Acute evaluation and management of the anterior shoulder dislocation

Mark Remmler, PA-C, Thomas Schaller, MD

August 02, 2010

PDF of CME Shoulder 0810

Acute evaluation and management of the anterior shoulder dislocation

POSTREDUCTION MANAGEMENT 

As in the prereduction period, neurovascular evaluation remains vital following reduction. Postreduction neurovascular integrity needs to be confirmed as injury may occur during the reduction, even when an atraumatic technique is used. Occasionally, patients will present with a prereduction neurologic deficit. Nerve function may return with reduction; however, nerve palsy can last for months. Visser and colleagues found that neurologic deficits secondary to anterior shoulder dislocation can last for up to 45 months.¹³  

Radiographic evidence of successful reduction is mandatory. We recommend a three-radiograph postreduction series that includes AP, scapular-Y, and axillary lateral views (Figure 3). Radiographs will not only confirm successful reduction but also reveal any associated fractures of the humeral head or glenoid, which may play a role in treatment beyond the acute episode in the ED. Once again, the axillary lateral image is the most significant because it allows the PA to fully assess the congruency of the glenohumeral joint. Kahn and Metha demonstrated the role of postreduction radiography in identifying associated fractures.¹⁴ Prereduction radiographs identified 62.5% of fractures; however, 37.5% of fractures could be seen only on postreduction radiographs.¹⁴ 

A phenomenon called pseudosubluxation of the glenohumeral joint may be encountered in the early postreduction radiographs. Axillary nerve dysfunction can produce shoulder girdle weakness, which causes the humeral head to sag relative to the glenoid. This is typically a self-limited finding that resolves in 2 to 3 weeks. A good set of shoulder radiographs that includes the axillary lateral view will confirm that the finding is a pseudosubluxation and not a failed reduction attempt. 

Immobilization of the injured shoulder is required following reduction. Traditionally, the arm is placed in a sling with the shoulder internally rotated. In recent years, anatomic studies of the injured capsule and labrum challenged this dogma. The challenging hypothesis theorized that by placing the shoulder in a relatively externally rotated position these structures heal in a more anatomic position. Theoretically, this would result in more reliable, effective healing and a lower recurrence rate. Recent literature reviews show that this debate is confounded by relatively poor evidence; therefore, an evidence-based decision to choose one method over another cannot be made at this time.^15,16  

Follow-up should occur within 1 week after reduction. Long-term management largely depends on the patient's age and the injury (ie, a first-time dislocation versus a recurrent dislocation). As a rule of thumb, younger patients have a greater chance of recurrent dislocations. Two to 4 weeks of immobilization is required after reduction; however, older persons may require shorter periods of immobilization to prevent stiffness. Gentle assisted-active range of motion is instituted following immobilization, with eventual progression to full-active range of motion with strength training. 

CONCLUSION 

Proper management of the traumatic shoulder dislocation is paramount to diminishing the likelihood of postreduction sequelae. Application of atraumatic reduction techniques will ensure patient safety, minimize patient discomfort, and facilitate better outcomes. Currently, few randomized comparative trials that evaluate multiple reduction techniques have been conducted. However, several prospective studies demonstrate the efficacy of various reduction techniques. No single reduction method is 100% successful; therefore, preference for a particular method is based on the clinician's comfort level and experience. JAAPA 

Mark Remmler practices in orthopedics at Orthopedic Trauma Services, Bronson Methodist Hospital, Kalamazoo, Michigan. Thomas Schaller practices at the Steadman-Hawkins Clinic of the Carolinas, Greenville, South Carolina. The authors have indicated no relationships to disclose relating to the content of this article. 

IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read Emergency or urgency? How to effectively manage a hypertensive crisis; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to www.aapa.org and searching for keyword JAAPA post-tests. All others may complete and submit the post-test online at no charge at www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.

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