The Approach to Shoulder Dislocation in the Emergency Setting
The Approach to Shoulder Dislocation in the Emergency Setting
This article will help emergency physicians decide which technique for relocation of a shoulder best fits their patient. Specifically, this article will review the pertinent anatomy, types of dislocation, relocation techniques (including use with and without analgesia), as well as injuries commonly associated with a shoulder dislocation.
Introduction
Shoulder dislocations are a common occurrence in the emergency department (ED). It has been estimated that 1-2% of people will have a shoulder dislocation, mostly from traumatic sources, in their lifetime.1,2 The incidence of shoulder dislocations in the United States has been estimated to be 11.2 per 100,000 person-years in a rural county3 to 23.9 per 100,000 person-years in a national sample.4 The later study of nearly 9000 patients estimated that approximately 70,000 shoulder dislocations required emergency care in the United States each year, with 72% occurring in males.4 Approximately half of these occurred in the context of athletic activity, notably football and basketball.4 The shoulder is the most commonly dislocated joint in the body, capable of dislocating in multiple directions, most commonly anteriorly.
Posterior glenohumeral dislocation is much less common than anterior dislocation, with a prevalence of 1.1 per 100,000 population per year. This type of dislocation is most prominently associated with seizures and falls, but rarely may be caused by electrocution.5
Normal Anatomy
The shoulder is a ball and socket joint consisting of the humeral head and glenoid fossa of the scapula. It is held in place by both ligaments and muscles. The labrum, glenohumeral, and coracohumeral ligaments and joint capsule hold the joint in place at rest. The shoulder muscles, specifically the rotator cuff muscles supraspinatus, infraspinatus, teres minor, and subscapularis, provide support for the joint while it is in motion via balancing rotatory and in-line force. This is done with assistance from the deltoid, long head of the biceps, and pectoralis muscles.
Structures providing support against dislocation have been categorized by location. Anterior support for the shoulder is comprised of the following: anterior labrum, subscapularis, and anterior rim of the glenoid cavity. Posterior support is comprised of the greater tuberosity of the humerus, along with the supraspinatus and infraspinatus muscles.6
Anatomy of Dislocation
The most typical mechanism for dislocation entails forceful external rotation with the shoulder in abduction, dislodging the humerus anterior from the glenoid fossa. Contraction of the biceps and subscapularis muscles provides counter forces that prevent dislocation. The tendon of the long head of the biceps traverses the joint capsule and humeral head. When the biceps muscle contracts, it prevents anterior movement of the humeral head and may also restrict lateral movement, which is required for the humeral head to move past the glenoid rim. The subscapularis inserts on the lesser tubercle, producing internal rotation and medial movement of the humeral head. Contraction of the subscapularis prevents external rotation and maintains the large articular surface of the humeral head in contact with the glenoid fossa.7
Types of Shoulder Dislocations
The shoulder most commonly dislocates anteriorly, with the humeral head ending up in a subcoracoid and subglenoid position approximately 70% and 30% of the of time, respectively.8,9 In these dislocations, the humeral head sits anterior and medial to the glenoid, with the greater tuberosity sitting on the anterior or anteroinferior rim of the glenoid. (See Figures 1 and 2.) Anterior dislocations occur when the arm is in abduction, externally rotated, and in extension, such as can be seen with a fall onto an outstretched arm10 or onto the point of the shoulder.11 Such falls transmit forces through the glenohumeral joint. While anterior dislocations are most common in young male athletes following direct-contact trauma, repeat dislocations can produce a chronically unstable joint that may dislocate after minimal trauma. (See Table 1.)
