Tackling Shoulder Dislocations in the ED: Popped and Locked 

-Case-

A 22-year-old college baseball player comes into the ED clutching his right shoulder after an awkward diving catch. He’s supporting his arm with the opposite hand, and any attempt to move it brings visible grimacing. The shoulder appears squared off and flattened laterally. You palpate a prominent humeral head anteriorly as he mentions that this is not the first time something like this has happened to him.

-Evaluation-

Shoulder dislocations are one of the most common joint dislocations, especially in young, active patients. Anterior dislocations account for ~95% of cases and usually result from trauma with the arm in abduction, extension, and external rotation.

• Key Findings:
  • Arm held in slight abduction and external rotation
  • Loss of deltoid contour (“squared off” appearance)
  • Prominent humeral head anteriorly
  • Limited ROM and pain

Don’t forget the neurovascular exam! In anterior dislocations, the axillary nerve is most at risk. With this in mind, it’s important to check sensation over deltoid along with assessment of radial, median, and ulnar nerve function. Additionally, as with any trauma or extremity injury, always (and we mean always) check for distal pulses!

Imaging is key for making an “official” diagnosis – though shoulder dislocations are often quite pronounced to where there is little question as to the injury at hand. However, imaging also plays another important role: ensuring adequate management! While pre-reduction x-rays confirm the dislocation type and rule out fracture, a post-reduction film checks for proper alignment and associated injuries (Hill-Sachs, Bankart lesions).

-Management-

1. Pain control and sedation: intra-articular lidocaine, IV opioids, or procedural sedation as needed; IV benzos may also help with muscle relaxation in those without contraindications
2. Reduction techniques (go with what you know!):
   • Traction-countertraction: classic and effective with sedation
   • External rotation: gentle and often well tolerated
   • Stimson technique: patient prone, arm hanging with weight
   • FARES technique: fast, reliable method that’s easier on the physician performing the reduction that is ideal for solo reductions
3. Post-reduction care:
   • Confirm reduction clinically (improved ROM, decreased pain)
   • Repeat neurovascular exam + post-reduction films
   • Sling for ~1-2 weeks in most cases
   • Ortho referral for recurrent dislocations, large bony lesions, or younger athletes

Key Facts:

• Anterior = most common dislocation; arm will be held in abduction and external rotation
• Always check neurovascular status pre/post reduction!
• Choose a reduction technique you’re comfortable with
• Young athletes are at a high recurrence risk → need ortho follow-up!

Shoulder dislocations can look intimidating, but with the right technique and preparation, reductions are smooth and satisfying. A good neurovascular exam, appropriate sedation, and knowing your go-to method are key, and remember – a successful shoulder reduction doesn’t just pop the joint back in, it sets the patient on a path to recovery.

Want to learn more? Listen to our great podcast episode on shoulder dislocations!

Cheers,

Tamir Zitelny, MD