Review Article

Acute Management of Shoulder

Dislocations

Abstract
Thomas Youm, MD The shoulder joint has the greatest range of motion of any joint in the
Richelle Takemoto, MD body. However, it relies on soft-tissue restraints, including the
capsule, ligaments, and musculature, for stability. Therefore, this joint
Brian Kyu-Hong Park, MD
is at the highest risk for dislocation. Thorough knowledge of the
shoulders anatomy as well as classification of dislocations,
anesthetic techniques, and reduction maneuvers is crucial for early
management of acute shoulder dislocation. Given the lack of
comparative studies on various reduction techniques, the choice of
technique is based on physician preference. The orthopaedic
surgeon must be well versed in several reduction methods and
ascertain the best technique for each patient.

S everal shoulder dislocation reduc-

From the Department of Orthopaedic
Surgery, NYU Hospital for Joint
Diseases, New York, NY (Dr. Youm
and Dr. Park) and the Bone and Joint
Center at Kauai Medical Clinic, Wilcox
Memorial Hospital, Lihue, HI
(Dr. Takemoto).
Dr. Youm or an immediate family
member is a member of a speakers
bureau or has made paid presentations
on behalf of and serves as a paid
consultant to Arthrex. Neither of the
following authors nor any immediate
family member has received anything
of value from or has stock or stock
options held in a commercial company
or institution related directly or indirectly
to the subject of this article:
Dr. Takemoto and Dr. Park.
J Am Acad Orthop Surg 2014;22:
761-771
http://dx.doi.org/10.5435/
JAAOS-22-12-761
Copyright 2014 by the American
Academy of Orthopaedic Surgeons.
tion techniques have been described
in the modern literature, but little of
it synthesizes the early management
of acute shoulder dislocations. The
shoulder is the most commonly dis-
located large joint.1 With the increas-
ing activity level associated with
modern society, the incidence of
shoulder dislocation has risen to
24 per 100,000 person-years.2 The
highest percentage of primary dis-
locations occurs in males aged 10 to 20
years followed by the 50- to 60-year
age group.3,4 A thorough knowledge
of shoulder anatomy, classification of
dislocations, anesthetic techniques,
and a variety of reduction maneuvers
is essential for management of this
injury.
Pathoanatomy
The shoulder joint develops as an
appositional articulation and has the
greatest range of motion (ROM) of
any joint in the body due to a scarcity
of bony restraints and minimal
articular contact. Thus, the shoulder
is more reliant on soft-tissue re-
straints of the capsule, ligaments, and
musculature, placing this joint at high
risk for dislocation. The shoulder is
held reduced by static and dynamic
stabilizers (Table 1). Static stabilizers
maintain congruity of the shoulder
joint through buttressing support
and provide stability at the end
ranges of motion. Dynamic stabi-
lizers function via the neuromuscular
system, actively stabilizing the mov-
ing joint at the mid ranges of motion.
Static constraints of the shoulder
consist of the coracoacromial arch,
glenoid fossa, labrum, capsule, and
glenohumeral ligaments (GHLs). The
coracoacromial arch is formed by the
coracoid, coracoacromial ligament,
acromioclavicular joint, and clavicle.
These structures collectively provide
anterosuperior stability. Moreover,
the articular surface of the glenoid is
angled anteriorly and superiorly,
providing posterior and inferior sta-
bility. In contrast to the acetabulum of
the hip joint, the glenoid has a smaller
articular surface, thereby rendering
the shoulder less stable. The articular
surface of the humeral head is three

