Managing Anterior Shoulder Dislocation

Abstract

IntroductionAnterior shoulder dislocation is the most common large joint dislocation encountered in the emergency department (ED). The age range of patients is wide, although it is most common in young adults and rare in children. Many emergency physicians have developed substantial expertise in the care of these patients. The following is not meant to serve as a comprehensive guide to the care of patients with a shoulder dislocation; instead, it is a description of one approach, based on current evidence and years of practice.RadiographsAlthough many texts call for routine radiographs before and after the reduction of a shoulder dislocation, the literature does not support this conservative approach. A number of studies support selective radiography, sparing radiographs for recurrent dislocators with an atraumatic mechanism when the physician is clinically confident of the dislocation or reduction.1Harvey R.A. Trabulsy M.E. Roe L. Are postreduction anteroposterior and scapular Y views useful in anterior shoulder dislocations?.Am J Emerg Med. 1992; 10: 149-151Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 2Hendey G. Necessity of radiographs in the emergency department management of shoulder dislocation.Ann Emerg Med. 2000; 36: 108-113Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 3Hendey G. Kinlaw K. Clinically significant postreduction radiographic abnormalities in anterior shoulder dislocations.Ann Emerg Med. 1996; 28: 399-402Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 4Shuster M. Abu-Laban R. Boyd J. Prereduction radiographs in clinically evident anterior shoulder dislocation.Am J Emerg Med. 1999; 17: 653-658Abstract Full Text PDF PubMed Scopus (48) Google Scholar, 5Shuster M. Abu-Laban R. Boyd J. et al.Prospective evaluation of a guideline for the selective elimination of pre-reduction radiographs in clinically obvious anterior shoulder dislocation.CJEM. 2002; 4: 257-262PubMed Google Scholar Radiographs are indicated for patients with a first-time dislocation or when the mechanism involves blunt force trauma that may have produced a fracture, or when the physician is clinically uncertain of the joint position.2Hendey G. Necessity of radiographs in the emergency department management of shoulder dislocation.Ann Emerg Med. 2000; 36: 108-113Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 3Hendey G. Kinlaw K. Clinically significant postreduction radiographic abnormalities in anterior shoulder dislocations.Ann Emerg Med. 1996; 28: 399-402Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 6Emond M. Le Sage N. Lavoie A. et al.Clinical factors predicting fractures associated with anterior shoulder dislocation.Acad Emerg Med. 2004; 11: 853-858Crossref PubMed Scopus (0) Google Scholar However, a common scenario involves a patient with several previous dislocations who sustains a dislocation while reaching up or rolling over in bed. In this setting, the patient may be spared the time, expense, and radiation associated with routine radiography. Some physicians manage this group of patients with no radiography whatsoever.A neurovascular examination should be conducted before and after reduction, with particular attention to sensation over the deltoid (axillary nerve). Documenting a thorough postreduction examination is even more crucial when radiographs are omitted.Analgesia and AnesthesiaShoulder dislocation produces a significant amount of pain and muscle spasm in most patients. Although emergency physicians can significantly reduce pain with intravenous medications, the most effective way to relieve it is to rapidly reduce the dislocation. Thus, 3 reasonable approaches emerge, each of which may be appropriate for various situations:Minimal or No MedicationPatients who present very soon after a dislocation, particularly cooperative patients with a recurrent dislocation, are often amenable to gentle reduction attempts without any medication (see next section). This option is especially applicable to the sports field, the ski slope, or even at ED triage. Examples of minimal medication range from oral ibuprofen, hydrocodone, or lorazepam to a single intramuscular injection of morphine. When successful, this approach can reduce a visit time from several hours to several minutes, with the rapid discharge of a happy patient.Intra-articular InjectionInjection of the glenohumeral joint with 10 to 20 mL of lidocaine or bupivacaine is a quick, simple procedure that provides good analgesia in most patients. Multiple studies comparing joint injection to procedural sedation have demonstrated equal rates of successful reduction, shorter times to discharge from the ED, and no complications.7Fitch R.W. Kuhn J.E. