Closed Reduction of a Dislocated Shoulder
Radiology Cases in Pediatric Emergency Medicine
Volume 4, Case 12
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
A 16 year-old boy is brought to the Emergency
Department by ambulance complaining of pain in his
right shoulder. He was at a shopping center in a
crowded video arcade when he turned suddenly and
struck his shoulder on the edge of a door. He felt his
shoulder pop out.
Exam: He is alert, cooperative, and moderately
anxious in moderate pain. He is of light body build. His
right upper extremity is internally rotated. The head of
the humerus is noted to be protruding anteriorly,
obscuring the deltopectoral groove. There is moderate
tenderness on palpation of the shoulder. No crepitus is
noted. His clavicle is non-tender. His mid and distal
humerus are non-tender. His elbow and forearm are
non-tender. His sensation and pulses are intact distally.
His axillary nerve function is intact (note the method of
View axillary nerve assessment.
In addition to routinely checking distal sensation and
major nerve function, the axillary nerve dermatome
should be routinely tested (by lightly brushing it or
testing pin prick sensation) and documented since it
may be injured during a shoulder dislocation.
He is given some intravenous morphine and is sent
to the imaging department for radiographs of his right
View shoulder radiographs.
Because of this patient's discomfort, he is unable to
fully cooperate with obtaining the proper radiographic
views. Thus, typically, the radiographic evaluation of a
dislocated shoulder involves the interpretation of less
than ideal views of the shoulder. AP and lateral views
should be ideally obtained. The structures are labeled
in the next set of images.
View labels on radiographs.
The position of the humeral head relative to
the glenoid is the most important criterion for
dislocation. Note that the humeral head is medial to
the glenoid and inferior to its normal position, since it
should overlie the glenoid in this view. However, the
humeral head is not entirely below the glenoid itself.
This radiograph is dark, making the visualization of the
clavicle, acromion (acr) and coracoid (co) process
difficult to see. They are outlined here to show their
positions. Note that the humeral head is just inferior to
the coracoid, but not totally inferior to the glenoid. This
"subcoracoid" type of anterior shoulder dislocation is
the most common type.
This view again shows the position of the
humeral head relative to the glenoid. The humeral
head should be overlying the glenoid, but it is clearly
medial to the glenoid and inferior to its normal position.
The acromion (acr) and clavicle are dark. They are
outlined to show their position. This view again
demonstrates the subcoracoid dislocation.
This lateral view may be difficult to interpret
at first unless you can tell how to locate the glenoid.
The glenoid is located by following the lateral border of
the scapula upward. This will lead to the inferior margin
of the glenoid as noted in this labeled view. The
humeral head should be articulating with the glenoid in
this view. However, it is clearly dislocated inferiorly
(relative to its expected position).
Try examining another set of shoulder radiographs
to apply these landmark identifications.
View second set of shoulder radiographs.
View labels on the above radiographs.
The acromion (acr), the clavicle, the
acromioclavicular joint (ac), and the coracoid (co) are
better seen in this radiograph. The glenoid is outlined
in black dots. The humeral head should be overlying
the glenoid. However, the humeral head is medial to
the glenoid and inferior to its expected position. The
humeral head is below the coracoid (co) but not
entirely below the glenoid. This is a another example of
a subcoracoid dislocation.
On this lateral view, locate the glenoid by
following the lateral margin of the scapula upward
(white dots) to the inferior margin of the glenoid (oval
white dots). The humeral head should be articulating
with the glenoid. However, the humerus is slightly
inferior to its expected location. The positions of the
clavicle, acromion (acr), coracoid (co), and sternum (st)
Such anterior dislocations of the shoulder commonly
present to an emergency department. Shoulder
dislocations are often associated with capsular tears
and, in older patients, avulsion fractures may also be
The three types of anterior shoulder dislocations:
subclavicular, subcoracoid (most common), and
subglenoid, are diagrammed below compared to the
normal shoulder anatomy.
View shoulder diagrams.
The dislocated humerus is labeled as "D" while the
expected normal location of the humerus head drawn in
a broken line is labeled as "N".
Both sets of radiographs displayed above show
subcoracoid dislocations. Note that while the humeral
head is inferior to its expected position articulating with
the glenoid (subcoracoid), the humeral head is not
entirely inferior to the glenoid (a subglenoid dislocation).
Many textbooks will recommend that radiographs of
the shoulder be obtained for all dislocations. In older
adults, associated fractures are not uncommon.
Fractures are less common in teenagers. A typical
history and a cooperative teenager would generally
indicate that no fracture is present. Loss of the normal
delto-pectoral groove is indicative of an anterior
dislocation since the humeral head commonly
protrudes anteriorly into this space.
