Glenohumeral dislocations make up more than half of all dislocations seen by emergency medicine physicians.

The glenohumeral joint can dislocate anteriorly, inferiorly, posteriorly, or superiorly.

In anterior or anteroinferior dislocations, the humeral head becomes dissociated from the glenoid fossa and can rest under the inferior rim of the glenoid, beneath the coracoid process and less commonly in an intrathoracic or subclavicular position (Figure 1.16).⁴

• 
  

  Anterior or anteroinferior shoulder dislocation is the most common type of traumatic instability, representing more than 90 percent of dislocations.

  
  
• 
  

  A Bankart lesion (Figure 1.17) and avulsion of the inferior glenohumeral ligament and labrum complex from the glenoid is the most common structural injury with shoulder dislocation occurring in greater than 90 percent of injuries.

  
  
  
  
  • 
    

    A Bankart lesion occurs when the labrum detaches with or without a bony fragment.

  
  
• 
  

  Humeral avulsion of the glenohumeral ligament occurs less than 10 percent of the time.

  
  
• 
  

  A Hill–Sachs lesion (Figure 1.18) is an impression fracture on the posterior humeral head that results from abutment against the anterior glenoid rim as it dislocates.

  
  
• 
  

  A Hill–Sachs lesion, glenohumeral ligament avulsion and Bankart lesion can all contribute to instability.

  
  
• 
  

  Anterior and anteroinferior dislocation occurs after a force is applied to an abducted and externally rotated arm.

  
  
• 
  

  The risk of dislocation is higher in individuals with a prior dislocation and they may dislocate during general daily activities.

  
  
• 
  

  The younger a patient is at the initial injury, the higher the likelihood of recurrence: age less than 20, 80 percent or greater; age 20–40, 26–48 percent; age greater than 40, 0–10 percent.

Dislocations commonly happen following a traumatic injury.

• 
  

  This can occur in contact sports like football and hockey, or from activities like throwing or reaching for an overhead object where the shoulder is flexed greater than 90° with slight external rotation.

  
  
• 
  

  Other scenarios where dislocation may occur include falls, motor vehicle accidents, lightning strikes, and seizures.

Patients usually complain of severe shoulder pain.

Additionally, patients may note deformity and inability to use the arm.

Typically, “squaring” of the shoulder is present with a loss of normal deltoid contour when compared to the uninjured shoulder.

Decreased active and passive range of motion will be present.

Patients will often refuse to move the shoulder.

The humeral head may be prominent anteriorly.

It is essential to document neurovascular findings pre and post reduction.

• 
  

  The axillary nerve is the most commonly injured nerve as the neurovascular bundle passes anterior to the glenohumeral joint.

X-rays are always indicated when a dislocation is suspected.

• 
  

  A shoulder trauma series should include an anterior-posterior (AP) view with the beam at right angle to the scapula (Figure 1.19), a “Y” view (true lateral) with the scapular wing seen “edge on,” (Figure 1.20) and an axillary view (Figure 1.21).

At a minimum, post-reduction radiographic views include an AP view and an axillary view.

It has been suggested that point-of-care ultrasound can also be an imaging modality used to diagnose glenohumeral dislocation and confirm reduction.⁵

Generally, CT scan and MRI are not indicated in the ED setting.

ED treatment includes prompt pain control and reduction of the dislocation.

Reduction is easiest before the onset of muscle spasm and pain; however, this is not common in the ED setting.

Recurrent dislocations are often more easily reduced.

Procedural sedation can be utilized to allow for reduction maneuvers.

Recent systematic review has suggested that reduction can be obtained using intra-articular lidocaine injection as an alternative to procedural sedation.

• 
  

  This study demonstrated decreased emergency department time and complications for intra-articular lidocaine compared with IV sedation.

  
  
• 
  

  This method may be considered as the first option for reducing shoulder dislocations.⁶

Ultrasound-guided brachial plexus and interscalene nerve blocks are additional alternatives to procedural sedation and intra-articular lidocaine injection.