December 2014, Vol 22, No 12 761

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Acute Management of Shoulder Dislocations
Table 1
Static and Dynamic Glenohumeral Joint Stabilizing Structures
Structure
Static Stabilizers
Coracoacromial arch
Glenoid fossa
Labrum
Capsule/GHLs
Superior GHL
Middle GHL
Inferior GHL
Dynamic Stabilizers
Deltoid
Rotator cuff
Long head of biceps tendon
Periscapular musculature
ER = external rotation, GHL = glenohumeral ligament, IR = internal rotation
times larger than that of the glenoid,
and only 25% to 30% of the humeral
head articulates with the glenoid at any
one time.5,6 For this reason, adhesion-
cohesion forces mediated by synovial
fluid are instrumental in centering the
humeral head on the glenoid.
Because of the lack of bony con-
straint of the glenoid fossa, which is
relatively flat and small, stability is
primarily conferred by soft-tissue
structures. The labrum increases
shoulder stability by contributing
50% of glenoid cavity depth and
increasing the total surface area.7
Along with the rotator cuff, the
labrum is integral to concavity com-
pression and provides a seal around
the joint.8 Any disturbance in the
labrum can disrupt the intra-articular
vacuum and alter the mechanics of
the joint. Once the negative pressure
seal is lost, the humeral head typically
translates inferiorly.
Capsular lesions allow increased
translation of the humeral head and
instability in the opposing direction.
The superior GHL resists inferior
humeral translation and is the primary
restraint of the adducted shoulder. The
morphology and size of the middle
762
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Function
Anterosuperior stability
Posteroinferior stability
[ Articular surface area, vacuum seal
Multidirectional stability
Stability in adduction
Anterior and ER stability in 45 abduction
AP and ER/IR stability in 90 abduction
Inferior stability
Compresses humeral head against glenoid
Depresses humeral head in abduction
Stabilizes scapula, scapulohumeral rhythm
GHL is variable, poorly defined, and
absent in 30% of shoulders.9 When
present, this ligament resists anterior
translation and limits external rotation
at 45 of abduction. The inferior GHL
consists of three bands and is the
strongest of all the GHLs. It provides
the greatest stability by resisting an-
teroinferior translation. The anterior
band of the inferior GHL prevents
anterior dislocation by limiting exter-
nal rotation at 45 to 90 of abduction.
The dynamic stabilizers include the
deltoid, biceps, rotator cuff, and scap-
ular stabilizing muscles. The long head
of the biceps has been thought to
depress the humeral head during
abduction, resulting in further stability.
However, the biomechanical function
of the biceps tendon is confounded by
conflicting electromyelography stud-
ies; some show activity in the biceps
tendon during active abduction, and
others do not.10,11
The rotator cuff provides dynamic
compression of the humeral head into
the glenoid through a phenomenon
known as concavity compression.
Direct attachments to the capsule allow
the rotator cuff muscles to contribute
to stability by increasing articular
Journal of the American Academy of Orthopaedic Surgeons
tension. During shoulder movement,
active compression of the humerus
against the glenolabral articular con-
cavity provides additional support. In
addition, proprioceptive muscular re-
flexes counter capsular stretch and
shoulder motion detected by sense re-
ceptors, further increasing stability.8
The trapezius, rhomboids, latis-
simus dorsi, serratus anterior, and
levator scapulae muscles stabilize
the scapula and increase dynamic
stability. With active glenohumeral
abduction, the scapula rotates about
the thorax. This synchronous move-
ment is referred to as scapulohumeral
rhythm. Patients with shoulder
instability have been found to have
excessive movement into protraction
or a delay in retraction with shoulder
elevation and increased spinal tilt,
thereby altering the normal scap-
ulohumeral rhythm. Changes in
scapulohumeral rhythm were found
to be caused by decreased activity in
the lower portion of the trapezius and
serratus anterior muscles.12
Classification
Shoulder dislocations are classified as
atraumatic or traumatic. Atraumatic
glenohumeral dislocation presents as
multidirectional instability. Related to
generalized ligamentous laxity, mul-
tidirectional instability is often bilat-
eral and responds well to nonsurgical
management. Underlying connective
tissue disease such as Ehlers-Danlos
syndrome or a bony abnormality such
as glenoid hypoplasia or excessive
glenoid retroversion should be con-
sidered when an atraumatic shoulder
dislocation occurs.
Up to 96% of shoulder dislocations
are traumatic in origin.3 Traumatic
dislocation is caused by a posteriorly
directed torque on an abducted and
externally rotated arm and is often
associated with contact sports or
a fall onto an outstretched arm.3,13
Subsequent unidirectional instability