| Table 1: Recurrence Rates by Age and Mechanism | ||
|---|---|---|
| Age | Recurrence Rate | Usual Mechanism |
|
Younger than 20 years |
80-90% |
Bankart lesion and inferior glenohumeral head dislocation |
|
20-40 years |
25-48% |
Disruption of the labral attachment of the glenohumeral ligament |
|
Older than 40 years |
0-10% |
Rotator cuff tears |
Figure 1: Anterior Shoulder Dislocation with Humeral Head in Subcoracoid Position on AP View
Other types of dislocations are uncommon (see Table 2), but of these, posterior dislocation in which the humeral head is posterior to the glenoid is the next most frequent. (See Figure 4.) It is caused by forced adduction, internal rotation, and flexion of the humerus. While the traditional teaching has been that these dislocations are caused by electrocution or seizures, the most frequent causes are trauma and seizures, in that order. Posterior dislocations may be bilateral, classically described with seizures or electrocution.5
| Table 2: Types of Dislocations |
|---|
|
Figure 2: Anterior Shoulder Dislocation with Humeral Head in Subglenoid Position on AP View
Figure 3: Anterior Shoulder Dislocation with Humeral Head Anterior to Glenoid on Scapular Y View
The true inferior (luxation erecta) dislocation occurs when the humerus is inferior to and not intact with the glenoid rim. It is caused by sudden hyperextension and is associated with severe injuries. Superior dislocations occur when the humeral head is above the glenoid. This type of dislocation is caused when the fully adducted arm receives sudden upward axial pressure. It is associated with tears of the supraspinatus and subscapularis. Lastly, the subclavicular and intrathoracic dislocations are both caused by a large lateral to medial force on the abducted humerus. The intrathoracic dislocation is associated with a fracture of the proximal humerus pulling the head of the humerus into the chest wall.
Physical Examination
Typically, the patient with an anterior shoulder dislocation holds his or her arm in adduction close to the body, in slight external rotation. Associated nerve injury with anterior dislocations is reported as occurring in 5% and 55% of patients, usually affecting the axillary nerve and manifested by decreased sensation over the deltoid muscle.
Shoulder Reduction Techniques
The premise of all shoulder relocation techniques is that the shoulder wants to return to its anatomical position; however, it is being kept from doing so by a combination of muscle spasms, pain, and broken bones. There are three general mechanisms for achieving shoulder relocation: leverage, scapular manipulation, and traction.12 (See Table 3.)
| Table 3: Summary of Shoulder Relocation Techniques | ||
|---|---|---|
| Technique | Summary | |
|
Kocher |
Patient’s arm close to body and elbow flexed to 90 degrees, gently rotated back and forth, and then the arm is raised vertically |
|
|
Milch |
Patient’s arm fully extended and close to body. Slowly abduct and externally rotate until at zero position |
|
|
Cunningham |
Patient’s arm adducted and elbow flexed to 90 degrees, arm resting on physician’s shoulder; patient shrugs shoulders while physician performs mid-biceps massage |
|
|
Scapular manipulation |
Physician pushes inferior tip of scapula inward and superior-lateral portion downward while an assistant applies gentle traction and external rotation |
|
|
Hippocratic |
Physician places foot in axilla and uses foot as fulcrum by pulling distal portion of affected arm medially |
|
|
Stimson |
Patient lies prone and provider hangs 10 lb weight from affected arm. |
|
|
Traction/counter-traction |
Assistant wraps sheet under affected axilla and pulls while physician applies counter-traction and external rotation |
|
|
Spaso |
Physician holds wrist of affected arm, lifts it in sagittal plane while applying gentle traction and external rotation |
|
|
Snowbird |
Patient sits up straight, a stockinette is tied to the proximal forearm, and physician pulls down with foot in stockinette while using hands for rotation |
|
|
Eskimo |
Patient lies lateral decubitus with affected arm up and physician abducts arm and lifts patient off the ground until shoulder relocates |
|
Leverage Methods
Leverage manipulation techniques (Kocher, Milch, and Cunningham) are based on the concept of the "zero position," the point at which all shoulder muscles are in line and there is no rotator or transverse force applied to the shoulder. When the scapula is pulled back toward the spine, zero position is acquired at approximately 100 degrees of abduction. When the scapula is rotated and pulled forward, the zero position is achieved with the shoulder elevated 45 degrees above the horizontal plane (described as 135 degrees of forward flexion) and abducted 165 degrees.13 The position looks as if the patient is pointing to something in the sky, with the arm halfway between pointing straight out front and due laterally. At this location, the articular surfaces of the humeral head and the glenoid fossa are opposed, making it easier for them to relocate. Achieving this position is the goal of the Kocher, Milch, and scapular manipulation methods. A useful website is www.shoulderdislocation.net, which has useful information on positioning and techniques.
