reverse Hill-Sachs lesions fractures most commonly seen in posterior dislocations disorders are also called a McLaughlin lesion injury in which is an impaction type fracture of the anteromedial aspect of the humeral head.

Diagnosis of Anterior Shoulder Dislocation

The diagnosis of Anterior Shoulder Dislocation is following

History

Patients may report:

  • A popping sensation may feel or not
  • Sudden onset of pain with decreased range of motion may feel or not.
  • The sensation or sensory function of joint rolling out of the socket.
  • Remember to ask about any previous dislocations that happened or not.
  • When the shoulder dislocates are found, the nerves can get stretched out or not. Some patients report stinging, pinch, and numbness in the arm and forearm at the time of the dislocation.

Physical

The physical examination should confirm by examination with a suspected dislocation.

  • The range of motion is diminished and painful or painless.
  • In the case of an anterior dislocation, the anterior arm is abducted position and externally rotated in thin patients may be feeling, there may be a prominent humeral head felt anterior or posterior directly, and the void can be seen posteriorly in the shoulder joints.
  • In the case of posterior dislocations are easy to miss and can be felt, because the arm is in internal rotation movement and adduction movement.
  • In thin patients, or unhealthy patients the prominent head can be palpated posteriorly in most cases.
  • Your doctors or health care provider and practitioners can miss posterior shoulder dislocations injury easily because the patient appears only to be guarding the extremity and shoulder joint.
  • When performing a detailed neurovascular examination before the reduction is imperative may be felt.
  • The injury to the axillary nerve most often during shoulder dislocation movement is as high as 40%.
  • Practitioners should record the neuromuscular examination profile before and after any dislocated shoulder joint.
  • First-time dislocators 
    • The patients presenting after a single acute injury and trauma event typically report a recent history of high-energy trauma, stiffness, or collision impact causing the dislocation.
    • Clinicians should inquire regarding:
      • Degree of trauma  in case of high- or low-energy impact mechanisms
      • Sports injury or activity and position may felt
      • Discern and concern in a true dislocation from a subluxation event may be felt
      • Elicit the requirement for on-field or on-site manual reduction in position; presentation to the emergency department +/- sedation requirements.
  • Chronic cases
    • The patients typically present after having delayed once the range of motion movement limitations begins to impact daily activities significantly.
    • The clinicians should gather knowledge and detailed history for any inciting instability events.
      • The initial injury may be felt and overlooked, and the patient subsequently develops chronic instability/recurrence with incidence.
      • The more heightened clinical suspicion is warranted in the setting position with  of:
        • The history of seizures or electrical shock types abnormality.
        • The polytrauma in which the shoulder instability was overlooked or missed and felt.
      • Low-energy, recurrent subluxation cases occur in most cases.

        • The shoulder instability occurs and episodes during sleep may be indicative in case of more complex instability that may involve significant bone loss.
        • The clinicians should elicit and examine for any medical comorbidities and mortality or family history of underlying connective tissue disorders or generalized hyperlaxity on the exam.

Provocative Examination Testing/Maneuvers

  • C-spine / Neck Exam –  In the co-existing cervical radiculopathy and cervical spondylosis with shoulder dislocation should be ruled out in any situation where the neck or shoulder pathology is considered. Observation of neck posturing, muscular symmetrical positions, palpable tenderness, and active/passive ROM should undergo an evaluation and examination. Special tests that are helpful include the Spurling maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular examination.
  • Shoulder Exam – The examiners should observe, elicited, and compare bilateral shoulder girdles muscle for any notable asymmetrical position, scapular proper posturing, muscle bulk comparison, or any types of atrophic changes. The skin should be observed properly for the presence of any previous surgical incisions, injury, lacerations, scars tissue formation, erythema with rounded redness, or induration.
  • Shoulder Instability Considerations – The global tissue laxity, erases, spasm should undergo an assessment by examining glenohumeral translation and hypermobility movement at the shoulder joints and other joints around the shoulder in the body if applicable. The hyperlaxity at other joints movements (e.g., elbow and knee hyperextension) may result in the clinical diagnosis that underlying MDI-related diagnoses or connective tissue disorders in the shoulder joint.
  • Anterior Apprehension Test – The anterior apprehension test is performed by lying the patient supine position on the examination table. The examiner positions the shoulder to 90 degrees of abduction and 90 degrees of external rotation movement while applying an anteriorly-directed force to the proximal humerus incorrectly. The test is positive if it reproduces the symptoms of anterior instability are occurs. Apprehension at lower degrees of abduction movement may suggest glenoid bone loss, osteoporosis. The patients may felt the shoulder during the examination, but in most circumstances, the provider can determine or understand if the apprehensive position is seen the patient’s feelings of anterior shoulder instability.
  • Jobe Relocation Test – The Jobe relocation test is utilized with the previous and pre-apprehensive testing maneuver. Once the patient reports a subjective feeling of reproducing the shoulder instability symptoms, pain, swelling, the examiner applies a posteriorly directed force to the joint while keeping the shoulder in the same apprehensive position.  The resolution or improvement of symptoms indicates a positive test result in most cases.
  • Load-and-shift Test  – The examiner uses one hand to apply an axial load through the elbow to center the humeral head within the glenoid joints. An anterior and posterior directed force is then applied at 0-, 45-, and 90-degrees of shoulder abduction movement. Increased translation at increasing degrees of shoulder abduction movement implies a compromise of the IGHL.