may occur after repeated traumatic
dislocations have damaged the cap-
sule and ligaments.3
Glenohumeral dislocations are
further classified by the direction of
the humeral head dislocation: ante-
rior, posterior and inferior.
Associated Injuries
In a study of 3,633 patients with
traumatic shoulder dislocation,
Robinson et al14 reported that 40% of
patients also had an associated
structural injury about the gleno-
humeral joint. Thirty-three percent of
patients sustained a rotator cuff tear
or fracture of the greater tuberosity.
The incidence of rotator cuff tear in
patients older than 40 years is espe-
cially high (20% to 54%15) secondary
to preexisting tendon degeneration.
Robinson et al14 also reported that
13% of patients sustained a neuro-
logic injury associated with shoulder
dislocation. The axillary nerve, which
is the most commonly injured nerve, is
susceptible to traction injury because
it transverses the axilla adjacent to the
inferior capsule. Injury to this nerve
may manifest as deltoid weakness
or numbness over the anterolateral
shoulder. However, normal sensation
does not exclude axillary nerve injury.
Bankart lesions, detachments of the
anterior labrum from the glenoid rim,
are associated with 85% of traumatic
anterior dislocations.16 Patients with
recurrent shoulder dislocations have
a higher incidence of Bankart lesions.
Posterior dislocations can result in
reverse-Bankart lesions of the pos-
teroinferior labrum.3,17 The Hill-
Sachs lesion, an impaction fracture
of the posterolateral humeral head
on the glenoid rim, is estimated to
occur in 40% to 90% of anterior
shoulder dislocations and 100% of
recurrent dislocations.18 Reverse
Hill-Sachs lesions affect the anterior
humeral head and occur in 86% of
posterior shoulder dislocations.18
December 2014, Vol 22, No 12
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Thomas Youm, MD, et al
a timely manner to avoid muscular
Radiographic Assessment spasm and neurovascular compromise
while ensuring gentle and technically
Radiography is essential for diagnosis
sound closed reduction. The ease of the
of shoulder dislocation. Radiographs
reduction partially depends on the
should be taken before and after
length of time since the dislocation and
reduction to plan reduction maneu-
the tone of the shoulder girdle muscu-
vers, ensure concentric reduction, and
lature. If the injury is tended to
evaluate for concomitant fractures. AP,
promptly, reduction without local pain
lateral, and axillary views are obtained
medication is feasible. However, if the
to identify the direction of the disloca-
patient is unable to relax or if the
tion and any associated fractures.
musculature is in spasm, reduction
The axillary view is critical to assess
may be more difficult and anesthesia
the relationship between the humeral
may be required.
head and the glenoid. To obtain this
In the office or emergency depart-
view, the patients arm is abducted,
ment setting, two anesthesia options
a cassette is placed superiorly on the
exist: intra-articular block or pro-
shoulder, and the beam is directed
cedural sedation. Compared with
superiorly into the axilla. Ideally, the
sedation, intra-articular block with
arm is abducted to 90; however, if
lidocaine has been shown to provide
patients have difficulty tolerating that
the same degree of analgesia and simi-
position, less abduction is acceptable.
lar success rates in reduction.19-22
Alternatively, a Velpeau view can be
Sedation is associated with more
obtained. The arm is adducted and
complications, greater time in the
internally rotated to the chest. The
emergency department, and higher
patient stands or sits at the edge of
costs.19-22 Therefore, intra-articular
a roentgenographic table and leans
block should be used first, with seda-
backward 30 to 45. The beam is
tion reserved for difficult reductions.
directed down through the shoulder
joint. The standard axillary view is
preferred over the Velpeau view Anterior Shoulder
because the Velpeau view produces Dislocation and Reduction
a distorted, magnified projection. Maneuvers
However, either view is acceptable.
Most shoulder dislocations (97%) are
The West Point and Stryker notch
anterior.3 The mechanism of injury is
views have traditionally been used to
typically forced abduction and exter-
assess for bony Bankart and Hill-Sachs
nal rotation of the arm. Alternatively,
lesions, respectively. CT and MRI
a posterior-to-anterior force directed
technology have largely replaced these
on the proximal humerus may result in
special views. CT can detect subtle
anterior dislocation. Anterior shoulder
fractures not identified on radiography,
dislocations are further subdivided into
such as Hill-Sachs lesions and glenoid
subcoracoid and subglenoid, with
rim fractures. MRI is used to identify
subcoracoid dislocations occurring
soft-tissue structural damage, particu-
most commonly.
larly Bankart lesions, ligament/capsule
The patient with an anterior
detachment, and rotator cuff tears.
shoulder dislocation will often pre-
sent with the arm held fixed, slightly
Acute Management internally rotated, and abducted. A
flattened shoulder silhouette is pres-
A myriad of reduction maneuvers ex- ent when the humeral head is located
ists. Regardless of the maneuver used, anterior, inferior, and medial to its
several general principles apply. Acute anatomic position. Passive and active
dislocations should be reduced in movement is restricted, as well. Here,
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 Acute Management of Shoulder Dislocations

