Shoulder Dislocations - Orthopedic Radiologic Imaging

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Shoulder Dislocations and is brought to you by Carrie Bissell, MD, Aaron Fox, MD, Kendrick Lim, MD, Angela Pikus, MD, and Courtney Owens, MD. It is has special guest editor: Laurence Kempton, MD

1. Shoulder Dislocations
Carrie Bissell, MD
1
, Aaron Fox, MD
1
, Kendrick Lim, DO
1
,
Courtney Owens, MD
1
& Angela Pikus, MD
1
Departments of Emergency Medicine
1
& Orthopedic Surgery
2
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD
1
and Laurence Kempton, MD
2
-Editors
Adult Orthopedic Imaging Mastery Project
Presentation #4

2. Disclosures
•This ongoing imaging interpretation series is proudly sponsored by the
Emergency Medicine andOrthopaedicSurgery Residency Programs at
Carolinas Medical Center.
•The goal is to promote diagnostic imaging interpretation mastery.
•There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

4. It’s All About The Anatomy!

5. Classification
95% 2-4% <1%

6. Journal Of Bone & Joint Surgery 2010;92:542-549.
National Electronic Injury
Surveillance System
Review of all patients presenting
to U.S. Emergency Departments
with shoulder dislocation between
2002 and 2006.
(n=8940).

7. Journal Of Bone & Joint Surgery 2010;92:542-549.
Bimodal distribution with peaks among malesbetween the ages of twenty and twenty-
nine years and among femalesbetween the ages of eighty and eighty-nine years.

8. Associated Injuries
A number of associated injuries may accompany shoulder dislocations:
Bony Injuries
•Hill Sachs Lesion
•Bankart Lesion
•Greater Tuberosity Avulsion Fracture
•Lesser Tuberosity Avulsion Fracture
•Humeral Head Fractures
Vascular Injuries
Neurologic Injuries

9. Objectives:
To identify the type and frequency of associated injuries in a group of Emergency Department patients
with shoulder dislocations.
Methods:
Retrospective, single-center review from 1995-2000, examining 190 cases.
Results:
•The mean age of the cohort was 34.3 years.
•Fifty-five patients (29%) had at least one fractureof which 76% were of the Hill-Sachs type.
•Sensory nerve deficits were would in 24 (12.6%) of patients, which persisted after reduction in 25%.
•No vascular injuries were identified in this patient cohort.
Acute Complications Associated With Shoulder Dislocations
At An Academic Emergency Department
The Journal of Emergency Medicine 2003; 74(2):141-146..

10. Hill-Sachs Lesions
•A Hill-Sachs (HS) lesion is an impaction fracture of the posterior-
superior humeral head following anterior shoulder dislocation.
•The lesion results when the dislocated humerus head collides with
the edge of the glenoid rim.
•Seizures and previous dislocation are risk factors for a HS lesion.
•Classic radiographic findings are a focal wedge-shaped concavity or
a vertical line in the posterior-superior humeral head.
•Treatment of HS deformities is based on the percentage of humeral
head articular surface involved in the lesion.

11. Hill Sachs Lesion

12. Hill Sachs Lesion

13. Hill Sachs Lesion

17. Reverse Hill Sachs Lesions
Reverse Hill Sachs Lesions Are Impaction Fractures Of The Antero-Medial
Humeral Head That Occur Following A Posterior Should Dislocation.

18. Bankart Lesion
•Bankart lesions may involve a labral tear, a fracture, or both.
•Bony Bankart lesions are fractures of the anteroinferior glenoid rim
and occur in up to 22% of first-time anterior shoulder dislocations.
•Young male athletes playing contact sports are at highest risk.
•Early management is crucial because, if left untreated, recurrent
anterior shoulder instability and glenoid bone loss can occur.
•Both nonsurgical and surgical treatment options are available
depending on the size of the lesion, with arthroscopic repair being
the most common treatment method.

19. Bankart Labral Tear Bony Bankart Lesion

20. Bony Bankart Lesions

22. Greater Tuberosity Avulsion Fractures
Occur Following Anterior Shoulder
Dislocations.

23. Lesser Tuberosity Avulsion Fractures
Occur Following Posterior Shoulder
Dislocations.

24. Objectives:
To assess the prevalence of major nerve injury following shoulder dislocation and examine risks.
Methods:
A 1-year retrospective cohort study of 243 consecutive adults with shoulder dislocation.
Results:
•Of 243 patients, 14 (6%) had a neurological deficit.
•Older age (p=0.02) was significantly associated with neurological injury.
•Sex, time to reduction and force of injury were not associated nerve injury in cohort.
•Patients with neurological injury had functional recovery to varying degrees.
Prevalence And Risk Factors For Nerve Injury Following
Shoulder Dislocation
Musculoskeletal Surgery 2023;107:345-350.

25. Objectives:
To evaluate the prevalence of neurological deficits, greater tuberosity fractures, and rotator cuff injuries
in a population of patients with anterior glenohumeral dislocation.
Methods:
Prospective database review of 3633 consecutive patients: mean age 47.6 years; 62% were male.
Injuries Associated With Traumatic
Anterior Glenohumeral Dislocations
Journal Of Bone & Joint Surgery 2012;94:18-26.
Isolated Neurological Deficit 5.8%
Rotator Cuff Or Greater Tuberosity Fracture25.7%
Combined Injuries (Neurologic + Orthopedic)7.8%
All Injuries Were More Common In Patients ≥60 years old.