View delto-pectoral groove.
This model shows a normal delto-pectoral groove
(arrows). This groove is normally not visible in an
anterior shoulder dislocation. The non-affected side
can be compared clinically.
In younger children with shoulder deformities,
radiographs are mandatory since a dislocated
shoulder is uncommon (fractures are more common).
Thus, are radiographs necessary in a teenager with
a typical anterior shoulder dislocation? It would seem
that such a patient is at low risk for fracture. Obtaining
radiographs may be an unnecessary delay that would
prolong the discomfort for such patients. Since poor
radiographs are often obtained initially, perhaps it would
be better to obtain radiographs following closed
reduction if clinical factors suggest this to be beneficial.
Higher quality radiographs would be obtained, the
patient would not suffer as long, and any complications
can be identified more definitively (because of better
radiographs) to receive appropriate care. Decisions on
when to obtain radiographs are not without controversy.
Understanding the pros and cons of obtaining
radiographs can assist you in deciding on whether to
obtain radiographs pre-reduction, post-reduction, both
pre- and post-reduction, or not at all.
Following closed reduction, the axillary nerve should
be reassessed. The joint should be palpated for any
signs of fracture. Range of motion should be
documented. The patient should feel as though their
shoulder is "back to normal". The patient should be
placed in a shoulder immobilizer. Follow-up with their
primary care physician or an orthopedic surgeon should
be arranged. Recurrent dislocations are common, and
these should be referred to an orthopedic surgeon to
consider corrective surgery (for ligament laxity).
Complications of an anterior shoulder dislocation
include: rotator cuff tears, avulsion of the greater
tuberosity, brachial plexus injury, axillary nerve injury,
humeral head fracture, glenoid rim fracture, etc. Most
of these complications are more common in older
patients (adults). Occasionally, soft tissue (rotator cuff,
capsule, muscle, or tendon) will be interposed in the
joint, making closed reduction difficult or impossible.
Orthopedic surgery is indicated for these patients.
Posterior shoulder dislocations are less common
and beyond the scope of this discussion. Posterior
dislocations should generally be referred to an
We will review four popular methods of closed
reduction of an anterior shoulder dislocation; 1) external
rotation, 2) Stimson (dangling weights) technique, 3)
traction-countertraction, and 4) scapular manipulation.
External rotation method:
This method is highly effective and is conceptually
the simplest since it does not require diagrams to
understand. This is the preferred reduction method of
one text (1) and my favorite as well.
View external rotation method.
With the patient's back (both shoulders) against the
gurney in the supine position, the affected upper
extremity is adducted against the torso. The elbow is
flexed to 90 degrees so that the long axis of the forearm
points to the ceiling (as noted in the photo). The upper
arm is externally rotated slowly and gently, using the
forearm as an external rotation lever. No traction
(pulling) is required. The rotation is halted as pain is
produced, then continued as muscle spasm and pain
subside. Reduction occurs spontaneously as the
forearm is rotated externally from the sagittal plane
(vertical in the supine patient) to the coronal plane
(horizontal in the supine patient). This maneuver can
also be performed with the patient sitting up or at 45
While this method is almost always successful, one
text recommends that if reduction does not occur
spontaneously after external rotation, the arm should be
slowly elevated and the humeral head should be lifted
into the socket.
Stimson (dangling weights) technique:
This technique involves the use of weights attached
to the wrist/forearm.
View Stimson technique.
The patient is positioned prone. 5 to 10 kg (10 to 20
pounds) of weight are strapped to the wrist or forearm
of the affected upper extremity. A special velcro wrist
brace can be used to attached the weights to the wrist,
or a soft restraint can also be used. The weighted arm
dangles, placing constant traction on the shoulder,
which gradually overcomes muscle spasm, and
reduction occurs spontaneously after about 20 to 30
minutes. Analgesia and/or muscle relaxation is
recommended. If reduction does not occur
spontaneously, reduction may be achieved by gently
rotating the humerus externally and then internally with
There are three things that I don't like about the
Stimson technique. 1) It is slow. 2) Most teenagers are
tall and our gurneys cannot be raised high enough to
prevent the dangling weights from touching the floor.
Note this in the photo. Additionally, patients tend to roll
toward their affected shoulder lowering the weights
further. 3) Since these patients are usually sedated,
and reduction occurs after some delay, a nurse must
watch the patient continuously to prevent the patient
from falling asleep and rolling off the gurney.
There are several variations on this method. All of
them involve inferior and/or lateral traction of the upper
View traction method #1.