Table 2
Reduction Techniques for Anterior Dislocations
Patient Success Rate
Method Type Position Description (%)

Hippocratic Traction Supine Longitudinal traction to arm with foot in axilla NR

Traction- Traction Supine Longitudinal traction to arm with counter NR
countertraction traction applied via sheet around chest wall
Chair Traction Sitting to With the arm held in place, patient applies 739723,24
standing traction by standing up from a seated
position.
Kocher Levering Supine or sitting Elbow flexed to 90; adduction, external 8110025,26
rotation, and forward flexion of shoulder
Stimson Traction Prone Arm hangs over edge of stretcher and NR
downward traction applied with weights
Milch Combination Supine or sitting Humeral head stabilized, arm fully abducted, 7010027-29
traction applied then humeral head pushed
over glenoid rim
External rotation Levering Supine or sitting Arm adducted then passively externally 789030-33
rotated
Spaso Traction Supine Scapula stabilized against stretcher and 688834-36
upward traction and external rotation
applied
Eskimo Traction Lateral Upward traction applied to abducted arm NR
decubitus and torso lifted off floor
Scapular Combination Prone Stimson technique 1 manual internal 799637-38
manipulation rotation and medialization of scapula
FARES Traction 1 Supine Arm adducted, vertical oscillating 889526,33
oscillation movement, gradual abduction with gentle
traction

FARES = fast, reliable, and safe; NR = not reported

we describe 11 reduction techniques
for management of anterior shoulder
dislocations (Table 2).
Hippocratic
Hippocrates described the earliest
reduction technique. The physician
places a foot in the patients axilla
while applying traction to the
affected arm with alternating inter-
nal and external rotation to disen-
gage the humeral head. This method
is largely historical and has been
abandoned because of the high rate
of traction injury to the brachial
plexus.
Traction-Countertraction
The traction-countertraction method
uses longitudinal traction to disen-
gage the humeral head. The patient is
placed supine. A sheet wrapped
around the patients chest and within
the axilla is pulled away from the
affected side by an assistant while the
affected limb is pulled inferiorly and
laterally at a 45 angle (Figure 1).
Alternatively, the sheet may be tied to
the railing of the stretcher if no
assistant is available. Slight external
rotation of the humerus may aid the
humeral head in clearing the anterior
glenoid rim. Once the humerus is
disengaged, slight lateral traction on
the proximal humerus may be
necessary.
Chair
In another traction-based maneuver,
the patient is seated sideways in a chair
with the affected arm hanging over
the backrest. The clinician holds the
supinated forearm stationary and the
patient slowly stands (Figure 2). A
73% success rate was reported in the
original description of this tech-
nique.23 Westin et al24 modified the
technique by tying a loop of stocki-
nette about the forearm, flexing the
elbow 90, and using the loop as
a pedal. The authors reported a suc-
cess rate of 97%, and anesthesia was
not required in 110 of 118 reductions
(93%).
Kocher
The Kocher technique was first
described in 1870.25 With the patient
supine or seated, the operator grasps
the patients forearm on the affected
side and flexes the elbow 90. The
patient adducts the affected arm and
actively externally rotates to 70 to