Lab Tests

  • Laboratory tests – Leukocytosis is one of the most important tests for shoulder dislocation that supports the possibility of infection and bone-related disease.
  • Serological test – Blood cultures, urine examination, stool examination, or other possible primary symptoms of shoulder dislocation, a bone infection that obligatory when a septic infectious shoulder dislocation is being considered for examination. The and elevated inflammatory condition markers like ESR or CRP include suggesting an infectious or inflammatory disease condition of the shoulder dislocation
  • A serum uric acid level – It is often considered by clinicians and doctors when got shoulder dislocation, tendonitis is suspected, but it is not a reliable and dangerous condition as it may be spuriously elevated or high in acute inflammatory conditions or acutely during a or not.
  • Random blood glucose –  The reference values for a normal random glucose test in an average adult are 80–140mg/dl (4.4–7.8 mmol/l), between 140-200mg/dl (7.8–11.1 mmol/l) is considered pre-diabetes, and ≥ 200 mg/dl is considered diabetes according to ADA guidelines you should visit your doctor or a clinic for additional tests to over sure.
  • Ultrasound – It is basically done to investigate the thickness of the fascia, ligament injury with a shoulder dislocation are likely to have a thickened tendon with the associated fluid collection and that thickness values >4.0 mm that are the diagnostic of in shoulder dislocation []
  • Musculoskeletal ultrasound – It can further visualize the tendon and bony attachment of the thigh sites, muscles, ligaments, and nerves. Ultrasound can also be used to identify the area and extent, nature of the injury  shoulder dislocation and used to evaluate periodically during the recovery phase. The most common findings on ultrasound are focal, fluid, tenosynovitis changes in the common flexor tendon position, how much thickening of the tendon sheath, partial or full-thickness tears, and tear of the tendon. Ultrasound did for dynamic imaging studies, which can provide the additional benefit in regards to evaluation for shoulder dislocation
  • Muscle Biopsy – Muscle biopsy is basically done to investigate abnormal congenital problems such as dutchmen muscular dystrophy, myasthenia graves, hemophilia, etc. A small part of the cell or tissue is collected from the thigh and send to investigate other abnormalities in shoulder dislocation.

Imaging

  • X-Ray – Conventional x-ray and radiography is the most widely used imaging modality and allows for the detection of bone fractures, osteoporosis, and abnormal pathologies condition like fracture, osteoporosis, erosions, osteonecrosis, osteoarthritis, or a juxta-articular bone tumor, neoplasm, and shoulder dislocation. Characteristic features of shoulder dislocation include marginal osteophytes formation in shoulder joint space gradually narrowing, subchondral sclerosis formation in the shoulder dislocation.
  • CT Scan – High contrast CT scan is more effective to diagnose procedures to investigate the shoulder dislocation. Abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, etc.
  • MRI – It is called magnetic radical imaging is also helpful to find the bone conditions, abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, shoulder dislocation. It is the final stage test to confirm that all shoulder dislocation or any other abnormality suspected others condition forearms pain, such as shoulder pigmentation, soft tissue injury and bone tumors, osteonecrosis, osteomyelitis, arthritis, and stress fracture.[,]
  • Bone scintigraphy – It is the most important test to diagnose bone cancer, neoplasm, fractures, necrosis of bone, and joints. It also helps to identify the tendon, sprained ligament, cartilage, muscle spasm, sprain, and strain with a shoulder dislocation.
  • Nerve Conduction velocity test – It a special test for leg pain or thigh pain. It is the procedure where test the sensation of the peripheral nerve stimuli to send the central nervous system means brain. It helps to identify the sensory and motor nervous system problem from the central to the peripheral cell.