26. A Strategy For Plain Film Imaging
See Appendix 1 For More Information

27. Plain Film Imaging
•Pre-and post-reduction imaging is the standard for most ED patients
•Several studies have sought to identify low-risk features in patients for
whom pre-reduction imaging can be safely deferred
•In the ED population with shoulder dislocation, post-reduction imaging
will identify associated injuries in up to one third of patients

28. Plain Film Imaging
The Fresno-Quebec Rule
1
accurately identifies a low-risk population in
whom the likelihood of associated fracture is remote and therefore pre-
reduction imaging can be safely deferred. It requires that all threeof the
following be present:
1.Age ≤35 years
2.A history of prior dislocation
3.Absence of significant trauma
2
1
See Appendix 1
2
Fall from a height, fall with direct impact, motor vehicle crash, seizure, electrocution

29. Plain Film Imaging
Consider this approach in the low-risk patient:
Fresno-Quebec Rule Criteria Met
Confirm Clinical Suspicion With Bedside Ultrasound
Perform Closed Reduction
Obtain Post-Reduction X-Rays

30. Plain Film Imaging
•The goals of plain film imaging are to: (1) diagnose the dislocation
type, and (2) identify associated bony injuries
•Different projections include:
•Anteroposterior (AP)
•Oblique
•Scapular Y
•Axillary
•Valpeau
Views From At Least
Two Different
Projections Increase
Diagnostic Accuracy

31. Plain Film Imaging
•The anteroposterior (AP) view alone will miss up to 50% of dislocations
•Supplementing the AP view with the scapular Y view, axillary view,or
both increases the accuracy of correctly identifying malposition of the
humeral head with respect to the glenoid fossa
•The oblique (Grasley) view and Valpeauview provide additional
definition of shoulder bony architecture, that helps diagnose associated
injuries

32. Anteroposterior

33. Oblique (Grasley)

34. Scapular Y

35. Axillary Upright

36. Axillary Supine

37. Valpeau

38. A Strategy For Plain Film Imaging
See Appendix 1 For More Information

39. Use Of Point Of Care Ultrasound
See Appendix 2 For More Information

40. POCUS To Assess For Shoulder Dislocation
Several studies have evaluated the use of POCUS in ED patients with
suspected shoulder dislocations and:
•The posterior approach is the most sensitive
•POCUS helps identify dislocations as well as successful reductions
•Sensitivities and specificities approach 100%
•The “time to an answer” is significantly less with POCUS than with
traditional plain film radiographs

41. Posterior Approach
•Stand behind the patient
•Support the elbow inferiorly and
adduct the shoulder
•Orient the curvilinear probe in a
transverse plane and identify the
scapula
•Move the probe laterally until you
find the glenoid and the humeral
head
•Assess for widening and/or
displacement between the glenoid
and the humeral head

42. Normal Left Shoulder
1
1
First scan the unaffected then the affected shoulder

43. Scapula
Normal Left Shoulder

44. Scapula
Humeral
Head
Normal Left Shoulder

45. Scapula
Humeral
Head
Deltoid
Normal Left Shoulder

46. Scapula
Humeral
Head
Deltoid
Infraspinatus
Normal Left Shoulder

47. Scapula
Humeral
Head
Glenoid Fossa
Deltoid
Infraspinatus
Normal Left Shoulder

48. Case #1: 21-Year-Old With A History Of Recurrent Right Shoulder Dislocations
Presents With Shoulder Pain After Reaching For an Object And Feeling A “Pop.”
Pre-Reduction Anterior Dislocation

49. Case #1: 21-Year-Old With A History Of Recurrent Right Shoulder Dislocations
Presents With Shoulder Pain After Reaching For an Object And Feeling A “Pop.”
Pre-Reduction Anterior Dislocation→= Humeral Head →= Glenoid

50. Case #1: 21-Year-Old With A History Of Recurrent Right Shoulder Dislocations
Presents With Shoulder Pain After Reaching For an Object And Feeling A “Pop.”
Post-Reduction →= Humeral Head →= Glenoid

51. Case #2: A 26-Year-Old With A History Of Recurrent Shoulder Dislocations
Presents With A Suspected Dislocation After Rolling Over In Bed.
Pre-Reduction Anterior Dislocation

52. Case #2: A 26-Year-Old With A History Of Recurrent Shoulder Dislocations
Presents With A Suspected Dislocation After Rolling Over In Bed.
Pre-Reduction Anterior Dislocation
→= Humeral Head →= Glenoid

53. Case #2: A 26-Year-Old With A History Of Recurrent Shoulder Dislocations
Presents With A Suspected Dislocation After Rolling Over In Bed.
Post-Reduction
→= Humeral Head →= Glenoid

54. Shoulder Dislocation
Cases From CMC

56. Anterior Shoulder Dislocation
Emergency Department Essentials
Mechanism of Injury•Forced abduction and external rotation
Physical Examination•Arm abducted and externally rotated, loss of deltoid contour
•The humeral head may be palpable anteriorly
ED Imaging •Antero-posterior (AP), axillary, scapular Y
•Consider point of care ultrasound
Associated Injuries•Hill-Sachs lesion, Bankart lesion, greater tuberosity avulsion fracture,
rotator cuff tears, neurovascular injuries are rare
ED Management,
Consultation, And
Splinting Techniques
•ALWAYS perform a neurovascular exam before & after reduction
•Closed reduction and immobilization (numerous techniques)
•Orthopedic Surgery consultation for patients with associated injuries
or failed closed reduction
Follow-Up •Primary Care for first-time dislocations without associated injury
•Orthopedic Surgery for repeat dislocations for physical therapy

57. With Anterior Dislocations, The Humerus Shifts Antero-Medially, Resulting
In A Loss Of Normal Contour With “Squaring” Of the Shoulder.