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review.Acad Emerg Med. 2008; 15: 703-708Crossref PubMed Scopus (51) Google Scholar, 8Wakai A. O’Sullivan R. McCabe A. Intraarticular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults.Cochrane Database Syst Rev. 2011; : CD004919PubMed Google Scholar The injection may be accomplished from either a lateral or slightly posterior approach, with ultrasonographic guidance (https://www.youtube.com/watch?v=siGzMvakY8s) or without it (https://www.youtube.com/watch?v=pIBJORPktDY).Joint injection must be conducted with good, sterile technique because it introduces the risk of septic arthritis. However, the procedure appears to be extremely safe, and case reports of subsequent complications are rare.9Esenwein S. Ambacher T. Kollig E. et al.Septic arthritis of the shoulder following intra-articular injection therapy. Lethal course due to delayed initiation of therapy.Unfallchirurg. 2002; 105: 932-938Crossref PubMed Scopus (22) Google Scholar Intra-articular injection is an excellent alternative to procedural sedation because it obviates the need for an intravenous line, monitoring, nursing time, and the small risk associated with procedural sedation medications. Intra-articular injection may easily be combined with minimal sedation and does not preclude procedural sedation if unsuccessful.Procedural SedationProcedural sedation offers excellent muscle relaxation and pain relief to facilitate the reduction of a dislocation, but it exposes the patient to the added time, expense, and potential adverse effects of powerful sedatives. I prefer to attempt most reductions with only minimal sedation or intra-articular injection, but in some cases, procedural sedation is necessary because of a difficult reduction or pain intolerance. Although there are many good pharmacologic options, propofol has the excellent combination of substantial muscle relaxation, rapid onset, and quick recovery.ReductionA large number of reduction techniques have been described in the literature, and countless published and unpublished variations are practiced successfully every day around the world. Most techniques share some common features that move the humeral head into a more favorable position relative to the glenoid, including external rotation, flexion, traction, and abduction. Frequently, the dislocated humeral head is impacted below the inferior glenoid rim, and these maneuvers release and reposition the humeral head toward its natural position. No single technique is best for every practitioner and every patient, but each clinician must find several techniques that can be practiced comfortably, with a high rate of success. Generally 1 or 2 attempts with a given technique are enough to determine whether success is likely or whether another method should be attempted. Many techniques are actually complementary and can be easily combined. The techniques described below have reported success rates ranging from 79% to 92% individually, but most have not been studied in combination.10Leidelmeyer R. Reduced! a shoulder, subtly and painlessly.Emerg Med. 1977; 9: 233-234Google Scholar, 11Milch H. Treatment of dislocation of the shoulder.Surg Gynecol Obstet. 1938; 3: 732-740Google Scholar, 12Mirick M.J. Clinton J.E. Ruiz E. External rotation method of shoulder dislocation reduction.JACEP. 1979; 8: 528-531Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 13Anderson D. Zvirbulis R. Ciullo J. Scapular manipulation for reduction of anterior shoulder dislocations.Clin Orthop Relat Res. 1982; 164: 181-183PubMed Google Scholar, 14McNamara R.M. Reduction of anterior shoulder dislocations by scapular manipulation.Ann Emerg Med. 1993; 22: 1140-1144Abstract Full Text PDF PubMed Scopus (60) Google Scholar, 15Stimson L. An easy method of reducing dislocations of the shoulder and hip.Med Record. 1900; 57: 356-357Google Scholar, 16Cunningham N. A new drug free technique for reducing anterior shoulder dislocations.Emerg Med. 2003; 15: 521-524Crossref Scopus (26) Google Scholar Several of my favorite combinations are described below. Again, this list is not comprehensive, and if you have a gentle reduction technique with a high success rate, stick with it.External Rotation Plus Milch10Leidelmeyer R. Reduced! a shoulder, subtly and painlessly.Emerg Med. 1977; 9: 233-234Google Scholar, 11Milch H. Treatment of dislocation of the shoulder.Surg Gynecol Obstet. 1938; 3: 732-740Google Scholar, 12Mirick M.J. Clinton J.E. Ruiz E. External rotation method of shoulder dislocation reduction.JACEP. 