Treatment of Anterior Shoulder Dislocation

The Treatment of  Anterior Shoulder Dislocation is following

Non-pharmacological treatment

  • Physiotherapy – It is one of the most common and effective non-pharmacological treatments in the world. It has a variety of treatment modules to erase acute and chronic pain. It is especially helpful in muscle spasticity, spasms related to tennis elbow or lateral epicondylitis, and elbows upper side pain front side and backside pain, and shoulder dislocation. Inflammatory and noninflammatory pain is treated by ultrasound therapy, MRI, Shortwave, microwave, wax therapy, IRR, laser therapy, interferential current therapy, iontophoresis, short-wave diathermy (SWD), and pulsed short-wave diathermy (PSWD)search faradaic current, galvanic current therapy, and wax therapy. Some studies have reported good outcomes with physiotherapy regimes of stretching and strengthening, with more favorable results than rest and reduced activity at short-term follow-up.
  • Deep transverse friction massage – AIt is a special type of massage technique called transverse friction massage is often used in shoulder dislocation patients. It is applied to the tendons and the muscles, using the tips of one or two fingers to heal shoulder dislocation.
  • Transcutaneous electrical nerve stimulation (TENS) – It is called  TENS devices that help to transfer electrical impulses that are helpful for the treatment of shoulder dislocation. These are supposed to keep the pain signals from reaching the brain by blocking pain message signals and increase the secretion of endorphins that are the body’s natural pain killer.
  • Extracorporeal shockwave therapy (ESWT) – It is a physiotherapy device that generates shock or pressure waves that are transferred to the tissue through the skin for healing shoulder dislocation. This is case assumed that to improve the circulation of blood in the tissue and speed up the healing process of shoulder dislocation
  • Eccentric exercises – It is partial help to healing tendons that are the mainstays of physiotherapy regimes. A stable shoulder and scapula function and strength are necessary for correct shoulder functioning; strengthening exercises of the scapular stabilizers that are including the lower trapezius, serratus anterior, and rotator cuff muscles.
  • Percutaneous radiofrequency thermal treatment – A radiofrequency electrode pad is attached percutaneously under an ultrasound guideline which produces a thermal effect in the injured shoulder dislocation when activated, inducing visual microanatomy and removing all pathological injured tissue. Good outcomes have been reported, and no reduction in tendon size has been observed in this case.
  • Acupuncture – It is the China-oriented acute and chronic treatment system where are needle is used to stimulate the pain receptor to reduce pain. It is also helpful in some spasticity formation pain, stroke, hemiplegia, and chronic rheumatoid arthritis pain in the hand, and shoulder dislocation.
  • Extracorporeal shock-wave therapy (ECSW) – It has been proposed as an alternative to non-operative management for shoulder dislocation. It worked by the generator of specific frequency sound waves that are applied directly onto the overlying skin of the shoulder dislocation tendon.
  • The use of low-level laser therapy – It has been proposed due to the stimulating effect of laser on collagen or types 2 collagen production in tendons to increase the healing of shoulder dislocation. Although laser was not initially viewed as particularly useful among frozen shoulder or adhesive capsulitis therapies and shoulder dislocation, a recent study has to indicate some short-term benefits when using an adequate dose and wavelength.
  • Armpit stretch – It is done with the support of your healthy arm, lift the arm with the frozen shoulder upper direction shoulder dislocation, and rest arms on a surface at about chest level. In this position, gradually or slowly bend your knee joints so that your armpit opens up and you can feel it stretching. Then stand up straight again.
  • External rotation stretch – It is a manual test perform by standing in a doorframe with the affected arm placed out to the side of your body, and the elbow joints bent at a 90-degree angle so that your forearm places is parallel to the floor. Keep the upper arm at your side. Then place the palm of your hand on the doorframe to stop the arm from moving. Now turn your upper body away from the arm to stretch the shoulder. It can be done with the supervision of a physiotherapist
  • Internal rotation stretch – In this case, patients stand with their back to the doorframe. Place the back of your hand on the affected side against your bottom so that your arm is at a slight angle. Now lean the back of that elbow against the doorframe gently “trapping” your elbow to keep it in place and turn your upper body slightly inward towards the arm.
  • Manipulation under anesthesia (MUA) – In this treatment in which the shoulder is freed by rotation while the patient is under short general or local anesthesia. This is usually a day procedure treatment system and generally lasts a maximum of 15 minutes including anesthetic time. There is an increased chance of the risk of homers fractures.
  • Whole-body cryotherapy (WBC) -It involves the exposure of extreme cold to the unclothed body in a chamber that circulates very cold air that is maintained between –110 ℃ to –140 ℃ for 2 minutes to 3 minutes. WBC is assumed to provide anti-inflammatory and analgesic effects to the body.[rx]
  • Diet – Diet may be normal or according to the doctor mentions food you can take for you, such as papaya, banana, potato, nut cereal, seasonal fruits, and drink of water. In your daily routine meal must have magnesium, calcium, iron, zinc, folate, vitamin B complex, Vitamin A, Vitamin C, etc.