58. Anterior Dislocation
31-Year-Old Fell On His Left Shoulder While Chasing His Dog
Case #1

59. Post-Reduction
31-Year-Old Fell On His Left Shoulder While Chasing His Dog
Case #1

60. 29-Year-Old Dislocated His Shoulder After He Rolled Over In Bed
Anterior Dislocation
Case #2

61. Post-Reduction
29-Year-Old Dislocated His Shoulder After He Rolled Over In Bed
Case #2

62. Anterior
Dislocation
19-Year-Old Dislocated His Shoulder Wrestling With A Friend
Case #3

63. Post-Reduction
19-Year-Old Dislocated His Shoulder Wrestling With A Friend
Case #3

64. 34-Year-Old Inmate Assaulted In Jail
Anterior Dislocation
Case #4

65. 34-Year-Old Inmate Assaulted In Jail
Post-Reduction, Note Hill Sachs Lesion (→)
Case #4

66. 34-Year-Old Inmate Assaulted In Jail
Hill Sachs Lesion & Greater Tuberosity Impaction Fracture (→)
Case #4

67. 34-Year-Old Inmate Assaulted In Jail
1-Month Follow-Up
Case #4

68. 34-Year-Old Inmate Assaulted In Jail
Case #4
6-Month Follow-Up

69. 25-Year-Old Assault Victim
Anterior Dislocation
Case #5

70. Post-Reduction
25-Year-Old Assault Victim
Case #5

71. Shoulder Dislocations In The Emergency Department:
A Comprehensive Review Of Reduction Techniques
The Journal of Emergency Medicine 2019;58(4):647-666.
This article reviews 26 total reduction techniques, as well as a variety of
modifications to these techniques. Each technique has distinct advantages and
limitations associated with its use. While there are limited data comparing specific
techniques, the individual success rates of most maneuvers range from 60% to 100%.
It is important for emergency physicians to be familiar with several different
reduction techniques in case the initial reduction attempt is unsuccessful or if
patient-specific characteristics limit the ability to perform certain techniques.

72. Anterior Dislocation Reduction Techniques

73. Axial Traction With Acromial Fixation
1.Position patient seated and supine,
2.With one hand, stabilize the
acromion process,
3.With the other hand, hold the
forearm or elbow and apply axial
traction to the patient's arm.
The Journal of Emergency Medicine 2019;58(4):647-666.

74. Bokor-BillmannTechnique
1.Position patient upright with back
against a firm surface,
2.Hold the patient's wrist with one
hand and elbow with the other,
3.Flex the humerus and elbow to 90
degrees,
4.Adduct the elbow to the midline,
5.Internally rotate the elbow, expect
reduction around 23-30 degrees of
rotation.
The Journal of Emergency Medicine 2019;58(4):647-666.

75. Chair Method
1.Position patient in chair, rotated so
the affected axilla is over the back of
the chair,
2.Apply gentle downward traction to
the elbow or forearm,
3.If unsuccessful, try external rotation
of the shoulder.
The Journal of Emergency Medicine 2019;58(4):647-666.

76. The Journal of Emergency Medicine 2019;58(4):647-666.
Cunningham Technique
1.Position the patient upright against a
hard surface,
2.Sit next to the patient and place the
hand of the affected arm on your
shoulder,
3.Place one hand on the patient’s
shoulder and the other on the
forearm,
4.Apply downward traction and move
the humerus into adduction,
5.Massage the trapezius, deltoids and
biceps,
6.Ask the patient to shrug shoulders.

77. Davos/AronenTechnique
1.Position the patient upright with the
ipsilateral knee in flexion,
2.Provider positions both hands
clasped or secured together in front
of flexed knee,
3.Instruction the patient to lean head
back, shrug shoulders, and attempt
to lie back in bed.
The Journal of Emergency Medicine 2019;58(4):647-666.

78. The Journal of Emergency Medicine 2019;58(4):647-666.
Elbow Technique
1.Place the patient supine,
2.With your outer arm, grasp the wrist
of the affected side,
3.Apply longitudinal traction,
4.Lift the arm to 45 degrees of forward
flexion and 45 degrees of abduction,
5.With inner arm, place your elbow on
the patient’s mid humerus,
6.Use your elbow to apply force in the
posterior and superior direction.

79. Eskimo Technique
1.Position the patient on the ground
with affected shoulder toward the
ceiling,
2.Lift the affected arm directly upward,
keeping the contralateral shoulder on
the ground,
3.Consider gentle pressure on the
affected humeral head.
The Journal of Emergency Medicine 2019;58(4):647-666.