Many reduction maneuvers exist. The most common are described here.

Traction/countertraction technique (Figure 1.22)

• 
  

  With the patient in a supine position, have an assistant wrap a sheet around the waist, through the patient’s axilla, and across the patient’s chest to provide counter traction. Alternatively, the patient can be secured to a stationary object if no assistant is available.

  
  
• 
  

  The operator then applies axial traction to the patient’s arm with a sheet wrapped around his or her own waist and the patient’s forearm with the elbow bent to 90°.

  
  
• 
  

  Successful reduction is usually indicated by a soft, palpable clunk and return of mobility.

Scapular manipulation technique (Figure 1.23)

• 
  

  This is most easily accomplished with the patient prone but can also be performed with the patient seated.

  
  
• 
  

  In the seated position, brace the uninjured shoulder firmly against a rigid support like a wall or the raised head of a hospital stretcher.

  
  
• 
  

  Have an assistant face the patient and gently raise the wrist of the affected arm until the shoulder is flexed to 90°.

  
  
• 
  

  The assistant then places the palm of his or her free hand against the midclavicular area of the injured shoulder for stabilization and gently puts anterior traction on the patient’s arm.

  
  
• 
  

  While forward traction is applied, the operator manipulates the scapula by adducting the inferior tip using thumb pressure and stabilizing the superior aspect with the upper hand.

  
  
• 
  

  In a prone position, have an assistant apply downward traction to the affected arm or use 5–10 pounds of hanging weight for traction prior to manipulating the scapula as described earlier.

Stimson or hanging weight technique (Figure 1.24)

• 
  

  This technique requires continuous patient observation.

  
  
• 
  

  Place the patient in a prone position.

  
  
• 
  

  Hang the affected arm over the edge of the bed with 10 pounds of weight for traction.

  
  
• 
  

  Spontaneous reduction usually occurs within 10–20 minutes.

  
  
• 
  

  If reduction is not accomplished, use the prone scapular manipulation technique.

After successful reduction the patient will require immobilization with a sling, sling and swathe, or shoulder immobilizer (Figure 1.25).

Significant controversy exists regarding the type and position of immobilization and duration of immobilization.

Studies have suggested that immobilization in external rotation (Figure 1.26) increases contact force between a Bankart lesion and the anterior glenoid rim, possibly influencing healing. In another study, decreased rate of recurrence (26 vs. 42 percent) was found following immobilization in external rotation compared with internal rotation; however, both remained high and noncompliance complicates treatment (53 vs. 72 percent).⁴

Patients should be counseled on non-weight bearing of the arm during the initial immobilization treatment phase.

For pain control, NSAIDs are the first line of treatment for pain and inflammation.

Providers might also consider adjunctive treatment with acetaminophen and narcotic pain relievers in certain cases.

Cold treatment modalities might also provide pain relief for patients.

Patients may be discharged safely after successful reduction of their shoulder dislocation.

Definitive treatment will most likely require rehabilitation and may include surgical stabilization.

Patients may be discharged safely after successful reduction of their shoulder dislocation.

An orthopedic surgery consult is indicated when ED providers are unable to perform a successful reduction, a fracture is present, or there is neurologic or vascular compromise.

Some patients may require admission if one of these complications is present.

Uncomplicated shoulder dislocation patients should follow-up with an orthopedic or sports medicine specialist within 3–5 days after discharge.

• 
  

  It is important to encourage close outpatient follow-up to ensure reassessment and avoid prolonged immobilization, which can lead to frozen shoulder (adhesive capsulitis), especially in older patients.

Return to work or sports occurs when the patient has full range of motion and near symmetric strength.

Several complications from shoulder dislocation are possible.

• 
  

  If attempts at closed reduction fail or signs of neurovascular injury develop, patients may require closed or open reduction in the operating room under general anesthesia.

  
  
• 
  

  Reduction injuries can occur, and it is important to use the least amount of force during reduction to avoid creating or exacerbating existing fractures, nerve and vascular injuries.

