Anterior shoulder dislocation — reduction in the ED

(a) Analgesia and sedation plan (4 marks).

^[2]- Perform the reduction under procedural sedation and analgesia (PSA) to the ACEP clinical-policy standard: a trained team — a sedationist dedicated to the airway and drugs, the operator, and a monitoring nurse; full monitoring — continuous pulse oximetry, ECG, blood pressure and capnography; supplemental oxygen and suction at the bedside; reversal agents (naloxone, flumazenil) immediately available.

• Ketamine 1 to 1.5 mg per kilogram IV is the preferred dissociative agent — IV onset around 1 to 2 minutes; suitable for this otherwise-fit young man. Pair with fentanyl 1 mcg per kilogram IV for analgesia (proven efficacy for closed reduction in the ED). (Alternatively propofol 1 mg per kilogram IV, with the caveat of hypoxia in a quarter to two-fifths of ED propofol sedations — operator must be airway-competent, with capnography giving early warning.)^{[11][12][13][14]}
• The recent oral intake (2 hours) is a consideration, not an absolute contraindication — fasting is weighed against the urgency of the reduction; proceed with the standard airway precautions.
• A sedation-sparing alternative is intra-articular lidocaine into the glenohumeral joint via the lateral approach — with little to no difference in success or satisfaction versus sedation, a shorter stay and no respiratory events on very-low-certainty evidence; reasonable here given the uncomplicated dislocation and intact neurovascular status.

(b) Two reduction techniques in sequence, with rationale (5 marks).

^[1]- First technique — scapular manipulation. Rationale: it is a low-force, low-sedation technique that works by realigning the glenoid with the humeral head rather than by overcoming the spasm — among the favoured contemporary biomechanical options, with no technique universally superior. Steps: position the patient prone with the affected arm hanging over the edge of the trolley (or sit forward); palpate the scapula; push the inferior tip medially toward the spine and rotate the superior aspect laterally so the glenoid fossa rotates to face the head; the joint reduces with a palpable clunk.

• Second technique — traction-countertraction (if scapular fails). Steps: reposition supine; wrap a sheet around the operator's wrists and around the patient's chest under the axilla as the counteranchor, an assistant holding it for countertraction; apply slow, steady longitudinal traction in line with the deformity for several minutes — sustained gentle force, never a jerk — until the head reduces.
• Do not exceed two or three good attempts under adequate sedation; if unsuccessful, escalate to orthopaedics or general anaesthesia rather than forcing, to avoid an iatrogenic fracture or neurovascular injury.

^[2](c) Immediate post-reduction assessment and disposition (4 marks).

• Repeat the neurovascular examination and document it — re-test the axillary-nerve sensation over the deltoid (the regimental-badge patch, injured in around 1 in 6 anterior dislocations) and the radial pulse; confirm no new deficit versus the pre-reduction record. A new axillary-nerve deficit is a surgical emergency.^[17]
• Post-reduction radiograph — AP and axillary lateral to confirm concentric reduction and to exclude an iatrogenic or revealed fracture (Hill-Sachs, Bankart, greater-tuberosity); new clinically significant fractures are uncommon, but the film remains the documented standard.
• Immobilise in a broad-arm sling (the arm in internal rotation) and arrange orthopaedic follow-up in 1 to 2 weeks; counsel on the high recurrence rate in the young (recurrent instability in nearly half of young nonoperative patients at 5 years) and the surgical-stabilisation option.^[15][16]
• Discharge once recovered from sedation, with analgesia and a clear safety-net (return if new numbness, cold limb, or severe pain).

^[2](d) Two findings that change the plan to a theatre reduction (2 marks).

• A fracture-dislocation on the radiograph — a displaced greater-tuberosity or surgical-neck fracture, or a significant Hill-Sachs lesion — reduced and fixed in theatre by orthopaedics; a forceful ED attempt displaces the fragment further.
• Failure to reduce after two or three good attempts under adequate sedation, or a locked joint (a significant Bankart/capsular interposition) — convert to general anaesthesia with muscle relaxation and, if needed, open reduction.