80. External Rotation (Hennepin) Maneuver
1.Hold the affected upper arm
adducted against the patient's side,
2.Hold the patient’s wrist, keeping the
elbow flexed 90°,
3.Slowly rotate the arm externally.
Reduction commonly occurs at 70 to
110°of external rotation and may
take up to 5 or 10 minutes,
4.If reduction is not achieved, maintain
the arm’s position and apply slow,
gentle traction at the elbow while
pushing the humeral head upward
into the glenoid using your thumb in
the axilla.
The Journal of Emergency Medicine 2019;58(4):647-666.

81. FARES Method
1.Grasp the wrist of the affected arm
and pull the arm to provide gentle
axial traction,
2.Begin smoothly and cyclically (about
2 cycles per second) moving the arm
up and down, about 5 cm above and
below the horizontal plane,
3.Gradually abduct the arm,
4.At 90°of abduction, if the joint has
not reduced, add gentle external
rotation and continue abducting,
5.Reduction is expected to occur by
120°.
The Journal of Emergency Medicine 2019;58(4):647-666.

82. GONAIS Method
G: Grasp a waist-high object
O: Opposite arm assists
N: Non-sedated
A: Auto-traction
I: Immobilize the grasped object
S: Squatting and stooping
The Journal of Emergency Medicine 2019;58(4):647-666.

83. Hippocratic Method
1.Begin with the patient supine, and
grasps the affected side at the hand
and forearm,
2.Place your heel in the axilla but do
not press down
3.Apply gentle traction and abduct the
arm slowly to reduce.
Axillary nerve injury a potential
complication.
The Journal of Emergency Medicine 2019;58(4):647-666.

84. Janecki’sForward Elevation Method
1.Place the patient supine
2.Grasp the wrist of the affected arm,
3.Elevate arm in forward flexion to
approximately 90 degrees,
4.Abduct the arm until shoulder is
reduced.
The Journal of Emergency Medicine 2019;58(4):647-666.

85. Kocher Technique
1.Position patient supine or upright
with arm adducted,
2.Use one arm to externally rotate the
forearm until you meet resistance,
3.Continue adduction and elevation in
forward flexion.
The Journal of Emergency Medicine 2019;58(4):647-666.

86. Legg Reduction Maneuver
1.Position patient upright in a straight
back chair,
2.Have an assistant apply downward
pressure on contralateral shoulder,
3.Assist with adduction of affected
shoulder to 90 degrees with elbow
extended,
4.Externally rotate the affected arm so
the palm is facing upward,
5.Adduct at the shoulder and flex the
elbow to the patients trunk,
6.Internally rotate the affected arm
across the chest.
The Journal of Emergency Medicine 2019;58(4):647-666.

87. Milch Technique
1.Patient lies in supine, with the
arm allowed to hang freely,
2.Place your hand on the
patient's shoulder, with your
thumb braced against the
dislocated humeral head,
3.With your far hand, gently
abduct the arm,
4.Push the humeral head back
into place, over the rim of the
glenoid, while abducting and
externally rotating the arm.
The Journal of Emergency Medicine 2019;58(4):647-666.

88. Nicola Method
1.The clinician stands behind the
seated patient,
2.Place a closed fist inside the axilla,
3.Rest the patient’s forearm on their
ipsilateral thigh and apply gentle
downward traction at the elbow,
4.Pulled the elbow medially, using the
axillary hand as a fulcrum.
The Journal of Emergency Medicine 2019;58(4):647-666.

89. Scapular Manipulation
1.With the patient prone, allow the
affected arm to hang over the side
of the stretcher,
2.Apply downward traction,
3.Use the fingers of one hand to
stabilize the superior aspect (base)
of the scapula while using both of
your thumbs to gently and gradually
apply a medial and dorsal force to
the inferior tip of the scapula,
4.Reduction may be subtle or even go
unnoticed.
The Journal of Emergency Medicine 2019;58(4):647-666.

90. SpasoMethod
1.Lay the patient supine,
2.Grasp the wrist or distal forearm and
gently apply vertical traction,
3.Slowly externally rotate the
shoulder,
4.If needed, gentle pressure can be
applied to the humerus to facilitate
reduction,
5.It is important to avoid excessive
force.
The Journal of Emergency Medicine 2019;58(4):647-666.

91. Stimson Technique
1.With the patient prone, hang
weights from the wrist
2.After 10 to 20 minutes, the muscle
spasm will usually relax enough to
allow the humeral head to reduce.
3.If reduction does not occur,
manually add downward traction or
apply gentle external rotation to the
upper arm,
4.Scapular manipulation can further
facilitate reduction.
The Journal of Emergency Medicine 2019;58(4):647-666.

92. Traction/Countertraction
1.Wrap a sheet around the patient’s
upper torso, passing the sheet under
the axilla of the dislocated shoulder,
2.Abduct the affected arm 90 degrees,
3.Apply longitudinal traction along the
affected arm while countertraction
is applied with the sheet,
4.Gradually increase pressure until the
shoulder is reduced,
5.Gentle, internal and external
rotation can further facilitate
reduction,
The Journal of Emergency Medicine 2019;58(4):647-666.