764 Journal of the American Academy of Orthopaedic Surgeons

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Figure 1
Photograph demonstrating the
traction-countertraction reduction
technique. A sheet is placed across
the patients torso and held by an
assistant or tied to the bed railing
while axial traction is applied to the
dislocated shoulder.
80 until resistance is felt. The phy-
sician forward flexes the arm and
reduction of the humeral head oc-
curs. This technique has a reported
success rate of 81% to 100%.
Stimson
Initially described in 1900, the Stimson
technique is performed with the
patient prone on the stretcher, and the
affected arm hanging over the edge.39
Downward traction is applied with
weights, starting with 5 lbs (2.27 kg;
Figure 3). Alternatively, the elbow
may be flexed 90 to relax the biceps
tendon, and the physician may apply
manual traction with a gentle rocking
motion. Reduction should occur
within 15 to 20 minutes. Advantages
of this method include the relative
ease of reduction and avoidance of
large amounts of force. One disad-
vantage is the difficulty providing
sedation with the patient in the prone
position.
Milch
The Milch technique was first
described in 1938 and is based on the
principle of recreating the injury.40
The patient can be positioned supine
December 2014, Vol 22, No 12
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 2
Photograph demonstrating the chair
technique for reduction of an anterior
shoulder dislocation. The patient
initially sits with the affected arm
hanging over a chair back and then
stands while the physician holds the
arm. The patient reduces the
shoulder using his own power.
or seated, with the physician on the
affected side. The physician places
a hand on the superior aspect of the
injured shoulder and uses a thumb
to stabilize the humeral head in
a fixed position while the arm is
abducted. Once the arm is fully ab-
ducted, gentle longitudinal traction is
applied, and the humeral head is
manipulated with the thumb over the
glenoid rim. This technique can be
modified by rotating the arm exter-
nally to allow the greater tuberosity to
tilt posteriorly and the thinnest profile
to pass over the glenoid rim.27-29
Success rates ranging from 70% to
100% have been reported.27-29 In
a study of 76 acute anterior shoulder
dislocations reduced with the Milch
technique, all shoulders were reduced
on the first attempt without anesthesia
or complications.28
External Rotation
In 1957, a self-reduction technique
was devised whereby the patient
would sit on a swiveling stool and
grasp a stationary object such as the
Thomas Youm, MD, et al
Figure 3
Photograph demonstrating the
Stimson technique for reducing
anterior shoulder dislocation. With
the patient in the prone position,
weights are hung from the wrist or
elbow.
leg of a table.41 The patient rotates the
body, passively externally rotating
the shoulder until reduction occurs.
This method has been modified to be
performed with the patient supine or
seated, with the arm fully adducted
and external rotation performed by
a clinician (Figure 4). Reduction
should occur at 70 to 110 of
external rotation. This method is
atraumatic and easy to perform, with
reported success rates ranging from
78% to 90% and .80% of patients
requiring no anesthesia.30-32
Spaso
The Spaso technique, which was ini-
tially described in 1998, is performed
with the patient positioned supine.42
The physician stands adjacent to the
affected arm, holding it in 90 of for-
ward flexion. Gentle vertical traction
is applied to the arm, followed by
slight external rotation (Figure 5). The
medial border of the scapula must be
kept in contact with the bed to stabilize
the glenoid. Reduction should occur
spontaneously after several minutes of
traction or the humeral head may be
manually pushed toward the glenoid
765
 Acute Management of Shoulder Dislocations