1979; 8: 528-531Abstract Full Text PDF PubMed Scopus (50) Google ScholarThe patient may be in a seated or supine position, with the elbow of the affected arm adducted into the side. Holding the patient’s elbow and wrist with some slight downward traction, slowly externally rotate the shoulder until reaching approximately 180 degrees (Figure 1). Often reduction is accomplished at this point, but if it has not yet occurred, begin the Milch technique.Starting with the arm in an externally rotated position, slowly raise it into a fully overhead position by slowly abducting it through a wide arc, maintaining some traction throughout (Figure 2). Pull the arm straight overhead; then gently place it back into a neutral position over the patient’s abdomen and examine the shoulder for a successful reduction.Figure 2Progressing from external rotation to the Milch technique. While traction is maintained, the patient’s arm is slowly taken through a wide arc, from the patient’s side, into a fully overhead position.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Stimson Plus Scapular Manipulation13Anderson D. Zvirbulis R. Ciullo J. Scapular manipulation for reduction of anterior shoulder dislocations.Clin Orthop Relat Res. 1982; 164: 181-183PubMed Google Scholar, 14McNamara R.M. Reduction of anterior shoulder dislocations by scapular manipulation.Ann Emerg Med. 1993; 22: 1140-1144Abstract Full Text PDF PubMed Scopus (60) Google Scholar, 15Stimson L. An easy method of reducing dislocations of the shoulder and hip.Med Record. 1900; 57: 356-357Google ScholarPosition the patient prone on the gurney with the affected arm hanging straight down toward the floor. Hang weight on the arm, or ask an assistant to pull traction on the “down” arm. With the patient in this Stimson position, begin scapular manipulation.Palpate the inferolateral border of the scapula. Place the thumbs along the scapular border, and with a steady, firm pressure, push the scapula in an upward, medial direction, toward the base of the patient’s neck (Figure 3). This maneuver should rotate the scapula in such a manner to release the humeral head from the inferior glenoid rim and realign the glenoid and humeral head. Reduction is often accomplished with the simultaneous application of pressure to the scapula and downward traction on the arm. This technique may also be applied with the patient in a seated position by applying the same forces in the same directions.Figure 3Scapular manipulation combined with Stimson. With the patient in a prone position, downward traction is applied (large arrow). Placing his thumbs along the inferolateral border of the scapula, the clinician pushes the scapula in an upward, medial direction, toward the base of the patient’s neck (small arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Cunningham16Cunningham N. A new drug free technique for reducing anterior shoulder dislocations.Emerg Med. 2003; 15: 521-524Crossref Scopus (26) Google ScholarThe patient and physician should sit in chairs facing each other at a slight diagonal. The patient slowly places the hand of the affected arm on the corresponding shoulder of the physician and sits straight up, relaxed, with shoulders pulled back.The physician places one forearm in the patient’s antecubital fossa, applying a slight downward force, and with the other, massages the patient’s biceps, deltoid, and trapezius (Figure 4). Reduction should gently occur as the patient relaxes and pulls the shoulders back.Figure 4Cunningham technique, facing the patient diagonally. Note the minimal traction by the clinician’s left hand while he massages with the right, instructing the patient to relax and pull back the shoulders.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Traction-CountertractionThis method has a high success rate and might be a good “final option” if other gentler options have failed. It requires more force and usually requires procedural sedation. Place the patient supine, with a sheet around the lateral chest wall of the affected side. Ask an assistant to hold the sheet from the opposite side. The physician applies traction by holding the patient’s wrist in an externally rotated position and pulling using body weight, with the shoulder abducted approximately 45 degrees. A better alternative for applying traction is to wrap a sheet around the physician’s waist and the patient’s flexed elbow and then lean away, using body weight (Figure 5).Figure 5Traction-countertraction. Sheets around the patient’s elbow and chest wall allow the clinicians to use their own body weight while spreading the forces over a larger surface area.View Large Image Figure ViewerDownload Hi-res image Download (PPT)ImmobilizationTraditionally, immobilization with the shoulder in a comfortable position of internal rotation, using a shoulder sling and swathe, has been recommended for 3 weeks postreduction for most patients. However, it is unclear whether 3 weeks is superior to 1 week with respect to the rate of recurrent dislocation.17Paterson W. Throckmorton T. Koester M. et al.Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature.J Bone Joint Surg Am. 2010; 92: 2924-2933Crossref PubMed Scopus (98) Google Scholar, 18Smith B. Bliven K. Morway G. et al.Management of primary anterior shoulder dislocations using immobilization.J Athl Train. 2015; 50: 550-552Crossref PubMed Scopus (11) Google ScholarSome authors have reported a significantly lower rate of recurrence after the shoulder was immobilized in external rotation, although others found no advantage to external rotation.17Paterson W. Throckmorton T. Koester M. et al.Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature.J Bone Joint Surg Am. 2010; 92: 2924-2933Crossref PubMed Scopus (98) Google Scholar, 18Smith B. Bliven K. Morway G. et al.Management of primary anterior shoulder dislocations using immobilization.J Athl Train. 2015; 50: 550-552Crossref PubMed Scopus (11) Google Scholar, 19Itoi E. Hatakeyama Y. Kido T. et al.A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study.J Shoulder Elb Surg Am. 2003; 12: 413-415Abstract Full Text Full Text PDF PubMed Scopus (194) Google Scholar, 20Khiami F. Gérometta A. Loriaut P. Management of recent first-time anterior shoulder dislocations.Orthop Traumatol Surg Res. 2015; 101: S51-S57Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 21Liavaag S. Brox J. Pripp A. et al.Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence: a randomized controlled trial.J Bone Joint Surg Am. 2011; 93: 897-904Crossref PubMed Scopus (117) Google Scholar It remains unclear whether this form of immobilization should be routinely recommended because its benefit may be partially offset by the inconvenience to the patient.DispositionMost patients should be referred to an orthopedic surgeon for at least 1 follow-up evaluation to discuss surgical options. There is some evidence that young active patients after a first-time dislocation have better functional outcomes after surgery, with less recurrence.22Handoll H. Almaiyah M. Rangan A. Surgical versus non-surgical treatment for acute anterior shoulder dislocation.Cochrane Database Syst Rev. 2004; : CD004325Crossref PubMed Scopus (146) Google Scholar, 23Kirkley A. Griffin S. Richards C. et al.Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder.Arthroscopy. 1999; 15: 507-514Abstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar Also, recurrent dislocators with frequent dislocations may opt for a surgical repair. However, patients who do not desire surgery may follow up with a primary care or sports medicine physician. Surgical techniques are generally directed at the repair of a Bankart lesion (tear of the inferior glenoid labrum), but it is unclear whether an arthroscopic or open approach is superior.23Kirkley A. Griffin S. Richards C. et al.Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder.Arthroscopy. 1999; 15: 507-514Abstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar, 24Pulavarti R. Symes T. Rangan A. Surgical interventions for anterior shoulder instability in adults.Cochrane Database Syst Rev. 2009; : CD005077PubMed Google Scholar IntroductionAnterior shoulder dislocation is the most common large joint dislocation encountered in the emergency department (ED). The age range of patients is wide, although it is most common in young adults and rare in children. Many emergency physicians have developed substantial expertise in the care of these patients. The following is not meant to serve as a comprehensive guide to the care of patients with a shoulder dislocation; instead, it is a description of one approach, based on current evidence and years of practice. Anterior shoulder dislocation is the most common large joint dislocation encountered in the emergency department (ED). The age range of patients is wide, although it is most common in young adults and rare in children. Many emergency physicians have developed substantial expertise in the care of these patients. The following is not meant to serve as a comprehensive guide to the care of patients with a shoulder dislocation; instead, it is a description of one approach, based on current evidence and years of practice. RadiographsAlthough many texts call for routine radiographs before and after the reduction of a shoulder dislocation, the literature does not support this conservative approach. A number of studies support selective radiography, sparing