93. Double-Traction Method
1.Wrap a sheet around the patient’s
torso, passing the sheet under the
axilla of the dislocated shoulder.
2.Wrap another sheet around the
humerus.
3.Abduct the affected arm
approximately 30 to 45 degrees.
4.Apply longitudinal traction along the
affected arm while superolateral
traction is applied to the humerus
and countertraction is applied to the
torso, with gentle rotation.
The Journal of Emergency Medicine 2019;58(4):647-666.

94. Zahiri Technique
1.Position the patient supine.
2.Standing on the affected side, grasp
the patient’s wrist and place the
other forearm near the other elbow,
3.Flex the elbow to 90 -120 degrees,
4.Create an “arm lock” by grabbing
the forearm that is holding the
patient’s wrist,
5.Slowly flex the patient’s shoulder to
90 degrees,
6.Perform external and internal
rotation.
The Journal of Emergency Medicine 2019;58(4):647-666.

96. Posterior Shoulder Dislocation
Emergency Department Essentials
Mechanism of Injury•Posterior force with the arm in flexion and adduction.
Physical Examination•Less obvious than anterior dislocations on inspection
•Prominence of posterior the shoulder and coracoid process
•Inability to externally rotate the arm
ED Imaging •Antero-posterior (AP), axillary, scapular Y
•Consider point of care ultrasound
Associated Injuries•Reverse Hill-Sachs lesion, Reverse Bankart lesion, lesser tuberosity
avulsion fracture, rotator cuff tears, neurovascular injuries are rare
ED Management,
Consultation, And
Splinting Techniques
•ALWAYS perform a neurovascular exam before & after reduction
•Closed reduction and immobilization (numerous techniques)
•Orthopedic Surgery consultation for patients with associated injuries
or failed closed reduction
Follow-Up •Orthopedic Surgery follow-up recommended

97. With Posterior Dislocation Movement Of The Humeral Head Is Less
Pronounced And Changes In Shoulder Contour Are More Subtle, Or Absent.

98. Light Bulb
Sign
Vacant Glenoid
Sign
Posterior Dislocation
Normal Appearance Of The Humeral
Head With An Elliptical Overlap Of
The Humerus And The Glenoid Fossa
Normal Shoulder
With Posterior Dislocation The Humeral Head Rotates Internally Creating A
Lightbulb Appearance Along With Loss Of The Normal Overlap With The Glenoid

99. 24-Year-Old Presents After A Seizure
Posterior Dislocation
Case #6

100. 24-Year-Old Presents After A Seizure
Post-Reduction
Case #6

101. The Same Patient Returns A 2
nd
Time After Another Seizure
Posterior Dislocation
Case #7

102. The Same Patient Returns A 2
nd
Time After Another Seizure
Case #7
Post-Reduction, Note Hill Sachs Lesion (→)

103. Posterior DislocationNormal Shoulder
Compare The Normal Appearance Of The Humeral Head On Left With The
”Lightbulb” Appearance Of The Dislocated Humeral Head On The Right.

104. Compare The Normal Elliptical Overlap Of The Humeral Head And The
Glenoid On The Left With the “Vacant Glenoid Sign” On The Right.
Posterior DislocationNormal Shoulder

105. 28-Year-Old Hit By A Car
Case #8
Posterior Dislocation, Note Hill Sachs Lesion (→)

106. Post-Reduction
28-Year-Old Hit By A Car
Case #8

107. 28-Year-Old Hit By A Car
Case #8
Post-Reduction, Note Hill Sachs Lesion (→)

108. Posterior Dislocation Reduction Techniques

109. Wilson Technique
1.Patient begins in seated position,
2.The first clinician adducts and
internally rotates the affected arm,
reaching for contralateral shoulder,
3.Apply downward traction along the
direction of the humerus,
4.The second clinician applies anterior
pressure to the posterior aspect of
the humeral head.
The Journal of Emergency Medicine 2019;58(4):647-666.

110. DePalma “Lever” Method
1.Perform in supine or seated
position,
2.Adduct and internally rotate arm,
3.Apply medial and downward
traction to distal forearm and lateral
force to distal humerus.
The Journal of Emergency Medicine 2019;58(4):647-666.

111. Godry’sModified Lever Method
1.Similar initial position to DePalma
Lever Method
2.Place forearm between humerus
and chest wall,
3.Apply longitudinal traction inferiorly.
4.Hyper-adduct the humerus with
forearm.
The Journal of Emergency Medicine 2019;58(4):647-666.

112. Caudal Traction
Apply isolated, downward traction to
the adducted extremity.
The Journal of Emergency Medicine 2019;58(4):647-666.

114. Inferior Shoulder Dislocation
Emergency Department Essentials
Mechanism of Injury•High-energy hyperabduction of the arm causing inferior
displacement of the humeral head.
Physical Examination•Abducted arm that is stuck in the overhead position, pain.
ED Imaging •Antero-posterior (AP), axillary, scapular Y
•Consider point of care ultrasound
Associated Injuries•Rotator cuff tears (up to 80 % of patients).
•Axillarynervepalsy/damage (up to 50-60% of patients).
•Axillaryarteryinjuries (3% of patients).
ED Management,
Consultation, And
Splinting Techniques
•ALWAYS perform a neurovascular exam before & after reduction
•Orthopedic Surgery consultation in the ED
•Closed reduction for challenging and typically required procedural
sedation
Follow-Up •Orthopedic Surgery follow-up recommended

115. With Inferior Dislocation The Ipsilateral Upper Arm Is Held In Marked
Abduction, With The Forearm Typically Held Above The Head.