Figure 4
Photograph demonstrating the external
rotation technique for reduction of
anterior shoulder dislocation. While the
arm is held adducted, slow, gentle,
passive external rotation is applied until
reduction occurs.
fossa. Success rates ranging from 68%
to 88% have been reported.34-36
Eskimo
This technique was originally devel-
oped in Greenland and was first
described in 1988.43 The patient lies
on the ground in the lateral decubitus
position. The clinician grips the dis-
located arm and applies a vertically
oriented force, lifting the contralateral
shoulder several centimeters off the
ground. The patient is held in this
position for several minutes until
reduction occurs. Although this tech-
nique is easy to perform, it may place
undue stretch on the brachial plexus.
There are no reported data on the
safety of the Eskimo technique.
Scapular Manipulation
Scapular manipulation is performed
by internally rotating and medializ-
ing the scapula. The patient is placed
prone, with the arm hanging over the
edge of the stretcher, as in the Stim-
son technique. Once gentle traction
is applied, the clinician stabilizes the
superior aspect of the scapula with
the thumb and applies medial force
on the inferior angle of the scapula
with the other thumb (Figure 6).
Reduction is often extremely subtle
and may be missed. Success rates
766
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 5
Photograph demonstrating the
Spaso shoulder reduction technique
in which vertically oriented traction is
applied with slight external rotation.
Contact between the scapula and the
stretcher must be maintained.
ranging from 79% to 96% have
been reported, and the major dis-
advantage of this technique is the
steep learning curve.37,38
Fast, Reliable and Safe
Sayegh et al26 described the Fast,
Reliable, and Safe (FARES) method
for reduction of anterior shoulder
dislocation. In this method, the
patient lies supine with the physician
standing on the affected side (Figure
7). The patient holds the arm ad-
ducted, with the elbow extended and
the forearm in neutral rotation. Axial
traction is applied without counter-
traction. A short-range oscillating,
vertical movement is rapidly per-
formed throughout the reduction
maneuver. The arm is slowly ab-
ducted. At 90 of abduction, the arm
is gradually externally rotated while
continuing abduction and vertical
oscillation. Reduction typically oc-
curs at 120 of abduction. The au-
thors claim that this technique is
easier to perform than traditional
methods.
Journal of the American Academy of Orthopaedic Surgeons
Figure 6
Photograph demonstrating scapular
manipulation. The scapula is reduced
to the humeral head by applying
medially directed pressure on the
inferior angle of the scapula with one
thumb and stabilizing the superior edge
of the scapula with the other thumb.
Posterior Shoulder
Dislocation and Reduction
Maneuver
Posterior dislocations comprise ,3%
of dislocations.17 Posterior dislocations
are often unrecognized or incorrectly
recognized; therefore, careful exami-
nation is required. Posterior shoulder
dislocations most commonly occur in
men aged 35 to 55 years.17 Traumatic
dislocations are responsible for about
half of posterior shoulder instability
cases.44 In a systematic review of the
literature on posterior shoulder dis-
locations, 34% were associated with
seizures.45
Posterior dislocations are often
difficult to diagnose. However,
posterior shoulder prominence
may be observed with the arm held
fixed, internally rotated, and ad-
ducted (Figure 8). Both passive and
active movements are restricted, as
well.
Closed reduction is often difficult
and may require sedation. It should be
attempted only within 3 weeks of the
injury and in patients with humeral
head defects that comprise ,20% of
the articular surface.17,46 Two oper-
ators are needed for the reduction

