Lit Matters #2: Shoulder dislocations in the ED

Anterior shoulder dislocation is the most common major joint dislocation seen in the ED, and emergency physicians reduce most cases without orthopedic rescue. This literature review focuses on real-world reduction success, the role of analgesia and sedation, and which patients may be harder to reduce.

Anterior Shoulder Reduction Success

• High ED success rate: Emergency physicians successfully reduced 92.2% of anterior shoulder dislocations in this retrospective cohort, reinforcing that most uncomplicated cases can be managed at the bedside.
• Orthopedic rescue uncommon: Failed reduction was defined by orthopedic consultation, and only 19 of 244 patients needed that next step; most of those were still reduced successfully in the ED.
• Technique data gap: Reduction method matters clinically, but nearly half of cases had no documented technique, limiting any real comparison between traction, leverage, and scapular approaches. We get into why that documentation gap matters in the episode.
• Medication seems to help: Only 25% of patients received analgesics or sedatives up front, yet in 17 of 19 failed cases the orthopedist used medications to facilitate reduction.
• Older patients harder to reduce: Older age and a fall mechanism were associated with lower first-pass physician success, a reminder that not all anterior dislocations behave like the classic young athlete presentation.

Analgesia and Sedation Implications

• Pain control is procedural: Shoulder reduction is not just a mechanical task; analgesia and sedation likely improve both patient experience and reduction conditions, even when the exact best strategy remains unsettled.
• No single best technique: Traction-countertraction, leverage methods, and scapular manipulation all remain in play because there is still no clear consensus on the best reduction approach.
• Drug choice variability: The study reflected broad real-world practice, including IV analgesics, intra-articular lidocaine, peripheral nerve blocks, and sedatives rather than a single standardized pathway.
• Signal not proof: Failed cases were associated with more IV analgesics and nerve blocks, but that likely reflects more difficult reductions rather than those medications causing failure. We walk through that interpretation in the episode.
• External validity caution: This cohort was older than the typical U.S. shoulder dislocation population, so any predictors of failure should be applied cautiously outside a similar practice setting.