116. Inferior Dislocation
49-Year Old Had His Arm Pulled Out During An Altercation
Case #9

117. Post-Reduction
49-Year Old Had His Arm Pulled Out During An Altercation
Case #9

118. 29-Year Old Grabs The Railing To Avoid Falling Down The Stairs
Inferior Dislocation
Case #10

119. Post-Reduction
29-Year Old Grabs The Railing To Avoid Falling Down The Stairs
Case #10

120. Inferior Dislocation Reduction Techniques

121. Traction/Countertraction
1.Lay patient supine,
2.One clinician applies longitudinal
traction on the humerus,
3.A second clinician will apply
countertraction using a cloth
wrapped around the mid-clavicle
4.Gently abduct the arm until it
reduces.
The Journal of Emergency Medicine 2019;58(4):647-666.

122. Two-Step Maneuver
1.Lay patient supine,
2.Convert the inferior dislocation to an
anterior dislocation by superiorly
rotating the extremity,
3.Reduce the shoulder using any of
the previous techniques.
The Journal of Emergency Medicine 2019;58(4):647-666.

123. A Strategy For Plain Film Imaging
Appendix 1

124. Orthopedics 1990;13(1):63-69.
Objectives:
To compare the axillary and scapular Y views in patients with suspected shoulder dislocation.
Methods:
Prospective evaluation of 75 consecutive patient for: (1) accuracy of diagnosis, (2) patient preference, (3)
ease of technique, and (4) diagnosis of associated pathology.
All patients received both views, in addition to an AP shoulder view.
Results:
•In 69 cases (92%) the scapular Y and axillary view results in the same diagnosis.
•In 6 cases (8%) the axillary view failed to demonstrate the correct diagnosis seen on scapular Y
•With the exception of the Hill-Sachs injury both views identified associated injuries similarly.
Current Recommendations: AP + Scapular Y or Axillary (or Both).
A 1
Roentgenographic Evaluation Of Suspect Shoulder Dislocation: A
Perspective Study Comparing The Axillary And The Scapular ‘Y’ View

125. Journal Of Emergency Medicine 2003;24(2):141-145.
Acute Complications Associated With Shoulder Dislocation At An
Academic Emergency Department
Objectives:
To identify complications related to shoulder dislocations in an Emergency Department population.
Methods:
This retrospective chart review was conducted in an academic ED for patients with shoulder dislocation
presenting July 1, 1995–June 30, 2000. 190 patients were included in the analysis; the mean age was 34 years.
Results
•Fifty-five patients had at least one fracture(29%), 48 of which (76%) were of the Hill-Sachs type. Despite
presence of a fracture, all shoulders underwent successful ED reduction.
•Sensory nerve deficits were found in 24 (12.6%), which persisted after reduction in 25% of these patients.
•No vascular injuries were identified.
•Although complications associated with shoulder dislocation were relatively common, these did not
significantly affect ED management.
A 1

126. American Journal of Emergency Medicine 2011;29:609-612.
Objectives:
To examine the percent of dislocations that also had fractures as a function of age to determine whether there
are some decades of life with a sufficiently low risk of fracture to avoid routine prereduction x-rays.
Methods:
Retrospective study of patients stratified by age at 19 Emergency Departments.
Results:
There were 7209 dislocations of which 465 (6.5%) had fractures.
Do All Patients With Shoulder Dislocations
Need Prereduction X-Rays?
Conclusion:
In the 2
nd
and 3
rd
decades of life, <1% of
patients had fractures. Because of the low
risk in this group routine prereduction x-
rays may not be necessary for them.
A 1

127. Academic Emergency Medicine 2004;11:853-858.
Clinical Factors Predicting Fractures Associated with an
Anterior Shoulder Dislocation
Objectives:
To identify risk factors for fractures associated with an anterior shoulder dislocations treated in an ED.
Methods:
Retrospective case-control study over five years of patients with an anterior shoulder dislocation treated at a
university-affiliated ED.
Results:
A total of 334 patients were included. Eighty-five (25.5%) had a clinically important fracture-dislocation. Using
logistic regression three risk-factors for fracture were identified.
Age >40 Years OR=5.18; 95% CI 2.74 to 9.78
First DislocationOR=4.23; 95% CI 1.82 to 9.87
Significant Trauma
1OR=4.06; 95% CI 1.95 to 8.48
1
Fall greater than one flight of stairs, assault, motor vehicle crash.
Conclusion:
Three risk factors predict clinically important fractures
that are associated with shoulder dislocation: age, first
episode, and mechanism of dislocation.
A 1