Kocher Method. The patient starts with the affected arm flexed at 90 degrees at the elbow and the arm fully adducted against the body. The physician holds the affected elbow and wrist while slowly externally rotating the humerus between 70-85 degrees, stopping when resistance of pain is felt. It is helpful to distract the patient with conversation. With the arm externally rotated and adducted, gently push (or lift) the mid-humerus anteriorly in the sagittal plane as far as possible. Then the arm is rotated internally until the hand on the affected arm points toward the opposite shoulder.14 No traction is applied.15-17 This method has been associated with complications when used with traction,18-20 which are not seen when using the original technique.21
Milch Technique. The patient starts with the arm extended. The physician stands in front of the patient facing him or her. One hand is placed with the fingers bracing the superior portion of the scapula and the thumb bracing the dislocated humeral head. The physician grasps the distal portion of the affected arm and slowly abducts and externally rotates the arm until at zero position. It is important that the humeral head only rotates and does not otherwise move, as that will be painful and require force to complete the movement. Once in zero position, the physician can use his or her thumb to gently push the humeral head into place.7 Multiple variations of this technique exist, and several include an element of traction.9,19,22
Cunningham Technique. The procedure starts with the physician standing next to patient’s affected arm while the patient’s arm is fully adducted and flexed at the elbow. Keeping the patient’s elbow flexed, rest his or her hand on the physician’s shoulder (if the patient’s right arm is affected, the patient’s right hand should rest on physician’s right shoulder), and the physician places his or her wrist on the affected forearm. Relax the patient by performing mild massage of the affected arm’s trapezius and deltoid muscles and with conversation. Then have the patient shrug his or her shoulders posteriorly and superiorly in order to stabilize the scapula while the physician performs mild massage of the biceps at mid-humerus level.23
Scapular Manipulation
This technique was originally described by Bosely in 1979 using the prone position in which the affected arm is allowed to hang free from the examiner’s table and is attached to a 10-pound weight.24,25 The physician then manipulates the inferior tip of the scapula medially and the superior portion of the scapula laterally. This has also been described with the patient upright or sitting using an assistant to apply gentle, firm traction on the affected arm while it is somewhat externally rotated and elevated in the sagittal position. The physician then makes the same scapular manipulation.12 Scapular manipulation with traction has also been described in the supine position.26
Traction
Hippocratic Method. The Hippocratic method starts with the patient supine. The physician places his or her foot in the axilla of the affected arm while holding the distal portion of the affected arm with his or her hand. Relocation is achieved using the inserted foot as a fulcrum by adducting the distal portion of the dislocated arm and using mild traction.27-29
Stimson Method. The Stimson method starts with the patient in the prone position. The affected arm is allowed to hang downward in forward flexion with the wrist attached to a 10-pound weight. Over time, the muscles fatigue and relax, and the shoulder joint spontaneously reduces.30-32
Traction/Counter-traction. The traction/counter-traction method starts with the patient prone or supine. An assistant wraps a sheet under the axilla of the affected arm and applies firm, steady traction. Meanwhile, the physician applies counter-traction to the affected arm while flexing the elbow 90 degrees and alternating between external and internal rotation until the humeral head relocates.10,16,29,33
Spaso Technique. The Spaso technique starts with the patient supine. The physician holds the wrist of the affected arm and lifts it in the sagittal plane to 90 degrees of flexion at the shoulder while applying gentle traction and then rotating externally.20