  
  
• 
  

  In patients greater than 40 years old, the risk of rotator cuff tear occurring with shoulder dislocation is significant increased, up to 40 percent in those older than 60.

  
  
• 
  

  Failure to recognize neurologic or vascular injury can lead to significant morbidity.

  
  
• 
  

  Patient noncompliance can lead to increased risk of recurrent dislocation.

  
  
• 
  

  Recurrent dislocations can lead to development of osteoarthritis.

  
  
• 
  

  Younger patients are more susceptible to recurrent dislocation.

  
  
• 
  

  While it is important to immobilize the affected shoulder initially, the patient should also be warned about complications of prolonged immobilization.

Shoulder dislocations in general are rare in children.

Most often they occur near the time of skeletal maturity in adolescents participating in contact sports.

Children have weaker epiphyseal growth plates that are more likely to fracture before dislocation occurs.

Chronic instability can occur in pediatric patients and is often due to an underlying connective tissue disorder (e.g., Marfan and Ehler–Danlos syndromes) or multidirectional instability.

On examination the shoulder may be unstable in several planes and these patients may demonstrate multiple lax joints.

Ensure patient’s pain is controlled and muscles are relaxed prior to attempting reduction.

In patients with recurrent dislocation, ask what reduction method has been successful in the past.

When choosing a reduction method, consider patient volume, staffing, and available equipment.

Consider intra-articular lidocaine injection as a first line option for reduction.

Use the minimum amount of force necessary during reduction to avoid causing new injury or exacerbating an existing one.

In elderly and pediatric patients, use extra caution during reduction and avoid causing friction injury to skin if sheets or straps are utilized.

Always consider alternative diagnoses, like coexisting cervical spine injury.

Other disorders such as myocardial infarction and splenic rupture can present with shoulder pain.⁷

Posterior shoulder dislocation results from glenohumeral dissociation where the humeral head is displaced posteriorly.

• 
  

  Posterior shoulder dislocation is an uncommon injury, accounting for less than 4 percent of shoulder dislocations.

  
  
• 
  

  Most of these injuries will reduce spontaneously unless there is an associated fracture.⁸

  
  
• 
  

  These injuries are commonly missed initially (up to 80 percent) by treating physicians and diagnosis within six weeks of injury is considered acute.

  
  
• 
  

  Reverse Hill–Sachs and Bankart lesions are common injuries associated with posterior shoulder dislocations.

The mechanism of injury is traumatic, usually occurring after a direct force to the anterior shoulder or a force directed posteriorly on an adducted, flexed, and internally rotated upper extremity.

Common historical features include direct blow to the anterior shoulder, seizure, electrocution, high-speed motor vehicle accident, and fall on an outstretched arm.

On physical exam, findings are less obvious than in anterior dislocation.

• 
  

  Patients generally hold their arm internally rotated and tight at their side.

  
  
• 
  

  Patients will be unable to actively or passively externally rotate or abduct their arm.

  
  
• 
  

  Fullness may be palpated posteriorly.

Essential imaging includes a shoulder trauma series.

• 
  

  The shoulder may appear normal on the AP view.

  
  
• 
  

  An axillary or Y view is required for diagnosis.

  
  
• 
  

  Abnormalities include loss of the normal elliptical overlap between the glenoid rim and humeral head on the AP view, and loss of normal alignment at the glenohumeral joint on the axillary view(Figures 1.27 and 1.28).

  
  
• 
  

  A “lightbulb sign” may be present on the AP view.

  
  
  
  
  • 
    

    This occurs when the humerus dislocates and internally rotates in posterior shoulder dislocation, causing the head contour to resemble a lightbulb when viewed from the front.⁹ (Figure 1.29)

    
    
  • 
    

    If x-ray is not diagnostic, consider CT for definitive diagnosis.

ED treatment is similar to anterior shoulder dislocation. A traction/countertraction technique should be used to achieve reduction.

• 
  

  The patient is placed in a supine position and a sheet is fixed around an assistant’s waist or a stationary object and wrapped around the patient’s chest through the axilla.