In this traction-countertraction method (#1), two
persons are required. One person pulls downward on
the affected arm (traction). The other person provides
counter traction in the opposite direction by pulling on a
sheet wrapped around the upper chest under the axilla
of the affected shoulder.
View traction method #2.
This method #2 is similar to traction method #1,
except that upward lateral traction is added by a third
person using another sheet as shown. This method is
not routinely recommended.
View traction method #3.
This method #3 was recently described in the
American Journal of Sports Medicine by sports
medicine clinics serving skiers in Utah. This report
refers to it as the Snowbird reduction technique. With
the patient sitting upright on a fixed chair (without
wheels), a one-meter loop of 10 cm (4-inch) cast
stockinette is hung from the patient's elbow of the
affected arm. The elbow is flexed. Downward traction
is provided by gradually applying downward tension on
the loop using your foot. The operator should assist the
patient in maintaining this elbow flexion to prevent the
loop from slipping. Countertraction is provided by the
chair, however, an assistant can be helpful by clasping
his hands around the chest in the axilla of the affected
shoulder to prevent the patient from tilting toward the
downward traction. The operator providing downward
foot traction can use his/her hands to apply rotation if
View traction method #4.
This method #4 is known as the Hippocratic method.
While many clinicians use this method, several
textbooks indicated that this method should NOT be
used. There are more effective methods than this one.
Scapular manipulation method:
This method is intriguing and is reported to be highly
effective. Forward traction is provided by pulling on the
forearm with countertraction over the clavicle as noted
in the photograph.
View scapular manipulation method.
As one operator provides the forward traction, a
second operator from the patient's back manipulates
the scapula by pivoting it clockwise for a right shoulder
and counter clockwise for a left shoulder. This is done
by pushing the inferior tip medially (adducting it) with
both thumbs as shown, while supporting the top of the
An alternative way of doing this is to have the
patient prone with forward traction provided by weights
attached to the affected arm as in the Stimson
technique. The scapula is then manipulated in the
Which method is the best to try first?
Only four methods would qualify to be considered
here. The external rotation method, the Stimson
technique, the Snowbird technique (traction method
#3), and scapular manipulation. I have only tried the
external rotation method and the Stimson technique
myself. Of these two, I find the external rotation
method to be preferable. The problems with the
Stimson technique limit its use. The best
traction-countertraction method seems to be the
Snowbird technique (traction method #3). However, it
is not as "elegant" as the external rotation method or
the scapular manipulation method. The external
rotation method is the simplest. The Snowbird
technique requires a somewhat elaborate set-up. The
scapular manipulation method has been shown to be
less successful when performed by inexperienced
operators. Thus, it is not the simplest method here.
However, all of these methods have been reported to
be highly effective overall.
Which method is the least painful?
The two recently described techniques in the
literature, the Snowbird technique and scapular
manipulation, were reported to be less painful
compared to other methods. This was concluded
because only a small fraction of the patients required
narcotic analgesics and/or benzodiazepines. While
most texts recommend narcotic analgesics and/or
benzodiazepines routinely, this often is not done. I
generally recommend IV narcotic analgesics and/or
benzodiazepines to patients prior to reduction.
However, in my experience, more than half the
teenagers decline this (when the patient is empowered
to make this decision) because it will delay reduction
which is what they really want. In these instances
where IV medications are declined, reduction using the
external rotation is achieved quickly and patients
tolerate it well. However, it is intriguing that the
scapular manipulation method is reported to be the
least painful in an uncontrolled study. Because of this,
it should be considered after identifying the anatomic
landmarks and practicing the technique on a colleague
(without a dislocated shoulder of course).
1. The Shoulder and Upper Arm. In: Simon RR,
Koenigsknecht SJ. Emergency Orthopedics: The
Extremities, second edition. Norwalk, CT, Appleton &
Lange, 1987, pp. 323-332.
2. Lyman JL, Ervin ME. Management of Common
Dislocations. In: Roberts JR, Hedges JR (eds).
Clinical Procedures in Emergency Medicine.
Philadelphia, W.B. Saunders Company, 1985, pp.
3. Westin CD, Gill EA, Noyes ME, Hubbard M.
Anterior Shoulder Dislocation: A Simple and Rapid
Method for Reduction. Am J Sports Med
4. Kothari RU, Dronen SC. Prospective Evaluation
of the Scapular Manipulation Technique in Reducing
Anterior Shoulder Dislocations. Ann Emerg Med
5. McNamara RM. Reduction of Anterior Shoulder
Dislocations by Scapular Manipulation. Ann Emerg
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