Snowbird Technique. The snowbird technique starts with the patient sitting up very straight. An assistant can help to ensure that the patient’s back is straight. The affected elbow is flexed 90 degrees and a stockinette is tied to the proximal forearm and connected to the foot of the physician. This allows the physician to continue to apply downward traction while using both hands to rotate the shoulder as needed.34
Eskimo Technique. In the Eskimo technique, the patient lies supine in lateral decubitus with the affected arm upward. The physician and an assistant hold the affected wrist, abduct the arm until it is above the level of the shoulder, and gently lift the patient off the ground a couple of centimeters and hold until the shoulder is relocated. This technique may require the assistance of a third person to apply direct pressure on the humeral head in the axilla.34
Other Traction Techniques. There are several techniques similar to the Hippocratic one that use a fulcrum and traction to reduce the shoulder. One is the Manes technique, in which the physician places his or her forearm, bent 90 degrees, into the axilla of the affected arm. The other arm grasps the patient’s wrist on the affected arm and adducts the arm using the physician’s own arm as a fulcrum over which the reduction occurs. The arm grasping the patient’s wrist can also apply gentle downward traction.35 Similar techniques using a chair as the fulcrum are described by Nordeen and White.36,37 The slump technique also uses an examiner’s forearm in the axilla as a fulcrum, along with longitudinal traction.38
Associated Orthopedic Injuries
Fractures occur in approximately 30% of shoulder dislocations. (See Table 4.) The most common injuries are the Hill-Sachs lesion and Bankart lesion.39,40
| Table 4: Associated Injuries |
|---|
|
Figure 4: Posterior Shoulder Dislocation with Humeral Head Posterior to Glenoid on Scapular Y View
The Hill-Sachs lesion, also called the hatchet deformity, occurs in 54-76% of cases. It is due to a compression fracture or impaction injury to the posterolateral aspect of the humeral head, resulting in a groove. This can be viewed best with internal rotation on the post-reduction X-ray.39-42 (See Figures 5 and 6.) This lesion results from collision of the humeral head with the anterior glenoid rim as it dislocates. The clinical significance of a Hill-Sachs injury is that it may predispose the patient to recurrent instability of the joint.43
Figure 5: Chronic Hill-Sachs Deformity
Figure 6: CT Showing Large Hill-Sachs Lesion
For posterior dislocations, an anterior humeral head defect, generally referred to as a reverse Hill-Sachs lesion, may be noted. (See Figure 7.) Large reverse Hill-Sachs lesions are predictive of recurrent instability.5
Figure 7: CT of Posterior Shoulder Dislocation with Reverse Hill-Sachs Lesion
The Bankart lesion is due to impact of the humeral head against the antero-lateral inferior glenoid labrum during dislocation. It is associated with joint capsule rupture and inferior glenohumeral ligament damage.30,44 (See Figure 8.) It is more common in younger patients and has a high associated dislocation recurrence rate of 85-87%.30,41,45
Figure 8: MR Image of Hill-Sachs and Bankart Lesion
Other less common injuries include SLAP (Superior Labral tear, Anterior to Posterior) and avulsion of the greater tuberosity (10-16%).8,39,40,46,47 Coracoid fracture can result in painful non-union with dislocation of the shoulder and humeral shaft fracture and is associated with high-impact trauma.
The glenohumeral ligaments are damaged in approximately 55% of shoulder dislocations and are more common in younger patients.41,47 Rotator cuff tears are more commonly associated with shoulder dislocations in the older patient population.48
Other Injuries
Up to about one-half of shoulder dislocations may be associated with nerve damage,46 with axillary nerve damage being the most frequent, and with brachial plexus injury reported but less common. Axillary nerve damage is manifested as weakness on elevation and abduction, with numbness or paresthesias along the lateral aspect of the arm, as the nerve innervates the posterior deltoid and the teres minor.
If the brachial plexus is injured, clinicians must look for signs of axillary artery damage, including pain in the axilla, axillary hematoma, or cool limbs with diminished or no pulses. Arterial injuries are rare, but are more common in the older patient population.
