Sideline Management of Shoulder Dislocation

Introduction

The most common large joint dislocation is the glenohumeral joint (5). The shallow articular surface of the glenoid puts the glenohumeral joint at high risk for dislocation (1). The glenoid labrum aids in deepening the glenoid surface to help stabilize the shoulder (1). The shoulder also relies on the glenohumeral capsular ligaments and rotator cuff to stabilize the shoulder (4). Over 95% of glenohumeral dislocations occur in an anterior and inferior direction (1). These injuries occur when the shoulder is abducted and externally rotated (1).

Case Vignette

You are evaluating an athlete on the sideline with a suspected shoulder dislocation. He reports some tingling in his arm. Which of the following nerves need to be assessed after an anterior shoulder dislocation?

A) Axillary nerve

B) Radial nerve

C) Median nerve

D) Ulnar nerve

Diagnosis

When an athlete has a suspected shoulder dislocation, they will typically be holding the arm in a cradle-like position (1). The shoulder will also lose its normal rounded position (4). If the diagnosis is not clear, ask the patient to reach across and grab the opposite shoulder and if they cannot do it, then the shoulder is likely dislocated (4). Once a dislocation is suspected, the provider must assess for axillary nerve injury. The axillary nerve can be assessed by lightly touching the lateral upper arm and assessing for deltoid contraction (1). In a study looking at shoulder dislocations in skiers, sensory abnormalities due to axillary nerve injury were found in 17% of patients (2).

Axillary nerve innervation

Image 1. Sensory innervation of the axillary nerve (6).

Treatment

Once the diagnosis of anterior glenohumeral dislocation is suspected, reduction should occur before muscle spasm occurs (1). There are multiple different ways to reduce a shoulder joint, which we will discuss below. In this review, we are highlighting some of the most common techniques. Success of the traction-countertraction technique has been found to be 84% (6). Risk factors for a failed reduction include age over 55 years old, greater tuberosity fracture, and glenoid rim fracture (6).

Countertraction technique: Using a towel or one hand to provide countertraction, the provider creates traction and gradual abduction until the shoulder reduces (1).

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Countertraction technique

Image 2. Countertraction technique for shoulder dislocation (1).

FARES method: Grasp the wrist with the patient’s elbow extended and slowly abduct the shoulder with longitudinal traction. Then, apply continuous vertical oscillations for 2-3 seconds while continuing shoulder abduction. Once the shoulder reaches 90 degrees, slowly externally rotate the arm continuing with abduction, traction, and oscillations (3).

FARES method

Image 3. FARES method of shoulder reduction (3).

Chair method: Have the athlete sit in a chair sideways with their arm hanging over the back of the chair. The affected arm is grabbed at the wrist and the forearm is supinated while traction is applied. The patient is asked to stand up and reduction may occur (4).

 

Chair method

Image 4. Demonstration of the chair method (4)

Spaso method: The patient is supine and the wrist is grasped and traction is applied while the shoulder is flexed. The shoulder is then externally rotated and reduction may occur (4). It is important to maintain contact between the scapula and the table during reduction (5).

Spaso method reduction

Image 5. Spaso method reduction (4)

Milch method: The arm is grabbed at the forearm with the thumb against the humeral head. The arm is abducted while the provider’s thumb stabilizes the humeral head to prevent downward rotation. Once the arm is abducted, the provider applies traction with the thumb to reduce the humeral head (4).

Milch method of reduction

Image 6. Milch method of reduction (4)

Postreduction assessment of the axillary nerve should again be performed (1). If neurologically intact, the patient should be placed in a sling and will then need follow up radiographs (1). General guidelines include two reduction attempts and if unsuccessful, sending the patient to the ER (4).

Conclusion

The glenohumeral joint is commonly dislocated and typically seen following forceful abduction and external rotation of the shoulder. Neurologic assessment should be performed on the sideline and if the patient is neurovascularly intact with suspected dislocation, a reduction should be attempted. There are many different ways to reduce the shoulder and providers need to become familiar with one or two methods.

By Gregory Rubin, DO

rubinsportsmed.com

Case Conclusion

Correct Answer: Axillary nerve. The axillary nerve is most frequently affected after an anterior glenohumeral dislocation. The innervation of the nerve must be evaluated over the lateral portion of the deltoid.
Dala-Ali, Benan, et al. “Management of Acute Anterior Shoulder Dislocation.” British Journal of Sports Medicine, vol. 48, no. 16, Aug. 2014, pp. 1209–15. PubMed, doi:10.1136/bjsports-2012-091300.
– More Shoulder Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/shoulder/

– Read More @ Wiki Sports Medicine: https://wikism.org/Glenohumeral_Dislocation

References

  1. Skelley, Nathan W., et al. “In-Game Management of Common Joint Dislocations.” Sports Health, vol. 6, no. 3, May 2014, pp. 246–55. PubMed, doi:10.1177/1941738113499721.
  2. Westin, C. D., et al. “Anterior Shoulder Dislocation. A Simple and Rapid Method for Reduction.” The American Journal of Sports Medicine, vol. 23, no. 3, June 1995, pp. 369–71. PubMed, doi:10.1177/036354659502300322.
  3. McClelland, JoAnna M., and Kevin R. Vincent. “Clinical Pearl Procedure: Reducing an Anterior Shoulder Dislocation on the Sideline.” Current Sports Medicine Reports, vol. 15, no. 5, Oct. 2016, pp. 311–12. PubMed, doi:10.1249/JSR.0000000000000289.
  4. Schupp, Christian M., et al. “Sideline Management of Joint Dislocations.” Current Sports Medicine Reports, vol. 15, no. 3, June 2016, pp. 140–53. PubMed, doi:10.1249/JSR.0000000000000266.
  5. Youm, Thomas, et al. “Acute Management of Shoulder Dislocations.” The Journal of the American Academy of Orthopaedic Surgeons, vol. 22, no. 12, Dec. 2014, pp. 761–71. PubMed, doi:10.5435/JAAOS-22-12-761.
  6. Dala-Ali, Benan, et al. “Management of Acute Anterior Shoulder Dislocation.” British Journal of Sports Medicine, vol. 48, no. 16, Aug. 2014, pp. 1209–15. PubMed, doi:10.1136/bjsports-2012-091300.
  7. Furuhata, Ryogo, et al. “Risk Factors for Failure of Reduction of Anterior Glenohumeral Dislocation without Sedation.” Journal of Shoulder and Elbow Surgery, vol. 30, no. 2, Feb. 2021, pp. 306–11. PubMed, doi:10.1016/j.jse.2020.06.005.