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Clinical Assessment. Findings on physical examination of an anterior dislocation
include a palpable defect just inferior to the acromion, with loss of the usual
rounded contour of the shoulder. On palpation, there is displacement of the
humeral head most commonly anterior to the glenoid fossa, with the arm
frequently held at the side with inability to tolerate any range of motion. Posterior
dislocations are rare, and may present with the arm held in adduction with slight
internal rotation, a flattened appearance anteriorly, and prominent coracoid
process. Inferior dislocations are the rarest form of shoulder dislocation, and the
patient will often present with the arm maximally abducted and adjacent to the
head. Complete examination and documentation should include assessment of
distal neurovascular status before and after reduction. The axillary nerve is the
most commonly injured neurovascular structure, reported in up to 42% traumatic
anterior dislocations.
Management. In order to define the direction of displacement, an additional
axillary (Y) view, should be obtained along with standard views (anteroposterior
and axillary) of the shoulder. Treatment of anterior dislocation through closed
reduction can be accomplished by numerous techniques (see Chapter 130
Procedures , section on Closed Reduction of Dislocations). Pain management is
fundamental for a successful reduction. A wide range of approaches have
demonstrated efficacy from procedural sedation to analgesia with mild sedation to
local intra-articular lidocaine injections. Repeat radiographs are recommended
after reduction to confirm anatomic placement as well as to look for any
traumatic fractures such as Hill–Sachs deformities, Bankart lesions, and greater
tuberosity fractures ( Fig. 111.11 ). The Hill–Sachs deformity is a cortical
depression in the humeral head caused by the glenoid rim at the time of
dislocation. This deformity may destabilize the joint and result in recurrent
dislocation. A Bankart lesion is an avulsion of a bony fragment during anterior
dislocation when the glenoid labrum is disrupted; this lesion is felt to be the
primary lesion in recurrent anterior instability. Given the rarity of posterior and
inferior dislocations, urgent orthopedic consultation in the ED is recommended
for these injuries prior to reduction. Additional indications for consultation

include irreducible dislocations, displaced greater tuberosity fractures, and large
bony glenoid lesions.
After reduction, patients should be placed in a sling and swathe to stabilize the
joint at discharge. Duration and position of the arm during immobilization is
debated. Guidelines range from 1 to 6 weeks of immobilization, but data is poor
on the relationship between duration of immobilization and outcome in skeletally