Shoulder dislocation and axillary-nerve assessment — Rapid

Synopsis

Recognise anterior and posterior shoulder dislocation, document axillary and wider neurovascular function, achieve safe timely reduction, confirm congruence and associated fracture, and prevent recurrent instability and stiffness.

Anterior dislocation usually produces loss of rounded contour and an abducted slightly externally rotated arm; posterior injury holds internal rotation.
Before reduction, document radial pulse, refill, deltoid contraction, lateral upper-arm sensation and radial, median and ulnar motor and sensory findings.
Obtain AP plus axillary or scapular-Y radiographs to confirm direction and identify greater-tuberosity or neck fracture.
Give adequate analgesia and use a trained controlled technique with procedural sedation or intra-articular analgesia according to patient and setting.
Stop repeated force if reduction fails or an associated fracture is suspected and escalate to anaesthesia and orthopaedics.
After reduction, repeat the same neurovascular examination and obtain radiographs confirming congruence and associated bony injury.
Use short sling support and early guided movement; prolonged immobilisation increases stiffness, particularly in older adults.
Arrange follow-up for first-time instability, fracture, nerve deficit or persistent cuff weakness and give clear recurrence precautions.

Key red flags

Absent pulse, cool hand, expanding axillary swelling or progressive neurological deficit requires immediate reduction and vascular or nerve specialist escalation.

An open wound, skin tenting, proximal humeral or surgical-neck fracture, or irreducible joint makes repeated closed attempts unsafe.

Posterior dislocation after seizure or electric shock is easily missed; fixed internal rotation and inability to externally rotate requires an axillary or scapular-Y view.

Anterior dislocation

Flattened shoulder contour, prominent acromion and an abducted externally rotated supported arm are typical.

Posterior dislocation

Fixed internal rotation and inability to externally rotate after seizure or electric shock should trigger dedicated views.

Axillary deficit

Reduced deltoid contraction or lateral-arm sensation suggests axillary-nerve injury, but normal sensation alone is insufficient.

Vascular compromise

Pulse loss, coolness, delayed refill or expanding axillary swelling requires immediate orthovascular action.

Investigation priorities

AP and axillary or scapular-Y radiographsFirst step

Confirm direction, exclude fracture and document the joint before reduction.

Management branches

Before reductionDefine direction and limb safety

Clinical deformity suggests a shoulder dislocation.

Give analgesia, inspect skin and document pulses, refill and named nerve functions.
Obtain orthogonal imaging unless vascular or skin threat makes delay unacceptable.
Identify fracture, previous instability and sedation risk and call appropriate reduction support.

Key medicines

Paracetamol for adult shoulder painUse 500 mg to 1 g by mouth as needed for adult arm pain, allowing 4 hours between administrations and limiting the total to 4 g daily.Lower the maximum for low body weight or hepatic risk and include combination products in the total.

Procedural sedation medicinesUse only a locally approved weight-based regimen administered by a credentialed clinician with continuous monitoring, airway equipment and formal recovery.Shock, fasting, cardiorespiratory disease, pregnancy and interacting sedatives alter selection; analgesic opioid alone is not full procedural sedation.

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