Shoulder Dislocations

NP here….What are your thoughts on shoulder dislocations? Does an anterior dislocation require immediate reduction? What if they go out to ED and come back dislocated again? It is thought that these offenders dislocate on purpose in order to go on a field trip. I have heard that anterior dislocations do not need to be reduced as they do not cause neurovascular problems. What has been your experience? Thought?  Thank you for your time!

Great topic! You have asked two questions here. The first question is whether shoulder dislocations need to be reduced immediately (since transporting a jail patient to the ER after hours can be a hassle) or whether the dislocation can wait until the next day to be reduced. The second questions is how to handle those patients who can dislocate and relocate their shoulders at will, and will use this trick to manipulate both the jail and ER staff.

The first question is easier. Can a patient with a shoulder dislocation wait until the next day to have the dislocation reduced? The short answer is “No.” Shoulder dislocations need to be reduced as soon as possible. There are several reasons for this.

  1. The first is that the dislocation has torn and stretched the ligaments that normally hold the shoulder joint in place. The longer the shoulder is out of place, the more damage these ligaments sustain and the longer it will be until they heal.
  2. The second reason that shoulder dislocations should be reduced as soon as possible is that the rim of the glenoid can cause a divot-like fracture of the humeral head called a Hills-Sachs deformity. The longer the rim of the glenoid is putting pressure on the head of the dislocated humerus, the worse this lesion can become.
  3. The third reason to reduce shoulder dislocations quickly is that there is indeed a potential for neurovascular damage. First, the axillary nerve can be injured, resulting in decreased sensation to the deltoid region. Axillary nerve injuries occur in around 10% of shoulder dislocations and so are not uncommon. More severe brachial plexus injuries can also occur, but, fortunately, are rare. Finally, the axillary artery can be injured, though this is rare (<1%). Heaven help you if you miss it, though!
  4. The fourth reason to reduce anterior shoulder dislocations quickly is a medico-legal argument. Even when reduced quickly, many of these patients will continue to have shoulder problems–like recurrent dislocations, associated injuries, arthritis, etc. You do not want them blaming these problems on you because you delayed their treatment!
  5. The final reason to reduce shoulder dislocations quickly is that it is so easy to do. The newer techniques, such as scapular retraction or the Mich technique can often reduce shoulder dislocations even without sedation or anesthesia! If you do not know how to reduce a shoulder dislocation, talk to your nearest friendly ER doctor, who will teach you how. Or even just watch the techniques online.

The Voluntary Dislocator

The second question is harder. There are those individuals who, because of multiple previous dislocations, can voluntarily dislocate and relocate their shoulders at will. For most of these patients, this is simply a trick to amuse their friends. Some patients like this, however, use this ability to manipulate medical staff. When I worked as an Emergency Physician (in my previous life), I saw several such patients who demanded large doses of IV narcotics before they would allow their shoulders to be reduced. Now that I am a Correctional Physician, I see these same patients again, since they tend to end up in jail. When voluntary dislocators end up in jail, they commonly dislocate their shoulders and demand to be taken to the ER or to be given narcotics at the jail. Since they cannot be reduced without their cooperation, you are kind of stuck between acceding to their demands (bad idea) or leaving them dislocated–and worrying about the potential complications and liability.

The key insight to successfully managing a complicated and manipulative patient like this is The Patient Case Conference. You have to get all of the people involved in this case together in the same room or on a conference call and jointly make a treatment plan. For the voluntary dislocator, such a conference would include an ER representative, an orthopedist who knows about the patient, the jail representative and whoever else you want there–like mental health and jail security. As the patient’s current Primary Care Practitioner, you would present the case and then the attendees would discuss how to proceed.

The best long term solution for a voluntary dislocator would be to have surgery to tighten up their shoulder so that they cannot voluntarily dislocate anymore. If the patient is not willing to agree to this, or if there is some other reason the surgery cannot be scheduled, then the conference attendees need to decide about the proper use of narcotics for this patient, when he needs to go to the ER and when he can be left dislocated, etc. I have found that when voluntary dislocators no longer receive narcotics when they go to the ER, often they don’t demand to go there anymore. A Case Conference like this where all of the relevant specialists agree on a care plan is like gold to the primary practitioner, because it gets you off the hook for making decisions that the patient may not like.

As always, what I have written here is my personal opinion, based on my training, research and experience. I could be wrong! You are free to disagree, but if you do, please say why in comments!

How do you handle patients who can voluntarily dislocate their shoulder in your facility? Please comment!

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