Medications

  • Non-steroidal anti-inflammatory drugs (NSAIDs) – It is considered to be the fast-acting nonsteroidal anti-inflammatory drugs (NSAIDs) as including acetylsalicylate, aspirin, naproxen, ibuprofen, indomethacin, and etodolac, ketorolac in pain is acute. NSAIDs drugs work by inhibiting cyclo-oxygenase enzyme to prevent the synthesis of prostaglandins, prostacyclin, and thromboxanes. It has also some side effects of aspirin at high doses when used are including tinnitus, hearing loss, and gastric intolerance.[rx]
  • Nerve relaxant –  It is basically used to reduce neuropathic pain, inflammation, nerve root entrapment, myalgia, neuralgia, and fibromyalgia, and frozen shoulder or adhesive capsulitis and shoulder dislocation. Your doctor may prescribe gabapentin, pregabalin, vitamin B1, B6, B12, etc. Major side effects are abdominal pain, nausea- vomiting.
  • Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, tennis elbow, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, shoulder dislocation etc. A side effect may be nausea- vomiting, abdominal pain, cramping [rx]
  • Topical diclofenac, camphor, menthol, and nitroglycerin – or glyceryl trinitrate has shown short-term benefits in the frozen shoulder or adhesive capsulitis but overall results for treatment for tendinopathy or shoulder dislocation have been mixed depending on the site of application.
  • Oral corticosteroids – These provide short-term pain relief for improved range of motion and function. The benefits often do not last longer than a few weeks, and the result is excellent for the treatment of shoulder dislocation. Oral medications such as non-steroidal anti-inflammatory drugs (NSAIDs) and oral steroids can be used at the same time. Although the use of oral steroids has some limitations and is described in the literature they are not a commonly used interventional treatment in the UK. Major side effects are increase metabolism, muscle cramp, abdominal pain, electrolyte imbalance, etc.[rx]
  • Intra-articular steroid injections – In shoulder dislocation treatment the intraarticular steroid such as methylprednisolone, and triamcinolone injections have been shown to improve function more quickly, decrease pain, and increase range of motion. Often patients who receiving injections early in the shoulder dislocation course are more likely to obtain a benefit. Multiple injections can be given to provide symptomatic relief permanently.[rx] Major side effects are increase metabolism, muscle cramp, abdominal pain, electrolyte imbalance, etc.[]
  • Hydrosilation or Arthrographic distension – In this treatment modality, the joint is injected with saline and steroid to dilate the glenohumeral capsule, tendons, ligament, or in which increased and dilatated of the joint capsule with sterile saline or other solution such as local anesthetic or steroid are used at the same time in supervision or guided by radiological imaging such as arthrography. This has been shown to reduce pain and improve range of motion and function in the short term. [rx]
  • Suprascapular nerve blocks – It is another treatment procedure that may be beneficial in terms of pain relief but not a movement or increase range of motion of shoulder joints, and repeated joint distension may improve movement.rx]
  • Sodium hyaluronate injection – A small number of diverse studies have found that sodium hyaluronate injection in the shoulder dislocation is very effective that helps to control pain and increase range of motion. It may have a high risk of bias, provide insufficient evidence to make conclusions about the effectiveness of sodium hyaluronate in the treatment of shoulder dislocation.]
  • Calcitonin –  It is a kind of polypeptide hormone secreted from parafollicular cells of the thyroid.  It plays a significant role in managing rheumatoid arthritis, osteoarthritis,  complex regional pain syndrome, fracture, frozen shoulder or adhesive capsulitis, shoulder dislocation, and metastasis of the bone tumor., And it is also thought to decrease the systemic inflammatory response and stimulate the release of endorphins that are the natural pain killer in the body.
  • Extra-articular collagenase injection – It is pushed into the anterior shoulder capsule midway between the bicipital groove and coracoid at the maximal external rotation in the supervision of the endoscopy procedure. It shows excellent results in an improved functional score, shoulder motion, and pain compared to injection of placebo (0.9% saline/2 mM CaCl2). Patients also benefited from subsequent injections. Side effects include tenderness and ecchymosis at the injection sites, which resolved between 7 and 14 days. MRI obtained or done 3 months after collagenase injection pushing to be sure to the clinically significant injuries to the rotator cuff or surrounding structures of shoulder joints.