  
  
• 
  

  The operator then will loop a sheet around his or her waist and provide traction on the patient’s forearm with the elbow flexed to 90°.

  
  
• 
  

  Traction is applied smoothly and firmly with the shoulder held in adduction and internal rotation.

  
  
• 
  

  The assistant can provide gentle pressure on the humeral head in a posterior and lateral direction to disengage it from the glenoid.

  
  
• 
  

  After the humeral head is disengaged, the arm can be externally rotated with caution as humeral fracture can occur if the humerus is not completely disengaged from the glenoid.

Post-reduction treatment and disposition is identical to anterior shoulder dislocation and should include radiographic imaging, repeat exam with careful attention to neurovascular exam, immobilization, and follow-up instructions.

Complications from posterior shoulder dislocation include the following:

• 
  

  Humerus fracture

  
  
• 
  

  Acute redislocation

  
  
• 
  

  Avascular necrosis

  
  
• 
  

  Posttraumatic osteoarthritis

  
  
• 
  

  Joint stiffness and functional limitation

Posterior shoulder dislocation in pediatric patients is extremely rare and has not been well studied.

Making the correct diagnosis is critical in posterior shoulder dislocation.

A complete shoulder trauma x-ray series is essential for diagnosis and includes AP, axillary, and Y views.

• 
  

  An axillary view is essential to rule out a posterior shoulder dislocation, and if needed, help the x-ray technician to achieve appropriate patient positioning.

Chronic posterior dislocation and complex fracture dislocation will likely require open reduction and internal fixation or humeral head replacement.

Intra-articular lidocaine injection is more difficult to perform in posterior shoulder dislocation, but can be used by experienced providers.

Smooth, firm traction is required for successful reduction. Providers should not become impatient and use excessive force or impatient maneuvers.

Impatience or excessive force can lead to increased likelihood of complications.

Aftercare must include complete neurovascular examination and postreduction radiographs.

Seek input from orthopedic surgery consultant, as this injury is rare.

Inferior shoulder dislocation is a rare but serious type of shoulder dislocation.

The mechanism of injury is hyperabduction of the arm where the neck of the humerus is leveraged against the acromion and the humeral head is forced out inferiorly.

This requires significant force, such as during a motor vehicle accident.

Patients will present with an obvious visual dislocation with the arm stuck overhead, and will complain of severe pain and inability to move the shoulder.

On exam the patient’s shoulder will be locked in abduction with their arm held against or behind their head.

• 
  

  The dislocated humeral head may be palpable along the lateral border of the chest wall.

A complete shoulder trauma x-ray series including AP, axillary, and Y views is essential due to the high incidence of associated fractures.

• 
  

  The humeral shaft will be seen parallel to the spine of the scapula with the humeral head sitting inferior to the glenoid (Figure 1.30).

ED treatment is similar to anterior and posterior shoulder dislocation. An axial (in-line) traction or two-step method should be utilized for reduction.

To perform the axial traction method, place the patient in a supine position. The operator should be at the patient’s head on the affected side.

• 
  

  An assistant can provide countertraction using a sheet wrapped around the waist and across the patient’s chest and above the affected shoulder.

  
  
• 
  

  The operator then applies axial traction in line with the abducted arm.

  
  
• 
  

  Increase the degree of abduction and apply cephalad pressure to the humeral head to assist in reduction.

  
  
• 
  

  After the reduction the arm should be immobilized in full adduction and supination.

The two-step reduction method requires converting the inferior dislocation to an anterior dislocation (step one) then reducing the anterior dislocation (step two).

• 
  

  With the patient supine, the operator stands at the patient’s head on the affected side.

  
  
• 
  

  The hand closest to the patient is placed on the lateral aspect of the patient’s mid-humerus with the other on the medial condyle.

  
  
• 
  

  The operator pushes anteriorly with the hand on the mid-humerus and pulls posteriorly with the hand on the medial condyle. This will bring the humeral head into an anterior position.