Analgesia
Opiates and benzodiazepines have long been the staple medications for shoulder dislocations, and some believe they should always be used.9,16,49 However, many of the techniques mentioned here have been described without the need for additional analgesia.15,18,34,38,39,50 While there will still remain a subset of patients who benefit from the use of opiates, benzodiazepines, or sedation, there are new techniques for analgesia using local anesthetics.
The first entails intra-articular injections of local anesthetic. The generally described approach is using 4 mg/kg (up to 200 mg) of 1% lidocaine and injecting into the joint using the lateral approach. While this is potentially beneficial in that it can be done quickly and allow for reduction without the need for sedation, it has had mixed results in the literature with regard to success and patient satisfaction.51 There is also the risk of joint infection.
Another option is an interscalene block. Few studies have looked at this, but one notes less time spent in the ED and no difference in pain or patient satisfaction. The drawback to this technique is that it is ultrasound-guided and, therefore, it is provider-dependent and comes with the risk of paralyzing the phrenic nerve. Some consultants prefer that the patient be rendered completely unresponsive, making propofol or etomidate treatment options.
Imaging
Not all shoulder dislocations require a pre-procedural X-ray; however, most do. The exceptions to this are those that frequently dislocate with atraumatic or minor trauma mechanisms, as there is a very low likelihood that these patients have an associated spiral humeral fracture or a bone fragment in the way of relocating the shoulder. All others would benefit from a pre-procedural X-ray. Pre-reduction X-rays may identify any fracture fragments that may impede reduction. Posterior dislocations have been missed historically during the initial medical evaluation, perhaps because orthogonal views were not used during the initial assessment.5 Radiography typically consists of internal/external anteroposterior (AP), scapular Y, and axillary views of the affected shoulder. A Stryker notch view may be obtained to specifically look for a Hill-Sachs lesion.
All patients, except those who have recurrent dislocations from minor trauma, should also receive post-reduction imaging. One study looking at the prevalence of post-reduction iatrogenic fractures in first-time dislocations in those patients older than 40 years noted a significant association between those who had a humeral head fracture on initial imaging and then had a humeral neck fracture on follow-up imaging.52
Point-of-care ultrasound is a new technique being used to diagnose shoulder dislocation in the emergency department. With normal anatomy, the humeral head is viewed just below the acromion, whereas when dislocation exists, there is widened space between the acromion and the humeral head. Ultrasound may also reveal an empty glenoid fossa, disappearance of the humeral head, or visualization of the humeral head below the coracoid process.53 The drawback to this modality is the user-dependent nature of ultrasound and the difficulty with identifying associated fractures. The benefits to the use of this bedside imaging include quicker diagnosis and treatment of a painful condition, decreased wait, and avoidance of ionizing radiation without the patient going to and from X-ray. In one recent report of 69 shoulder dislocations, two of which were posterior, the sensitivity and specificity for assessment of complete shoulder reduction were 100%.53 An earlier report had confirmed ultrasound diagnosis in two cases of posterior shoulder dislocation.54 A potential advantage of ultrasound is the identification of posterior shoulder dislocations when the plain radiographs are not clearly diagnostic. (See Figures 9 and 10.)
