Dislocated shoulder - 4

Important Good preparation and adequate sedation/analgesia make these easy.   

Posterior dislocation - techniques
1. Apply gentle, prolonged axial traction on the humerus.
2. Apply gentle anterior pressure while coaxing the humeral head over the glenoid rim.
3. Slow external rotation may be needed.    

Inferior dislocation - techniques
1. Maintain gentle axial traction on the humerus while gentle abduction is applied.
2. Apply countertraction across the ipsilateral shoulder.
3. Following reduction, slowly adduct the arm.
4. Buttonholing of the humeral head through the capsule usually requires open reduction. 

Sedation and Analgesia

There are many different approaches to this problem, depending on the availability of drugs and equipment and patient suitability.

Opiate based
[opiate] +/- [benzodiazepine] +/- [nitrous oxide]

Local Anaesthetic based
Lidocaine injection into the joint

Induction agent based

For more discussion, see meditute on conscious sedation.

The key for these procedures is that they must be done in a safe environment by experienced doctors. There should always be at least two doctors, with one doctor with advanced airway skills who is not involved in the reduction.

Our personal practice is to use nitrous oxide and bolus fentanyl followed by immediate reduction - this has a rapid onset and offset and can be completely reversed.
This rarely fails, but propofol (once the patient is fasted >4 hrs) is our next choice.

The combination of opiates and benzodiazepines can easily result in an apnoeic patient, and is not suitable for unsupervised junior staff.