  
  
• 
  

  Next, adduct the patient’s arm and move the hand on the medial condyle to grasp the wrist.

  
  
• 
  

  With the arm in adduction, externally rotate the shoulder by pulling on the wrist.

  
  
• 
  

  After reduction is accomplished, immobilize the arm in adduction and supination.¹⁰

Post-reduction treatment and disposition is identical to anterior and posterior shoulder dislocation and should include radiographic imaging, repeat exam with careful attention to neurovascular exam, immobilization, and follow-up instructions.

Complications of inferior shoulder dislocation include:

• 
  

  Avulsed capsule

  
  
• 
  

  Rotator cuff tear

  
  
• 
  

  Fracture of the acromion, clavicle, inferior glenoid fossa, or greater tuberosity

  
  
• 
  

  Neurovascular injury including brachial plexus injury

  
  
• 
  

  Vascular injury including axillary vein thrombosis¹¹

There is limited literature regarding inferior shoulder dislocation in pediatric patients. Evaluation and treatment should follow that for adult patients.

80 percent of patients with inferior shoulder dislocation will have associated fracture of the greater tuberosity or rotator cuff tear.

60 percent will have neurologic compromise and 3 percent will have vascular injury.

AC joint sprain and separation occurs from trauma to the joint and the surrounding AC ligaments and coracoclavicular (CC) ligament. It is commonly referred to as a separated shoulder.

In adults, the normal width of the AC joint is 1–3 mm.

• 
  

  May be wider in children or adolescents and narrower in older adults.

There are six types of injuries classified by the Rockwood classification system:

• 
  

  Type I: Ligament sprain without tearing or rupture of ligaments

  
  
• 
  

  Type II: AC ligaments are torn and the CC ligaments are sprained.

  
  
• 
  

  Types III–VI: AC and CC ligaments are torn and further classification is based upon direction of displacement of the distal clavicle.

The mechanism of injury is typically impact from a collision or from a fall onto the shoulder with the arm in the adducted position.

This type of injury will cause a sprain or disruption of the AC ligaments first, followed by the CC ligament.

Indirect injury to the AC joint can occur, for example, from a fall on an outstretched hand.

• 
  

  These injuries will usually only affect the AC ligaments and spare the CC ligament.

The patient with AC joint injury will typically present complaining of shoulder pain that localizes to the AC joint.

• 
  

  They will often splint the arm in an adducted position and will be hesitant to range the shoulder when asked.

  
  
• 
  

  There may be an obvious deformity of the shoulder, depending on the severity of injury.

  
  
  
  
  • 
    

    This injury may be confused with a shoulder dislocation.

On physical examination, an abnormal contour of the shoulder may be present when compared to the contralateral side.

• 
  

  On inspection, bruising, swelling, and tenting can all be noted near the AC joint.

  
  
• 
  

  Patients will have significant tenderness at the AC joint.

  
  
• 
  

  To assess for stability of the AC ligaments, attempt to translate the clavicle in an anterior-posterior direction.

  
  
• 
  

  Vertical stability confirms the integrity of the CC ligament and is tested by moving the clavicle in the cephalad and caudal directions.

  
  
• 
  

  The crossover test will be positive in these patients.

  
  
• 
  

  Neurovascular injury is possible, and one should perform a complete neurovascular examination of the affected extremity.

Essential diagnostics include a shoulder trauma x-ray series.

• 
  

  An AP view is necessary and should include both clavicles and shoulders.

  
  
• 
  

  An axillary view will help to assess the anterior posterior displacement of the clavicle (important for diagnosing type IV injuries).

  
  
• 
  

  Stress views are generally not required in the ED setting.

There are six types of ligamentous injuries to the AC joint (Figure 1.31):

• 
  

  Type I: X-rays will be normal.

  
  
• 
  

  Type II: X-rays will demonstrate slight widening of the AC joint and the distal clavicle may be slightly elevated compared to the contralateral side.

