A 27-year-old snowboarder arrives holding his left arm against his chest, jacket sleeve torn and snow melting into the fabric. His shoulder looks squared-off rather than rounded, and every attempt to move the arm produces a sharp gasp; the hand is warm, with a palpable radial pulse. He says he “felt it come out” when he landed, but the radiograph has not yet been obtained and the next move is still yours.

— What’s your move? Read on.

Before you read
  • What neurovascular examination must be documented before and after treatment?
  • When is the “obvious” dislocation actually a fracture-dislocation?

When to Think of It

Suspect significant injury with deformity, focal bony tenderness, loss of active motion, mechanism involving fall onto an outstretched hand, axial loading, traction, or direct blow. Think specifically of shoulder dislocation, proximal humerus fracture, elbow dislocation, radial head/neck fracture, distal radius fracture, scaphoid injury, metacarpal fracture, and tendon or nerve disruption.

Sick or Not Sick

Sick vs. not sick is primarily neurovascularly threatened or open/unstable injury vs. intact, closed, stable injury. The call that matters most is whether perfusion, nerve function, skin integrity, or joint congruity requires immediate reduction or operative consultation.

The First Fifteen Minutes

  • Remove rings, bracelets, and constrictive clothing; splint in the position found and repeat/document motor, sensory, and pulse/capillary-refill examination.
  • Obtain AP and lateral radiographs of the injured region; add an axillary or scapular-Y shoulder view when tolerated, and obtain joint-above/joint-below imaging when fracture location is uncertain.
  • For moderate pain: acetaminophen 1,000 mg PO, because central analgesia reduces pain without sedation. If unable to take PO, acetaminophen 1,000 mg IV over 15 minutes; check local maximum dosing and reduce in significant liver disease.
  • For severe pain: fentanyl 1 mcg/kg IV or 1–2 mcg/kg IN, usual adult initial maximum 100 mcg, because rapid μ-opioid analgesia facilitates examination and reduction. Reassess ventilation and repeat smaller titrated doses as needed.
  • If an isolated shoulder dislocation or other painful deformity has intact perfusion and no concerning fracture on imaging, perform gentle reduction with procedural analgesia/sedation. For a cooperative adult: ketamine 1 mg/kg IV, because dissociative analgesia preserves spontaneous breathing and muscle relaxation; reduce to 0.5 mg/kg IV in older or medically fragile patients and repeat 0.25–0.5 mg/kg if needed. Use institutional sedation protocol and airway monitoring.
  • If ketamine is unsuitable and the patient is hemodynamically stable: propofol 0.5–1 mg/kg IV, titrated in 0.25–0.5 mg/kg increments, because brief deep sedation permits muscle relaxation; anticipate apnea and hypotension. Dose variability is meaningful—check institutional protocol.
  • Do not force reduction through resistance, worsening pain, or abnormal imaging; stop and obtain urgent orthopedic consultation.

Definitive Care & Disposition

Re-image after reduction and repeat neurovascular examination. Immobilize shoulder dislocations in a sling; refer for early follow-up, especially first-time anterior dislocation, greater tuberosity fracture, recurrent instability, or suspected rotator cuff injury. Urgent orthopedic management is required for open fractures, irreducible dislocations, fracture-dislocations, unstable elbow dislocations, compartment syndrome, ischemia, tendon laceration, or persistent nerve deficit. Scaphoid tenderness with normal films needs thumb-spica immobilization and repeat imaging or MRI. Stable, closed fractures with intact neurovascular status can generally discharge with splinting, analgesia, and timely fracture-clinic follow-up.

How This One Kills

The dangerous miss is documenting “radial pulse intact” while failing to assess the axillary, radial, median, and ulnar nerves—or reducing a dislocation without recognizing an associated fracture that makes manipulation harmful.
The Differential — What Else Looks Like This
  • Proximal humerus fracture — focal bony tenderness and abnormal radiographs rather than a purely empty glenoid; missed fracture-dislocation can worsen displacement.
  • Acromioclavicular separation — superior clavicle step-off with preserved glenohumeral alignment; confusing it with dislocation leads to the wrong reduction.
  • Elbow fracture-dislocation — radiocapitellar and ulnohumeral malalignment, often with coronoid or radial-head fracture; missed instability causes recurrent dislocation.
  • Acute compartment syndrome — escalating pain with passive stretch and tense compartments; a normal pulse does not exclude limb-threatening ischemia.

The Second-Day Story

Older adults may have a low-energy proximal humerus fracture with little deformity but profound inability to lift the arm. Children may have a subtle physeal injury with normal-appearing initial films. Patients with neuropathy or intoxication may not report pain reliably, so compare both limbs, examine active and passive motion, and let focal tenderness, alignment, and neurovascular findings drive imaging and consultation.
Back to Our Patient
Back to our 27-year-old snowboarder: the squared shoulder and intact pulse trigger immediate recognition of an anterior shoulder dislocation, but the team documents axillary, radial, median, and ulnar nerve function and obtains radiographs to exclude a fracture-dislocation. Because he is neurovascularly intact and imaging shows no associated fracture, he receives titrated fentanyl, then monitored ketamine sedation and gentle reduction. Post-reduction films show a congruent joint, and the examination remains intact; he is placed in a sling, given follow-up and return precautions, and discharged for orthopedic review.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“This is a 27-year-old previously healthy snowboarder with acute left shoulder pain and deformity after landing directly on the arm, with a sensation that the shoulder came out. He has a squared-off contour and inability to move the shoulder, but no open wound or numbness, and the hand is warm with a palpable radial pulse and intact axillary, radial, median, and ulnar motor and sensory function. Radiographs show an anterior glenohumeral dislocation without associated fracture. My assessment is an uncomplicated anterior shoulder dislocation without neurovascular compromise. I plan IV fentanyl, monitored procedural sedation with ketamine, gentle reduction, repeat neurovascular examination and post-reduction films, followed by sling immobilization and orthopedic follow-up if successful.”

Study Directive

  • Draw the motor and sensory examination for axillary, radial, median, ulnar, and musculocutaneous nerves from memory.
  • Review normal AP, lateral, axillary, and scapular-Y views for shoulder and elbow alignment.
  • Practice a verbal pre-reduction/post-reduction neurovascular checklist.
  • On your next shift, identify three upper-extremity injuries and state the specific reason each requires discharge, urgent consultation, or emergent reduction.

Recent Literature

  • Review or guideline Metacarpal Fractures: An Evidence-Based Review to Guide Treatment
    Stash N, Kamal RN, Richard M, et al. · J Am Acad Orthop Surg, 2025 · PMID 40627824 · cited 2×
    Provides evidence-based guidance for deciding which metacarpal fractures need reduction or surgical referral versus immobilization and outpatient follow-up.