Figure 9A: Posterior Shoulder Dislocation (difficult to discern on AP view)
Figure 9B: Posterior Shoulder Dislocation Visible on Scapular Y View
Figure 10: Bedside Ultrasound of Posterior Shoulder Dislocation
Magnetic resonance imaging (MRI) is typically ordered in the setting of recurrent dislocations, rather than in the ED. It is, however, the gold standard to image injuries to the labrum/joint capsule and rotator cuff, and for gauging the size of Hill-Sachs deformities and glenoid bone loss. (See Figure 8.) MRI can visualize tearing of the anterior labrum and disruption of the scapular attachment of the anterior band of the inferior glenohumeral ligament (soft tissue Bankart injury), as well as an avulsed anterior labrum that remains attached to the glenoid (Perthes lesion). Injuries to the rotator cuff, especially the subscapularis tendon, may be seen in the setting of dislocation, but do not affect emergency management.43
Recurrence and Follow-up Care
One study estimates that 1-2% of people will have a shoulder dislocation, mostly from traumatic sources, in their lifetime. (See Table 1.) The rate of recurrence of shoulder dislocation is higher in those whose first dislocation occurred at a younger age.55
After reduction, the traditional method of treatment has been to keep the shoulder immobilized in a sling or brace for 2-3 weeks in internal rotation. There have been immobilization techniques that keep the arm in external rotation, based on MRI evidence for better coaptation of the humerus on the glenoid neck,50 but it was shown that external rotation did not lower the incidence of recurrence in a follow-up study.57
All shoulder dislocations without fracture would benefit from shoulder rehabilitation, including early range of motion, followed by rotator cuff muscle strengthening. However, if the dislocation is associated with a fracture, the patient should be referred to follow up with an orthopedist to determine the length of time to heal and whether it is a stable fracture. Surgical intervention is more effective than non-operative treatment for prevention of recurrent dislocations after a primary dislocation.58-61
For patients who have relapsing dislocations, a home relocation technique has been described by Boss-Holzach-Matter.8 With this maneuver, the patient sits on a hard surface, bends the knee on the ipsilateral side of the affected arm to 90 degrees, and interlocks the fingers of both hands behind the knee. The patient then shrugs his or her shoulders forward, mindful of relaxing the shoulders, while slowly leaning backward. This requires patience by the patient and careful technique. It is recommended that before prescribing it, the physician should monitor the patient performing this technique. As a rule, earlier surgical intervention may be favored in younger patients, those with a large glenoid defect, and highly active athletes who participate in sports that involve overhead throwing or contact.43
Authors’ Recommendations
With a multitude of techniques available, the physician must determine which technique fits the respective patient’s scenario the best. The authors suggest starting with the position in which the patient presents. In other words, if the patient presents with the arm adducted and internally rotated, then the patient is already in the starting position for the Cunningham or Kocher technique. Conversely, if the patient presents with the arm fully extended and slightly abducted, he or she is already in the starting position for the Milch technique, scapular manipulation, or one of the traction techniques.
As noted previously, up to 30% of dislocations involve a fracture,39,40 and other injuries to the soft tissue, nerves, and vessels have been described.46,48 To reduce the chances of causing or worsening a complication, the authors favor the less traumatic techniques — those using leverage and scapular manipulation — as first-line. These can be done with or without analgesia. Cunningham proposed a similar recommendation and went further by arguing that the use of techniques primarily relying on traction should no longer be used.11
There is no consensus as to whether immobilization is helpful or, if so, what the optimal duration of immobilization is. Immobilization has not been shown to affect the rate of recurrence, and is performed mainly for comfort.
Summary
A variety of techniques exist for the relocation of dislocated shoulders. Often, the patient will present in a manner that favors one method, but if the first attempt is unsuccessful, the physician may try a different technique and/or add a type of analgesia to improve the likelihood of success. Both pre- and post-reduction X-rays are recommended for most patients. All patients should follow up with qualified personnel for either range of motion and strengthening or further surgical evaluation.
References
- Kroner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg 1989;108(5):
288-290. - Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 1995;4(2):107-112.
- Simonet WT, Melton LJ 3rd, Cofield RH, et al. Incidence of anterior shoulder dislocation in Olmstead County, Minnesota. Clin Orthop Relat Res 1984;186:
186-191. - Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am 2010;92:542-549.
- Robinson CM, Seah M, Akhtar MA. The epidemiology, risk of recurrence, and functional outcome after an acute traumatic posterior dislocation of the shoulder. J Bone Joint Surg Am 2011;93:1605-1613.
- Rapariz JM, Martin-Martin S, Pareja-Bezares A, et al. Shoulder dislocation in patients older than 60 years of age. In J Shoulder Surg 2010;4(4):88-92.