128. Emergency Medicine Journal 2022;39:662-665.
Risk Factors For The Presence Of Important Fractures In ED Patients
With Shoulder Dislocation: A Retrospective Cohort Study
Objectives:
To determine the risk factors for an important fracture in ED patients with shoulder dislocations.
Methods:
Retrospective review of 602 patients.The primary end point was the presence of an important fracture
(excluding Bankart and Hill-Sachs fractures).
Results:
81 (13%) of patients had fractures. Three risk factures for fracture (below) were identified. When all three of
these factors were absent [n=166 (28%)] the risk of important fracture was 0.6%.
Age >40 Years OR=2.7; 95% CI 1.5 to 4.8
First DislocationOR=4.3; 95% CI 1.7 to 10.8
Significant Trauma
1
OR=5.5; 95% CI 2.6 to 30
Conclusion:
Prereduction X-rays may be safely avoided
when all 3 of these factors are absent.
1
Fall from a height, fall with direct impact, motor vehicle crash,
seizure, electrocution.
A 1

129. Journal of Emergency Medicine 2018;55(2):218-225.
Objectives:
To refine and combine two existing clinical decision rules for selective radiography in the ED management of
anterior shoulder dislocation, thus creating the Fresno-Quebec rule (FQR) that included three criteria: (1) age
>35, (2) first dislocation, (3) history of significant blunt trauma.
Methods:
Prospective cohort study in two academic emergency departments. 207 patients were included of which 24
(11.8%) had important fracture.
Sensitivity100% (95% CI 87.5-100%)
Specificity50% (95% CI 42.5-57.5%)
NPV 100% (95% CI 96-100%)
Conclusion:
The refined Fresno-Quebec shoulder dislocation rule detected
all clinically important prereduction fracture-dislocations and
could have reduced prereduction films by 44%.
Selective Prereduction Radiography In Anterior Shoulder Dislocation:
The Fresno-Quebec Rule
A 1

130. European Journal Of Emergency Medicine 2023;30(6):438-444.
Objectives:
To evaluate the performance of the Fresno-Québecrule in identifying patients with clinically suspect anterior
shoulder dislocation who do not require a prereduction radiograph. The rule requires that the patient: (1) be
35 years, (2) have a history of prior dislocation, (3) not be a victim of significant trauma.
Methods:
A multicenter, retrospective cohort study from 2015 to 2021. 2129 patients of whom 9.7% had fractures.
Sensitivity96% (95% CI 92-98%)
Specificity36% (95% CI 34-38%)
NPV 99% (95% CI 98-99%)
Conclusion:
The Fresno-Québecrule has high sensitivity in identifying
clinically significant fractures in patients with an anterior
dislocation. Use of the rule could reduce imaging by 30%.
Performance Of The Fresno-Quebec Rule In Identifying Patients With
Concomitant Fractures Not Requiring A Radiograph Before Shoulder
Dislocation Reduction: A Multicenter Retrospective Cohort Study
A 1

131. Turkish Journal Of Trauma And Emergency Surgery 2021;27(1):115-121.
Objectives:
To evaluate the efficacy of the Fresno-Quebec Rule for detecting a shoulder fracture-dislocation.
Methods:
Single center review of 135 patient [89 (65.9%) men; 46 (34.1%) women; mean age 46 years (16–89)]. Ninety
nine (73.3%) of the cases had their shoulder dislocated for the first time.
Results:
Thirty-four patients (25.2%) had fracture dislocation. None of the 18 patients with atraumatic recurrent
dislocation had concomitant fracture,whereas fracture occurred in 4 of 18 patients with traumatic dislocation
who had a history of recurrent dislocation.
Conclusion:
The Fresno-Quebec Rule was 100% sensitive for detecting fracture dislocations.
Diagnostic Accuracy Of The Fresno-Quebec Rule And Risk Factors For
Associated Fracture In Patients Presenting To The Emergency Department
With Anterior Shoulder Dislocation: A Retrospective Study
A 1

132. Turkish Journal Of Trauma And Emergency Surgery 2021;27(1):115-121.
A 1

133. The Journal Of Emergency Medicine 2007;33(2):169-173.
Objectives:
To determine whether post-reduction radiographs add clinically important information to what is seen
on pre-reduction X-rays inEmergency Department (ED) patients with anterior shoulder dislocation.
Methods:
Prospective, observation study of 55 patient with anterior shoulder dislocation how had both pre-and
post-reduction X-rays performed.
Results:
•Post-reduction X-rays confirmed successful reduction in 100% of cases.
•16 fracture were seen on post-reduction X-rays, of which 6 were notseen on pre-reduction X-rays.
Conclusion:
•More than one-third (37.5%) of associated fractures may be visible only on post-reduction X-rays.
•Post-reduction X-rays are recommended in all ED patient undergoing shoulder dislocations reduction.
The Role Of Post-Reduction X-Rays After Shoulder Dislocation
A 1

134. Use Of Point Of Care Ultrasound
Appendix 2

135. Objectives:
To determine the impact of implementing an in-service educational intervention for emergency medicine
(EM) residents on the use of POCUS to diagnose and manage shoulder dislocations in ED.
Methods:
In-service training for 20 novice EM residents followed by a convenience sample of patients in the ED.
Results:
•Seventy-eight patients were evaluated to rule out shoulder dislocation and/or fracture. A diagnosis of
the dislocated shoulder was made in 55 of 78 patients (70.5%), 53 of whom had anterior dislocations.
Resident-driven POCUS had a sensitivity and specificity of 100% to diagnose and rule out shoulder
dislocations, and to confirm the adequacy of reductions.
•Results from a POCUS were available 22 ±2.8 minutes sooner than x-ray for initial diagnosis and 27 ±
2.9 minutes (P < 0.0001) sooner than x-ray for assessment of reduction.
Emergency Medicine Resident–Driven Point of Care Ultrasound
for Suspected Shoulder Dislocation
Southern Medical Journal 2019; 112(12):605-609.
A 2