  
  
• 
  

  Type III: X-rays will show significant increased displacement of the distal clavicle as well as widening of the CC space.

  
  
• 
  

  Type IV: Axially x-ray will show posterior displacement of the clavicle.

  
  
• 
  

  Type V: X-rays will show significant increased displacement of the distal clavicle as well as of the CC space.

  
  
• 
  

  Type VI: These types of injuries are extremely uncommon. On x-ray the distal clavicle will be visualized in a subcoracoid or subacromial position.

The type of injury sustained drives treatment in the ED.

Type I: X-rays will be normal. Advise patients on rest, ice, and use of a sling for 7–10 days.

Type II: X-rays will demonstrate slight widening of the AC joint. Advise patients to use a sling for up to two weeks. They will often require rehabilitation in physical therapy.

Type III: X-rays will show significant increased displacement with stress views. Definitive treatment is usually nonsurgical but surgical repair may be advised by some surgeons, especially for athletes or laborers.

Type IV: Axillary x-ray will show posterior displacement of the clavicle. If closed reduction is possible, treat like a type III injury, otherwise these patients will require emergency orthopedics consult for surgical reduction and repair.

Type V: Gross displacement is noted on x-ray. Patients will require emergency orthopedic surgery consult. Definitive treatment is generally with open reduction and internal fixation.

Type VI: These types of injuries are extremely uncommon. On x-ray the distal clavicle will be visualized in a subcoracoid or subacromial position. If closed reduction is possible, treat like a Type III injury, otherwise these patients will require ORIF.

Fracture of distal clavicle associated with rupture of the CC ligament often will require surgical intervention.

Patients with Type I, Type II, and Type III injuries can be safely discharged from the ED. They will require routine follow-up with their primary care provider or in the orthopedic or sports medicine clinic.

Patients with Type IV, Type V, and Type VI injuries and injuries associated with fractures will require orthopedic consultation and disposition.

NSAIDs are first line of treatment for pain control. More significant injuries may require opiates for analgesia.

Patients may return to work or sports once they have normal strength, and full pain-free range of motion.

Complications may occur with both nonsurgical and surgical treatment of AC joint injury.

• 
  

  Complications of nonoperative treatment include skin breakdown as well as osteolysis at the distal clavicle and degenerative changes at the AC joint.

In pediatric patients, consider performing a Zanca (AC joint) view (Figure 1.32) to exclude associated fractures.

• 
  

  A Zanca view is an AP view with the beam directed toward the AC joint with 10°cephalic tilt, with the voltage idealized for soft tissue to avoid over penetration.

Pediatric injuries are classified using the Dameron and Rockwood classification system, which is very similar to the Rockwood adult classification system.

Treatment for pediatric injuries essentially follows that for adult injury.

Concomitant injuries do occur and can be masked by the more painful AC joint injury.

Stress views are generally not obtained in the ED.^{12, 13}

Sternoclavicular (SC) joint dislocation occurs when the medial end of the clavicle becomes displaced anteriorly or posteriorly relative to the sternum.

The most common mechanism of injury is a direct blow to the anterior chest, such as a steering wheel injury that occurs during a motor vehicle accident.

• 
  

  This typically results in posterior SC joint dislocation.

  
  
• 
  

  Posterior SC joint dislocation can be associated with occlusion of the superior vena cava or esophagus.

A lateral or posterior force to the shoulder girdle will result in an anterior SC joint dislocation.

• 
  

  This type of dislocation is generally benign.

Scapulothoracic dissociation occurs as a result of severe high-energy trauma and can cause complete disruption of the SC joint.

• 
  

  These injuries can be associated with axillary artery and brachial plexus injury.

On presentation, patients will localize pain with possible deformity at the SC joint after traumatic injury.

• 
  

  Patients may complain of dysphonia, dysphagia, or dyspnea.

Physical exam will demonstrate soft tissue swelling and tenderness at the medial clavicle.

• 
  

  Patients may laterally flex their neck toward the affected side to relieve pressure on the SC joint.