- Milch H. The treatment of recent dislocations and fracture-dislocations of the shoulder. J Bone Joint Surg 1949;31A:173-180.
- Ceroni D, Sadri H, Leuenberger A. Radiographic evaluation of anterior dislocation of the shoulder. Acta Radiol 2000;41:658-661.
- Canales Cortes V, Garcia-Dihinx CL, Rogdriguez Vela J. Reduction of acute anterior dislocations of the shoulder without anesthesia in the position of maximum muscle relaxation. Int Orthop (SICOT) 1989;13:259-262.
- Daya M. Rosen’s Emergency Medicine, Concepts and Clinical Practice, 5th ed. St. Louis: Mosby; 2002.
- Cunningham N. Techniques for reduction of anteroinferior shoulder dislocation. Emergency Medicine Australasia 2005;17:463-471.
- McNamara R. Reduction of anterior shoulder dislocations by scapular manipulation. Ann Emerg Med 1993;22:
1140-1144. - Saha A. Mechanism of shoulder movements and a plea for the recognition of zero position’ of glenohumeral joint. Clin Orthop 1983;173:3-10.
- Kocher T. Eine neue Reductionsmethode fur Schulterverrenkung. Berliner Klin Wehnschr 1870;7:101-105.
- Thakur AJ, Narayan R. Painless reduction of shoulder dislocation by Kocher’s method. J Bone Joint Surg Br 1990;72B:524.
- Apley AG, et al. Apley’s System of Orthopaedics and Fractures, 7th ed. Oxford: Butterworth-Heinemann; 1993.
- Berkenblit SI, MacAusland WR Jr, Hand MB. Kocher’s technique without traction reduces dislocation. Academy News. American Academy of Orthopaedic Surgeons. March 18, 2000.
- Garnavos C. Technical note: modifications and improvements of the Milch technique for the reduction of anterior dislocation of the shoulder without premedication. J Trauma 1992;32:801-803.
- Janecki CJ, Shahcheragh GH. The forward elevation manuever for reduction of anterior dislocations of the shoulder. Clin Orthop Relat Res 1982;164:177-180.
- Miljesic S, et al. Reduction of anterior dislocation of the shoulder: The Spaso technique. Emerg Med 1998;10:173-175.
- Uglow M. Kocher’s painless reduction of anterior dislocation of the shoulder: A prospective randomised trial. Injury 1998;29:135-137.
- Russell JA, Holmes EM 3rd, Keller DJ, et al. Reduction of acute anterior shoulder dislocations using the Milch technique: A study of ski injuries. J Trauma 1981;21:802-804.
- Cunningham N. A new drug free technique for reducing anterior shoulder dislocations. Emerg Med 2003;15:521-524.
- Bosley RC, M. J. Scapula manipulation for reduction of anterior dislocations: A new procedure. American Academy of Orthopaedic Surgeons, 1979.
- Anderson D, Zvirbulis R, Ciullo J. Scapular manipulation for reduction of anterior shoulder dislocations. Clin Orthop Relat Res 1982;164:181-183.
- Doyle WL, Ragar T. Use of scapular manipulation method to reduce anterior shoulder dislocations in the supine position. Ann Emerg Med 1996;27:92-94.
- McRae R. Practical Fracture Treatment, 1st ed. Edinburgh: Churchill Livingstone; 1987.
- Watson-Jones R. Fractures and Joint Injuries, 6th ed. Edinburgh: Churchill Livingstone; 1982.
- Uehara DT. Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York: McGraw-Hill: 2000.
- Rowe C. Acute and recurrent anterior shoulder dislocations of the shoulder. Orthop Clin North Am 1980;11:253-270.
- Lippert F. A modification of the gravity method of reducing anterior shoulder dislocations. Clin Orthop 1982;165:
259-260. - Rollinson P. Reduction of shoulder dislocations by the hanging method. S Afr Med J 1988;73:106-107.
