Shoulder dislocation and axillary-nerve assessment

Direction and associated injury determine management. Anterior dislocation is common after abduction and external rotation; posterior injury follows seizure, electric shock or direct force and can look deceptively normal on an AP film. Ask about previous instability, connective-tissue laxity, sport, seizure and mechanism. Inspect contour, but avoid repeated movement. Examine the whole limb because multi-nerve or arterial injury can accompany severe displacement.

Reduction should be timely, humane and planned. Radiograph first when practical to identify fracture, but do not allow unsafe tissue or vascular compromise to persist. Choose analgesia and sedation from physiology and resources and avoid unmonitored force. A successful reduction requires a post-reduction image and repeat nerve and vascular documentation. Persistent weakness in an older patient triggers early rotator-cuff assessment; recurrent instability requires shoulder-specialist review rather than repeated sling-only care.

Pre-reduction imaging must show the glenohumeral relationship in two planes. An AP view identifies obvious anterior displacement and associated greater-tuberosity injury; an axillary, modified axillary or scapular-Y view prevents posterior dislocation being overlooked. Review the surgical neck before traction because an unrecognised fracture can displace during manipulation. CT is reserved for complex fracture-dislocation, glenoid bone loss or a non-concentric joint rather than routine simple dislocation. When the hand is poorly perfused or skin is critically tented, urgent controlled realignment takes precedence over a perfect radiographic series.

Axillary-nerve documentation requires both deltoid contraction and lateral upper-arm sensation. Also test wrist, finger and thumb extension, thumb opposition, finger abduction and the relevant sensory territories because a high-energy displacement can injure the plexus rather than one terminal nerve. Palpate radial pulse and record temperature and capillary refill. If a deficit changes after reduction, splinting or transfer, repeat the full examination immediately and obtain senior peripheral-nerve or vascular input. A normal sensory patch does not compensate for absent deltoid motor function.

After reduction, compare the joint with the opposite side and identify Bankart, Hill-Sachs, greater-tuberosity or glenoid injury. Test stability only within a safe specialist-directed arc; repeated apprehension manoeuvres in emergency care add little. A short period of support followed by pain-limited rehabilitation suits a simple stable injury. Young contact athletes need counselling about recurrence and timely shoulder review. Older adults need early re-examination for rotator-cuff failure when active elevation or external rotation remains weak despite improving pain, because delayed recognition can limit repair options.

Sedation and aftercare require individual modifiers. Frailty, cardiorespiratory disease, intoxication, fasting uncertainty and concurrent opioids increase procedural risk and may favour theatre anaesthesia or a different analgesic technique. Pregnancy does not justify leaving a joint displaced; involve obstetric and anaesthetic teams when gestation or physiology warrants and select imaging and medicines appropriately. Recurrent prosthetic dislocation follows an implant-specific route because component orientation, infection, loosening and surgical approach alter both reduction technique and movement precautions.

The recurrence consultation considers age, sport, occupation, hyperlaxity and bony defects rather than counting episodes alone. A first traumatic dislocation in a young contact athlete can produce a substantial labral lesion and merits early shared discussion of rehabilitation versus stabilisation. Repeated anterior events may enlarge glenoid and humeral defects until they engage in functional positions. CT quantifies bone loss when surgical planning requires it; MRI or arthrogram defines capsulolabral injury. Physiotherapy restores scapular control, rotator-cuff endurance and confidence without repeatedly provoking apprehension.

Give explicit return precautions after discharge. New hand coolness, weak deltoid contraction, expanding axillary swelling, recurrent deformity or uncontrolled pain needs urgent reassessment. Persistent numbness is tracked against a mapped baseline; protection of an insensate skin area prevents pressure injury. The patient should know how long to use the sling, which movements are allowed, when therapy and fracture review occur and how to obtain help if the joint redislocates. Self-reduction attempts are discouraged because an associated fracture or nerve injury can be worsened.