Figure 7
Photograph demonstrating the Fast,
Reliable, and Safe (FARES)
technique. While the clinician
maintains traction, short, vertical,
oscillating movements (orange
arrow) are performed during gradual
abduction and external rotation of the
arm (blue arrow). Note there is no
sheet across the torso to provide
countertraction.
maneuver. The physician forward
flexes the shoulder to 90 then ad-
ducts and internally rotates the arm
to disengage the humeral head from
the glenoid rim. The assistant main-
tains cross-body traction while the
physician applies gentle, anteriorly
directed pressure to the posterior
humeral head. Finally, external rota-
tion can be attempted to complete
and confirm reduction.17,45,46
Inferior Shoulder Dislocation
and Reduction Maneuvers
Inferior shoulder dislocation is
exceedingly rare, comprising ,1% of
all shoulder dislocations.47,48 These
injuries are also known as luxatio
erecta humeri because of the resul-
tant fixed, abducted position of the
arm following dislocation. These
dislocations are high-energy injuries
that occur when a hyperabduction
force applied to the arm levers the
proximal humerus onto the acromion.
Subsequently, the inferior capsule and
labrum are injured and the humeral
head disengages inferiorly from the
glenoid. The humeral head is then
December 2014, Vol 22, No 12
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 8
AP (A) and axillary (B) radiographs of the shoulder demonstrating a posterior
dislocation. On the AP view, the humerus is held in internal rotation, and the
proximal humerus demonstrates the light bulb sign, which is characteristic of
a posterior shoulder dislocation.
lodged in the infraglenoid region, re-
sulting in the characteristic fixed, ab-
ducted position of the arm47 (Figure 9).
Bony, soft-tissue, or neurovascular
injuries about the shoulder are com-
monly associated with inferior dislo-
cation. The reported incidence of
concomitant fractures of the greater
tuberosity and rotator cuff tears is as
high as 80%.49 Additionally, the inci-
dence of neurologic injury is as high as
60% and vascular compromise is as
high as 39%.48,49 Although the inci-
dence of these associated injuries is
based on a small case series, a high
suspicion for associated structural and
neurovascular injury must be main-
tained when evaluating a patient who
presents with luxatio erecta.
Traction-Countertraction
As with anterior dislocations, the
application of axial traction to the arm
aids in reduction of an inferior shoul-
der dislocation. A sheet is wrapped
around the upper torso and held in
place by an assistant for counter-
traction. Superiorly directed traction
Thomas Youm, MD, et al
is applied to the arm, and shoulder
abduction is gradually decreased.50
Two-step
The two-step technique converts an
inferior dislocation to an anterior
dislocation. Once converted, any
maneuver for reducing an anterior
dislocation can be used. The exam-
iner stands at the patients head and
pushes laterally on the abducted
humeral shaft with one hand, while
simultaneously pulling superiorly on
the medial epicondyle with the other
hand (Figure 10). This maneuver
will move the humeral head out of
the infraglenoid position and rotate
it anteriorly around the glenoid rim.
If conversion is successful, the arm
may be adducted against the chest
wall. External rotation, traction-
countertraction, or any other ante-
rior dislocation reduction technique
may then be performed.50
Comparison of Techniques
Few studies have compared different
methods of closed reduction (Table 3).
767
 Acute Management of Shoulder Dislocations
Figure 9
AP (A) and axillary (B) radiographs of the shoulder demonstrating an inferior
dislocation with associated greater tuberosity fracture. This patient was unable to
adduct her arm.
In a study of 111 patients, Beattie
et al51 compared the Milch and
Kocher techniques. Overall, there
was no difference between the two
methods in terms of success rate.
However, the Milch technique was
found to be more successful in pa-
tients aged ,40 years when per-
formed within 4 hours of dislocation.
The authors recommended the tech-
nique as a first-line treatment. For
obese patients, the authors recom-
mended the Kocher technique,
despite the lack of statistical signifi-
cance. In a recent randomized study,
60 patients with anterior shoulder
dislocations were treated with either
the Milch or Stimson technique. The
success rate on the first reduction
attempt was 82% with the Milch
technique versus only 28% for the
Stimson technique.52
In a randomized control trial, 154
patients with acute anterior shoulder
dislocations were treated with the
FARES method, the Hippocratic
technique, or the Kocher technique.26
The FARES method was found to be
more successful, quicker, and less
painful than the Hippocratic and
Kocher techniques. In another ran-
domized control trial, the FARES
method was compared with the
768
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
external rotation technique in 160
patients with acute anterior shoulder
dislocation.33 Again, the FARES
method was found to be more suc-
cessful, quicker, and less painful.
Postreduction
Rehabilitation
Following successful reduction, the goal
of rehabilitation is to regain maxi-
mum ROM while retaining stability.
The affected arm is immobilized for
a minimum of 3 to 4 weeks, and limi-
ted physical rehabilitation is recom-
mended. The program should begin
with passive ROM exercises. In patients
with anterior shoulder dislocations, re-
strictions include no external rotation
past neutral and no abduction past 90
for the first 4 to 6 weeks after injury.
Conversely, in patients with posterior
dislocations, internal rotation is lim-
ited for 4 to 6 weeks. Isometric con-
tractions for muscle rehabilitation can
begin immediately after the injury to
strengthen the stabilizing musculature.
Return to athletic activities can occur
after the patient regains full strength
and ROM without pain. The timing of
return to contact sports has not been
well established in current literature,
Journal of the American Academy of Orthopaedic Surgeons
Figure 10
Photograph demonstrating the two-
step technique for converting an
inferior dislocation to an anterior
dislocation. The first step consists of
applying a force over the lateral
humeral shaft. while the medial
elbow is pulled in the opposite
direction. This will direct the humeral
head anteriorly, converting the
inferior dislocation to an anterior
dislocation.
but we restrict patients from returning
to contact sports for a minimum of 2
months.
In patients with limited active
ROM, weakness, or persistent pain 2
to 3 weeks after closed reduction,
rotator cuff pathology is suspected,
and MRI should be obtained.15 This
is especially true for patients older
than 40 years who are at higher risk
for rotator cuff tear. MRI should
also be obtained in cases of recurrent
dislocation to evaluate for underly-
ing pathoanatomy. CT is reserved
for suspected bone loss or further
evaluation of fractures (eg, bony
Bankart lesions) that may be seen on
radiography or MRI.
Clinical Outcomes
The primary end point in outcome
assessment is redislocation. Recur-
rent anterior dislocations are most
likely to occur 2 years after the initial
injury.13 Thus, 2 years can be used as
an end point in treatment.
 Thomas Youm, MD, et al