Anterior Shoulder Dislocation

Reduction techniques for anterior shoulder dislocation

Scapular Manipulation  (80% to 100% successful)

  • Upright or prone positions
  • In the upright position of the hand, the patient is sitting up, may rest unaffected shoulder against the upright head of the bed or any other instrument or bed.
  • Standing behind position the patient and use one thumb over the tip of the scapula and push medially forcefully while pushing the acromion joint inferiorly with the other thumb.
  • In assistant simultaneously provided traction by grabbing the patient’s wrist with one hand and flexed the elbow with the other hand and pushing down on the elbow.
  • The reduction may be subtle, without obvious clunk.
  • Reduced risk of associated fractures and dislocated joints.

External Rotation Technique

The external rotation technique reduces anterior glenohumeral dislocation by overcoming spasms of the internal rotators of the humerus, unwinding the joint capsule and ligament, and enabling the movement of the external rotator of the rotator cuff muscle to pull the humerus posteriorly slowly.

  • Easy and can do alone or with the support of a physician.
  • With the patient supine, elbow flexed to 90 degrees position, elbow held with one hand, and wrist is held with another hand and
  • Slowly, have the patient allow the arm to fall to the side, externally rotating the forearm. The patient pauses with pain and allows muscles to relax. Over 5 to 10 minutes, the arm externally rotates, and reduction occurs
  • Reduction usually occurs with the arm externally rotated between 70 to 110 degrees

Cunningham Technique

  • The patient is seated with the examiner seated in front of the patient, and the patient places an ipsilateral hand on top of the examiner’s shoulder
  • The clinician rests one arm in the patient’s elbow joint creased and uses the other hand to massage the patient’s biceps muscle, deltoid muscle, and trapezius muscles
  • Having the patient relax and instruct to pull their shoulder blades together and straighten their backside.
  • The popular technique now since rarely conscious sedation needed

Milch Technique  (add Milch technique if external rotation unsuccessful)

  • The patient is in the supine position, fingers over the shoulder joint with thumb in the axilla to stabilize positions.
  • The arm is externally rotated in positions and then abducted over the patient’s head while maintaining external rotation movement with simultaneously placing direct pressure by hand and fingers over the humeral head.

Stimson Technique

  • In these cases no assistant needed to perform the movent and no need for conscious sedation
  • The patient is prone positions with the affected arm that are hanging off the side of the bed with 5 lb to  15 lb of weight in most cases.
  • The reduction is usually achieved within 30 minutes or more.

Traction Countertraction

  • In these case, a sheet is wrapped under the axilla, and with the help of one assistant provides continuous traction at the wrist or elbow joints while the other provides counter traction forcefully with the sheet from the opposite sidearm.

Spaso Technique

  • The patient is supine position while the examiner grasps wrist joints or distal forearm and lifts vertically with gentle vertical traction and external rotation movement.