- Orlinsky M, Shon S, Chiang C, et al. Comparative study of intra-articular lidocaine and intravenous meperidine/diazepam for shoulder dislocations. J Emerg Med 2002;22:241-245.
- Westin CD, Gill EA, Noyes ME, et al. Anterior shoulder dislocation: A simple and rapid method for reduction. Am J Sports Med 1995;23:369-371.
- Manes H. A new method of shoulder reduction in the elderly. Clin Orthop 1980;147:200-202.
- Nordeen MH, Bacarese-Hamilton IH, Belham GJ, et al. Anterior dislocation of the shoulder: A simple method of reduction. Injury 1992;23:479-480.
- White A. Dislocated shoulder — a simple method of reduction. Med J Aust 1976;2:726-727.
- Kuah D. An alternative slump reduction technique of anterior shoulder dislocations: A 3 year prospective study. Clin Sport Med 2000;10:158-161.
- Nicholson DA, Lang I, Hughes P, et al. ABC of emergency radiology. The shoulder. BMJ 1993;307:1129-1134.
- Perron AD, Ingerski MS, Brady WJ, et al. Acute complications associated with shoulder dislocation at an academic emergency department. J Emerg Med 2003;24:141-145.
- Beeson M. Complications of shoulder dislocation. Am J Emerg Med 1999;17:
288-295. - Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am 1996;78:1677-1684.
- Gyftopoulos S, Bencardino J, Palmer WE. MR imaging of the shoulder: First dislocation versus chronic instability. Semin Musculoskelet Radiol 2012;16:286-295.
- Bankart A. The pathology and treatment of recurrent instability of the shoulder joint. Br J Surg 1938;26:23-29.
- Wen D. Current concepts in the treatment of anterior shoulder dislocations. Am J Emerg Med 1999;17:401-407.
- Weaver J. Skiing-related injuries to the shoulder. Clin Orthop 1987;216:24-28.
- Cleeman E, Flatow EL. Shoulder dislocations in the young patient. Orthop Clin North Am 2000;31:217-229.
- Stayner LR, Cummings J, Andersen J, et al. Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231-239.
- Kothari RU, Dronen SC. Prospective evaluation of the scapular manipulation technique in reducing anterior shoulder dislocations. Ann Emerg Med 1992;21:1349-1352.
- Lacey T 2nd, Crawford HB. Reduction of anterior dislocations of the shoulder by means of the Milch abduction technique. J Bone Joint Surg Am 1952;34A:108-109.
- Hames H, McLeod S, Millard W. Intra-articular lidocaine versus intravenous sedation for the reduction of anterior shoulder dislocations in the emergency department. CJEM 2011;13:378-383.
- Atoun E, Narvani A, Even T, et al. Management of first-time dislocations of the shoulder in patients older than 40 years: The prevalence of iatrogenic fracture. J Orthop Trauma 2013;4:190-193.
- Abassi S, Molaie H, Hafezimoghadam P, et al. Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department. Ann Emerg Med 2013;62(2):170-175.
- Yuen CK, Chung TS, Mok KJ, et al. Dynamic ultrasonographic sign for posterior shoulder dislocation. Emerg Radiol 2011;18:47-51.
- Rowe CR. Prognosis in dislocation of the shoulder. J Bone Joint Surg Am 1958;38A:957-977.
- Itoi E, Hatakeyama Y, Kido T, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder: A preliminary study. J Shoulder Elbow Surg 2003;12:413-415.
- Liavaag S, Brox JI, Pripp H, et al. Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence. J Bone Joint Surg Am 2011;93:897-904.
- Godin J, Sekiya JK. Systematic review of rehabilitation versus operative stabilization for the treatment of first-time anterior shoulder dislocations. Sports Health 2010;2:156-165.
- Bottoni CR, Wilckens JH, DeBerardino TM, et al. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations. Am J Sports Med 2002;30(4):576-580.
- Burkhead WB Jr, Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1992;74(6):890-896.
- Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: Pathophysiology, diagnosis, and management. J Am Acad Orthop Surg 1998;6(1):65-72.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.