radiographs for recurrent dislocators with an atraumatic mechanism when the physician is clinically confident of the dislocation or reduction.1Harvey R.A. Trabulsy M.E. Roe L. Are postreduction anteroposterior and scapular Y views useful in anterior shoulder dislocations?.Am J Emerg Med. 1992; 10: 149-151Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 2Hendey G. Necessity of radiographs in the emergency department management of shoulder dislocation.Ann Emerg Med. 2000; 36: 108-113Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 3Hendey G. Kinlaw K. Clinically significant postreduction radiographic abnormalities in anterior shoulder dislocations.Ann Emerg Med. 1996; 28: 399-402Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 4Shuster M. Abu-Laban R. Boyd J. Prereduction radiographs in clinically evident anterior shoulder dislocation.Am J Emerg Med. 1999; 17: 653-658Abstract Full Text PDF PubMed Scopus (48) Google Scholar, 5Shuster M. Abu-Laban R. Boyd J. et al.Prospective evaluation of a guideline for the selective elimination of pre-reduction radiographs in clinically obvious anterior shoulder dislocation.CJEM. 2002; 4: 257-262PubMed Google Scholar Radiographs are indicated for patients with a first-time dislocation or when the mechanism involves blunt force trauma that may have produced a fracture, or when the physician is clinically uncertain of the joint position.2Hendey G. Necessity of radiographs in the emergency department management of shoulder dislocation.Ann Emerg Med. 2000; 36: 108-113Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 3Hendey G. Kinlaw K. Clinically significant postreduction radiographic abnormalities in anterior shoulder dislocations.Ann Emerg Med. 1996; 28: 399-402Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 6Emond M. Le Sage N. Lavoie A. et al.Clinical factors predicting fractures associated with anterior shoulder dislocation.Acad Emerg Med. 2004; 11: 853-858Crossref PubMed Scopus (0) Google Scholar However, a common scenario involves a patient with several previous dislocations who sustains a dislocation while reaching up or rolling over in bed. In this setting, the patient may be spared the time, expense, and radiation associated with routine radiography. Some physicians manage this group of patients with no radiography whatsoever.A neurovascular examination should be conducted before and after reduction, with particular attention to sensation over the deltoid (axillary nerve). Documenting a thorough postreduction examination is even more crucial when radiographs are omitted. Although many texts call for routine radiographs before and after the reduction of a shoulder dislocation, the literature does not support this conservative approach. A number of studies support selective radiography, sparing radiographs for recurrent dislocators with an atraumatic mechanism when the physician is clinically confident of the dislocation or reduction.1Harvey R.A. Trabulsy M.E. Roe L. Are postreduction anteroposterior and scapular Y views useful in anterior shoulder dislocations?.Am J Emerg Med. 1992; 10: 149-151Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 2Hendey G. Necessity of radiographs in the emergency department management of shoulder dislocation.Ann Emerg Med. 2000; 36: 108-113Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 3Hendey G. Kinlaw K. Clinically significant postreduction radiographic abnormalities in anterior shoulder dislocations.Ann Emerg Med. 1996; 28: 399-402Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 4Shuster M. Abu-Laban R. Boyd J. Prereduction radiographs in clinically evident anterior shoulder dislocation.Am J Emerg Med. 1999; 17: 653-658Abstract Full Text PDF PubMed Scopus (48) Google Scholar, 5Shuster M. Abu-Laban R. Boyd J. et al.Prospective evaluation of a guideline for the selective elimination of pre-reduction radiographs in clinically obvious anterior shoulder dislocation.CJEM. 2002; 4: 257-262PubMed Google Scholar Radiographs are indicated for patients with a first-time dislocation or when the mechanism involves blunt force trauma that may have produced a fracture, or when the physician is clinically uncertain of the joint position.2Hendey G. Necessity of radiographs in the emergency department management of shoulder dislocation.Ann Emerg Med. 2000; 36: 108-113Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 3Hendey G. Kinlaw K. Clinically significant postreduction radiographic abnormalities in anterior shoulder dislocations.Ann Emerg Med. 1996; 28: 399-402Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 6Emond M. Le Sage N. Lavoie A. et al.Clinical factors predicting fractures associated