136. Objectives:
To determine whether POCUS improves diagnostic accuracy when used with physical examination for the
diagnosis of shoulder dislocation, proximal humeral fracture and ascertaining successful reduction in the
ED.
Methods:
Prospective, single-center study where consecutive patients were randomized to a control group
(physical exam only) or an experimental group (physical exam + POCUS).
The study objectives were to measure diagnostic accuracy for both group for detecting shoulder
dislocation, any associated proximal humeral fractures, and confirming reduction. X-rays were used as
the reference standard for both groups.
Diagnostic Accuracy Of Point-Of-Care Ultrasound For Shoulder
Dislocations And Reductions In The ED: A Diagnostic Randomized Controlled Trial
Emergency Medicine Journal 2020; 39(9):655-661.
See The Next Slide For A Summary Of Results
A 2

137. Results:
A statistically difference (p <0.001) was found between the two groups for diagnostic accuracy (A) in
shoulder dislocation, proximal humerus fracture, and successful reduction.
Emergency Medicine Journal 2020; 39(9):655-661.
Physical Exam OnlyExam + POCUS
Dislocations A = 65% (n=132)A = 100% (n=158)
Humeral Fractures A = 46% (n=154)A = 98% (n=178)
Reductions A = 69% (n=130)A = 100% (n=148)
Conclusion:
The addition of POCUS to the physical examination significantly improved diagnostic accuracy for
dislocations, proximal humeral fractures and reduction confirmation.
Diagnostic Accuracy Of Point-Of-Care Ultrasound For Shoulder
Dislocations And Reductions In The ED: A Diagnostic Randomized Controlled Trial
A 2

138. Academic Emergency Medicine 2022; 29:999-1007.
Objectives:
This systematic review sought to evaluate the diagnostic accuracy of POCUS for diagnosing shoulder
dislocations.
Methods:
Systematic review and meta-analysis.
Results:
•Ten studies met our inclusion criteria, comprising 1,836 assessments with 636 dislocations (34.6%).
Overall, POCUS was 100% sensitive (95% confidence interval [CI], 85.6%–100%) and 100% specific
(95% CI, 79.4%–100%) specific for the diagnosis of shoulder dislocation with a LR+ of 11,254.8 (95% CI,
3.9–3.3e7) and a LR− of <0.1 (95% CI, < 0.1–0.2).
•When compared with the anterior/lateral technique, the posterior technique had greater sensitivity
but no difference in specificity. There was no difference between transducer types.
Ultrasound For The Diagnosis Of Shoulder Dislocation And Reduction:
A Systematic Review And Meta-Analysis.
A 2

139. References
Roentgenographic Evaluation Of Suspect Shoulder Dislocation: A Perspective Study
Comparing The Axillary And The Scapular ‘Y’ View.Orthopedics1990;13(1):63-69.
Emergency Medicine Resident–Driven Point of Care Ultrasound for Suspected Shoulder
Dislocation. Southern Medical Journal 2019; 112(12):605-609.
Diagnostic Accuracy Of Point-Of-Care Ultrasound For Shoulder Dislocations And Reductions
In The ED: A Diagnostic Randomized Controlled Trial. Emergency Medicine Journal 2020;
39(9):655-661.
Ultrasound For The Diagnosis Of Shoulder Dislocation And Reduction: A Systematic Review
And Meta-Analysis. Academic Emergency Medicine 2022; 29:999-1007.
Acute Complications Associated With Shoulder Dislocation At An Academic Emergency
Department.Journal Of Emergency Medicine 2003;24(2):141-145.

140. References
Do All Patients With Shoulder Dislocations Need Prereduction X-Rays? American Journal of
Emergency Medicine 2011;29:609-612.
Clinical Factors Predicting Fractures Associated with an Anterior Shoulder Dislocation.
Academic Emergency Medicine 2004;11:853-858.
Risk Factors For The Presence Of Important Fractures In ED Patients With Shoulder
Dislocation: A Retrospective Cohort Study. Emergency Medicine Journal 2022;39:662-665.
Selective Prereduction Radiography In Anterior Shoulder Dislocation: The Fresno-Quebec
Rule.Journal of Emergency Medicine 2018;55(2):218-225.
Performance Of The Fresno-Quebec Rule In Identifying Patients With Concomitant
Fractures Not Requiring A Radiograph Before Shoulder Dislocation Reduction: A
Multicenter Retrospective Cohort Study. European Journal Of Emergency Medicine
2023;30(6):438-444.

141. References
Diagnostic Accuracy Of The Fresno-Quebec Rule And Risk Factors For Associated Fracture In
Patients Presenting To The Emergency Department With Anterior Shoulder Dislocation: A
Retrospective Study. Turkish Journal Of Trauma And Emergency Surgery 2021;27(1):115-
121.
Anterior Shoulder Dislocation Reduction Techniques. The Journal of Emergency Medicine
2019;58(4):647-666.