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Dislocated Shoulder: Anatomy, Reduction, Immobilization, and Rehabilitation

Anatomy and Mechanism

The glenohumeral joint is a ball-and-socket with high mobility but low bony stability. Anterior dislocation (95%) occurs when the humeral head is forced out of the glenoid, usually by abduction + external rotation + axial load (fall on outstretched hand, throwing, tackle).

Clinical Presentation

  • Severe pain, arm held in slight abduction/external rotation
  • Loss of normal deltoid contour ("squared-off" shoulder)
  • Palpable humeral head anteriorly (subcoracoid or subglenoid)
  • Neurovascular exam critical: axillary nerve (deltoid sensation), brachial plexus, distal pulses.

Imaging

  • AP, scapular Y, axillary views (or trauma series) pre-reduction to confirm direction and exclude fracture.
  • Post-reduction films confirm reduction and detect new fractures (Hill-Sachs, Bankart, greater tuberosity).

Reduction Techniques (Closed)

  • Stimson (gravity-assisted): prone, affected arm hanging, 5–10 lb weight; gentle, minimal sedation.
  • Traction-countertraction: supine, axial traction + lateral traction on forearm.
  • Milch: abduction + external rotation + gentle traction.
  • FARES: fast, reliable, safe—oscillating abduction with axial traction.
  • Kocher / Hippocratic: historical; higher complication risk (fracture, neurovascular).

Procedural sedation (ketamine, propofol, etomidate) or intra-articular lidocaine facilitates reduction.

Post-Reduction Management

  • Immobilization: Sling + swathe (internal rotation) 1–3 weeks. External rotation bracing (e.g., Gunslinger) may reduce recurrence in young athletes but compliance challenging.
  • Early motion: Pendulum exercises at 1–2 weeks; avoid abduction/external rotation >30° for 4–6 weeks.
  • Physical therapy: phased—ROM → rotator cuff/scapular strengthening → proprioception → sport-specific.

Recurrence Risk

  • Age <20: 70–90%
  • Age 20–30: 50–70%
  • Age >40: <20% (but higher rotator cuff tear risk)
  • Contact athletes, bony defects (Bankart, Hill-Sachs >20%), ligamentous laxity → higher recurrence.

Surgical Indications

  • Recurrent instability (≥2 dislocations or subluxations)
  • First-time in young contact athlete / high-demand occupation
  • Significant bony defect (engaging Hill-Sachs, glenoid bone loss >15–20%)
  • Associated injuries requiring repair (rotator cuff tear >40 yo, vascular injury)

Arthroscopic Bankart repair ± remplissage, Latarjet for bone loss.

Key Takeaways

  1. Reduce promptly—delay increases muscle spasm and difficulty.
  2. Neurovascular check before and after.
  3. Immobilize briefly; early protected motion prevents stiffness.
  4. Recurrence driven by age, activity, structural damage.
  5. Surgical stabilization individualized to risk profile.

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