  
  
• 
  

  In posterior dislocation, there will be a palpable step-off at the lateral manubrium.

  
  
• 
  

  Swelling and a prominent medial head of the clavicle may be palpable in anterior SC joint dislocation.

  
  
• 
  

  SC joint sprain will present with mild to moderate pain at the SC joint without instability on physical exam.

Essential radiographic views include AP, and serendipity or tilt views.

• 
  

  In a serendipity view the beam is aimed at the manubrium with a 40°cephalic tilt (Figure 1.33).

  
  
• 
  

  CT is the most reliable imaging modality to determine dislocation.

  
  
• 
  

  CTA and MRA are useful in assisting with determining the direction of dislocation and in evaluation for vascular injury.

Treatment for SC joint sprain is conservative with a sling for comfort, analgesia as needed, and cold therapy. These injuries will generally resolve in one week.

A SC joint subluxation can occur and treatment follows that for SC joint sprain. Sling immobilization will be required for a longer duration.

Reduction is not typically needed for anterior dislocation.

• 
  

  Closed reduction may be needed for patients who engage in strenuous activity involving the upper extremities.

  
  
• 
  

  These patients may be safely discharged from the ED.

Closed reduction can be attempted in the ED for patients with posterior dislocation without evidence of airway, vascular, or esophageal injury.

• 
  

  Procedural sedation is recommended to accomplish these maneuvers.

  
  
• 
  

  General anesthesia is usually required for patients with severe pain and muscle spasms.

  
  
• 
  

  If reduction is unsuccessful, orthopedic surgery and thoracic surgery consults will be required for open or closed reduction in the operating room.

Classic method (abduction-traction technique) (Figure 1.34)

• 
  

  To perform this reduction maneuver, place a rolled-up towel or sandbag posteriorly between the shoulder blades with the patient positioned supine.

  
  
• 
  

  Traction is applied to the abducted arm against countertraction in an abducted and slightly extended position.

  
  
• 
  

  Direct pressure over the medial clavicle may reduce the joint in anterior dislocations.

  
  
• 
  

  Successful reduction is indicated by an audible snap or pop.

  
  
• 
  

  For posterior dislocations, manual manipulation of the medial clavicle may be necessary to dislodge it from behind the manubrium.

  
  
• 
  

  For difficult posterior dislocations, the medial clavicle may need to be prepared sterilely, followed by use of a towel clip to grasp the medial clavicle and lift it into a normal position.

Buckerfield and Castle technique (adduction-traction technique)

• 
  

  In this method, place a rolled towel between the supine patient’s shoulder blades.

  
  
• 
  

  The operator applies traction to the adducted arm while an assistant applies a posteriorly directed pressure to the shoulder.

  
  
• 
  

  This will lever the clavicle over the first rib into its normal position.¹⁴

In both of these techniques, the medial end of the clavicle may need to be manipulated using a towel clip or fingers.

Following reduction, the arm should be placed in a figure-of-eight brace (Figure 1.35) for immobilization.

• 
  

  Alternatively a Velpeau bandage or sling may be utilized.¹⁵

NSAIDs and cold therapy are first-line treatment for pain. More severe injuries may require opioid analgesics.

Generally, patients with anterior SC joint dislocation and uncomplicated posterior SC joint dislocation can be discharged from the ED.

If attempts at posterior SC joint dislocation reduction fail or if complicated SC joint dislocation is present, orthopedic surgery and/or thoracic surgery consult is warranted in the ED.

Routine sports medicine or orthopedic surgery follow-up is necessary after anterior SC joint dislocation.

After reduction, patients with posterior SC joint dislocation require close orthopedic surgery and/or thoracic surgery follow-up.

Patient may recover quickly from SC joint sprain, subluxation, and anterior dislocation. Return to work or sports can occur when patients regain full pain-free range of motion and near symmetric strength.

• 
  

  Patients with posterior SC joint dislocation will take longer to heal.

  
  
• 
  

  Recurrent instability may delay or preclude return to pre-injury levels of activity.