Fares Technique

  • In this case, the patient is supine positions with the upper extremity at their side of the shoulder joint.
  • The examiner holds the patient’s wrist and gently pulls the arm to provide traction
  • The arm is abducted in position while continuously moving the arm anteriorly and posteriorly in small oscillating movements (about 10 cm) and more.
  • If the shoulder has not reduced by 90 degrees of abduction, add an external reduction in most cases.

Fulcrum Technique

  • The patient is in the supine position or sitting, and a rolled towel or sheet is placed in the axilla area.
  • In this case, the distal humerus is adducted position with simultaneous posterolateral forcefully on the humeral head directly.
  • In this case, requires increased force may have increased complications in the shoulder joint.

Kocher’s and Hippocratic Techniqueoot

  • In this case, placed in the patient’s axilla before traction no longer recommended due to a higher risk of complications and further injury.

Posterior Shoulder Reduction

  • The patient is in a supine position. With the assistant applies anterior pressure forcefully to the humeral head while the examiner applies axial traction to the humerus with internal and external rotation movement of the humerus

Disposition After Shoulder Reduction

  • Place the patient in a sling position
  • A neurovascular exam may help in this case
  • Post-reduction imaging to confirm the abnormality
  • Follow-up with the assistance an orthopedic surgeon

Anterior glenohumeral joint dislocations

The best choice of reduction maneuver is provider and patient dependent in anterior glenohumeral joint dislocations. Intraarticular anesthetic injection inmost cases, or less frequently, procedural sedation technique, is required for adequate relaxation of anterior glenohumeral joint dislocations active stabilizers. Several types of methods are commonly performed reduction maneuvers are described below.

  • Kocher Method – The Kocher method was originally described in 1870 by some scientists. The patient is supine with the elbow flexed to 90 degrees position. The arm is then externally rotated movement until resistance is met. The clinician then adducts and internally rotates movement the shoulder until reduction is felt pain full. This technique does not involve traction. Modifications to this technique include additional traction.
  • Milch Technique – The patient is in the supine position. The clinician holds the wrist or elbow and applies axial traction while externally rotating and abducting in the directions of the arm.
  • Spaso Technique – Described in 1998, this technique involves traction and external rotation movement. The patient is supine, and the shoulder forward flexed to 90 degrees positions. The physician applies vertical axial traction and then external rotation in most cases.
  • Traction and Countertraction – In this method requires an assistant to provide counter-traction of the associate joint. The patient is supine with a sheet wrapped around the thorax to be held by an assistant on the contralateral side position. The clinician applies in-line axial traction force to the affected arm directly while the assistant provides counter-traction in the direction describes by the physician.
  • FAst, REliable, and Safe (FARES) Method – The patient is the supine position. Axial traction is applied with the arm in a neutral position of shoulder joints. Gentle anterior-posterior oscillating movements are performed (such as seen with handshaking) are applied as the arm is brought into abduction and external rotation. Sayegh et al. performed a prospective randomized study comparing their FARES method with the Hippocratic and Kocher method and found a shorter time to successful reduction and lower self-reported pain scores relative to the two classic methods.
  • Boss-Holzach-Matter Self-Assisted Technique – This is a self-reduction technique. The patient is seated with the ipsilateral knee flexed to 90 degrees positions. The patient is then asked to movement interlace both hands around the knee joints. The patient then leans back until their arms are fully extended while instructed to shrug their shoulders in forwarding directions. Marcano-Fernandez et al. found this method to be as effective and less painful compared to the Spaso technique with the added benefit of patient education.

Contraindications to a reduction in ED

Anterior Dislocation

  • The fractures of the humeral neck can lead to avascular necrosis in most cases.
  • Subclavicular and/or intrathoracic dislocations include a subacute dislocation in an elderly patient and an associated surgical neck fracture
  • In most cases avoid multiple attempts in injuries that include neurovascular compromise including brachial plexus involvement, axillary nerve, a musculocutaneous nerve, etc.  If prompt reduction cannot occur without further injury, may need surgical help or others.
  • The suspected arterial injury may need urgent angiography first to identify the injury.

Posterior Dislocation

  • The delayed presentation to the emergency department more than 6 weeks or more
  • Multipart or displaced fracture-dislocations.

Inferior Dislocation

  • Theumeral neck or shaft fractures should be done in a surgical setting
  • Any potential of vascular injury

References

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