with anterior shoulder dislocation.Acad Emerg Med. 2004; 11: 853-858Crossref PubMed Scopus (0) Google Scholar However, a common scenario involves a patient with several previous dislocations who sustains a dislocation while reaching up or rolling over in bed. In this setting, the patient may be spared the time, expense, and radiation associated with routine radiography. Some physicians manage this group of patients with no radiography whatsoever. A neurovascular examination should be conducted before and after reduction, with particular attention to sensation over the deltoid (axillary nerve). Documenting a thorough postreduction examination is even more crucial when radiographs are omitted. Analgesia and AnesthesiaShoulder dislocation produces a significant amount of pain and muscle spasm in most patients. Although emergency physicians can significantly reduce pain with intravenous medications, the most effective way to relieve it is to rapidly reduce the dislocation. Thus, 3 reasonable approaches emerge, each of which may be appropriate for various situations:Minimal or No MedicationPatients who present very soon after a dislocation, particularly cooperative patients with a recurrent dislocation, are often amenable to gentle reduction attempts without any medication (see next section). This option is especially applicable to the sports field, the ski slope, or even at ED triage. Examples of minimal medication range from oral ibuprofen, hydrocodone, or lorazepam to a single intramuscular injection of morphine. When successful, this approach can reduce a visit time from several hours to several minutes, with the rapid discharge of a happy patient.Intra-articular InjectionInjection of the glenohumeral joint with 10 to 20 mL of lidocaine or bupivacaine is a quick, simple procedure that provides good analgesia in most patients. Multiple studies comparing joint injection to procedural sedation have demonstrated equal rates of successful reduction, shorter times to discharge from the ED, and no complications.7Fitch R.W. Kuhn J.E. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review.Acad Emerg Med. 2008; 15: 703-708Crossref PubMed Scopus (51) Google Scholar, 8Wakai A. O’Sullivan R. McCabe A. Intraarticular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults.Cochrane Database Syst Rev. 2011; : CD004919PubMed Google Scholar The injection may be accomplished from either a lateral or slightly posterior approach, with ultrasonographic guidance (https://www.youtube.com/watch?v=siGzMvakY8s) or without it (https://www.youtube.com/watch?v=pIBJORPktDY).Joint injection must be conducted with good, sterile technique because it introduces the risk of septic arthritis. However, the procedure appears to be extremely safe, and case reports of subsequent complications are rare.9Esenwein S. Ambacher T. Kollig E. et al.Septic arthritis of the shoulder following intra-articular injection therapy. Lethal course due to delayed initiation of therapy.Unfallchirurg. 2002; 105: 932-938Crossref PubMed Scopus (22) Google Scholar Intra-articular injection is an excellent alternative to procedural sedation because it obviates the need for an intravenous line, monitoring, nursing time, and the small risk associated with procedural sedation medications. Intra-articular injection may easily be combined with minimal sedation and does not preclude procedural sedation if unsuccessful.Procedural SedationProcedural sedation offers excellent muscle relaxation and pain relief to facilitate the reduction of a dislocation, but it exposes the patient to the added time, expense, and potential adverse effects of powerful sedatives. I prefer to attempt most reductions with only minimal sedation or intra-articular injection, but in some cases, procedural sedation is necessary because of a difficult reduction or pain intolerance. Although there are many good pharmacologic options, propofol has the excellent combination of substantial muscle relaxation, rapid onset, and quick recovery. Shoulder dislocation produces a significant amount of pain and muscle spasm in most patients. Although emergency physicians can significantly reduce pain with intravenous medications, the most effective way to relieve it is to rapidly reduce the dislocation. Thus, 3 reasonable approaches emerge, each of which may be appropriate for various situations: Minimal or No MedicationPatients who present very soon after a dislocation, particularly cooperative patients with a recurrent dislocation, are often amenable to gentle reduction attempts without any medication (see next section). This option is especially applicable to the sports field, the ski slope, or even at ED tri