Table 3
Comparison of Reduction Maneuvers
No. of
Study (Design) Patients Maneuver Outcomes (P Value) Comments

Sayegh et al26 154 FARES versus Hippocratic Reduction on first or second FARES method is more
(RCT level I) versus Kocher attempt: FARES 88%, effective, faster, and less
Hippocratic 72.5%, Kocher painful than Hippocratic or
68% (P = 0.033) Time to Kocher methods.
reduction: FARES 2.3 min,
Hippocratic 5.5 min, Kocher
4.3 min (P ,0.001 )
Maity et al33 160 FARES vs ER Reduction on first or second FARES method is faster, less
(RCT level I) attempt: FARES 95%, ER painful and requires fewer
91% (P = 0.53) Number of attempts than ER. It is an
reduction attempts: FARES ideal first-line method.
1.14, ER 1.46 (P ,0.0001)
Time to reduction: FARES
2.1 min, ER 3.2 min
(P ,0.0001)
Beattie et al51 111 Milch versus Kocher Reduction on first attempt: No difference overall. Milch
(RCT level II) Milch 70%, Kocher 72% (NP) may be better for patients
aged ,40 years. Kocher may
be better in obese patients.
Amar et al52 60 Milch versus Stimson Reduction on first attempt: Milch technique superior to
(RCT level I) Milch 82%, Stimson: 28% Stimson technique in terms of
(P ,0.001) success rate and speed of
Time to reduction: Milch reduction.
4.6 min, Stimson 8.8 min
(P 0.007)

ER = external rotation, FARES = fast, reliable, and safe; NP = not published, RCT = randomized control trial

Age and sex are predictive factors for
recurrent shoulder dislocation after
primary traumatic anterior dislocation.
Recurrent dislocations are most com-
mon in patients aged #20 years.3 The
incidence of recurrent shoulder dislo-
cation decreases precipitously after
age 50 years.3 In a study of 252 pa-
tients treated for primary anterior
shoulder dislocation, 56% of younger
patients developed instability over 2
years and 66.8% developed instability
over 5 years.13 Men were found to
have a greater risk of recurrent insta-
bility than women.
The degree of trauma associated
with the initial dislocation also affects
outcome. Mechanism of injury, asso-
ciated fractures, nerve injury, and the
difficulty of reduction are all deter-
minants of outcome. Relative risk for
redislocation after primary anterior
dislocation is highest in patients who
sustained significant rotator cuff tear
and/or associated fracture resulting in
severe damage to the dynamic and/or
static stabilizers.53
Traditionally, participation in athlet-
ics has been thought to predispose the
patient to recurrent dislocation. How-
ever, conflicting evidence has been re-
ported on this point. Robinson et al13
found that, among patients younger
than 25 years, participation in athletics
did not yield a significant difference in
the rate of recurrence. In contrast,
Sachs et al54 found that participation
in contact sports or occupational use of
overhead motion increases the fre-
quency of recurrent dislocation after
acute traumatic anterior dislocation.
Many surgeons consider recurrent
dislocation an indication for surgery.
However, the patient may consider
recurrent dislocations as only a nui-
sance. Although recurrent dislocations
in highly competitive athletes or la-
borers may threaten the patients live-
lihood, in lower demand patients,
surgery may not be indicated. Sachs
et al54 reported that, over a 4-year
follow-up period after initial acute
traumatic anterior shoulder disloca-
tion, 18 of 37 patients (49%) in the
highest risk group for redislocation
requested surgery.
Summary
Dislocations should be tended to
promptly for the easiest possible
reduction and to minimize damage
to surrounding neurovascular struc-
tures. For anterior dislocations, we
recommend the use of an intra-

December 2014, Vol 22, No 12 769

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Acute Management of Shoulder Dislocations
articular block as a first-line method
of analgesia and reserve sedation for
failed awake reductions. Because of
the high success rates reported for
many reduction techniques and the
lack of comparative studies, the choice
of reduction technique depends on
the patient as well as physician famil-
iarity with each technique. Following
reduction, every patient should be
immobilized for a 3- to 4-week period,
followed by a gradual return to ROM
and activity. Methods for acute man-
agement of shoulder dislocation vary,
and the orthopaedic surgeon must be
well versed in several methods to best
ascertain the appropriate approach
for each patient.
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