exerpt from Student Project Option, 2008
Early reduction is recommended to be performed when dislocation has occurred, so to reduce the amount of muscle spasm that must be overcome and minimise the amount of stretch and compression of neurovascular structures (4). Self reduction can be performed by the patient as noted by studies carried out by Parvin in 1957 (26) and Aronen in 1995, this involves the patient locking their hands together around the ipsilateral knee and the patient leans backwards slowly. However most present to the Emergency Department for treatment, and it is here that a variety of techniques can be performed.
Once radiographic evidence has confirmed dislocation direction and any associated complications, via an AP and Axillary view, a variety of reduction techniques can be employed for the management of anterior dislocation, all with the aim to manipulate the dislocated humeral head back in the glenoid cavity. Classical techniques still taught include; Kocher, Hippocratic, Stimson's and Milch; many of the newer techniques are variations of the classics.
Techniques can be classified according to whether leverage, scapular manipulation or traction is employed. Traction can be further subdivided according to where the arm is placed whilst traction is applied.
Choice of technique depends on the experience and preference of the Doctor, facilities available, number of assistants available, time avilalable and the patient's condition.
Kocher's Method was first described in 1870 although one paper notes that this method may be as old as 3000 years old, since wall painting in the Egyptian tomb of Ipuy appears remarkably similar. Over the years many textbooks have included new elements to the technique, which has been associated with complications. However, the original technique is noted to be painless and excludes traction using leverage alone: "Bend the affected arm at 90º at the elbow, adducted against the body; the wrist and the point of the elbow can be grasped by the surgeon. Slowly externally rotate between 70º to 85º until resistance is felt; in a conscious patient take plenty of time and try to distract the patient with conversation and then continue. Lift the externally rotated upper arm in the sagittal plane as far as possible forwards now internally rotate the shoulder this brings the patient's hand towards the opposite shoulder". The humeral head should now slip back into the glenoid fossa with pain eliminated during this process.
Complications have been associated with this technique if the procedure is not carried out correctly, i.e. when traction is applied, when the procedure is carried out hastily. One paper notes these complications to include, tearing of the subscapularis muscle and spiral fracture of the humeral head. Another paper reports damage to the axillary vein and associated death (30).
Click for video of Kocher's Technique (wmv)
This has been adapted over the years however the original description uses leverage alone. The surgeon stands on the same side as the affected arm whilst the patient lies in a supine position. The surgeon's fingers are placed over the affected shoulder, to steady the displaced humeral head the thumb is braced against it. Next the surgeon's other hand gently abducts and externally rotates the patient's arm into an overhead position, whilst fixing the humeral head so that it does not move from it's dislocated position. The surgeon now gently pushes the humeral head back into the glenoid fossa with their thumb (9, 18).
The Milch Technique can also be done in the prone position. With the patient prone on a table, pillows are placed under the pectoral muscles of the involved shoulder, the arm is allowed to hang freely. Reduction from relaxation can occur spontaneously in this position. However if reduction does not occur the elbow is then flexed to 90º, and the hand of the affected arm is the placed over the forearm of the surgeon, whose fingers and thumb grasp the patients elbow firmly. The surgeon then performs gentle longitudinal traction, abduction and external rotation. The surgeon's other hand holds the proximal part of the patients humerus, the surgeon increases the gentle abduction and external rotation (31).
External Rotation is a modification of Kocher's Method, where only the first part of it's technique is used. The patient is position supine and keeps their arm adducted, bending their affected elbow at 90º, the surgeon grasps the patients affected elbow and wrist. Very gently the forearm is externally rotated; the shoulder is usually reduced by the time the arm is in the coronal plane (32).
Hippocratic Method begins with the patient supine, the surgeon grasps the affected side at the hand and forearm. The stockinged heel of the surgeon is placed in the axilla (not pressed hard) this acts as a fulcrum whilst the arm is adducted9. Potential complication can result in damage to the axillary nerve (4).
Stimson's Method usually requires the patient to have a powerful anagelsic beforehand, and has the patient prone on a table with the affected arm hanging down in forward flexion. A sandbag is placed under the clavicle on the affected side, and an approx. 10lb weight is applied to the wrist on the affected side. The spasming muscles eventually relax and the joint normally reduces spontaneously (9,18).
Matsen's Traction Counteraction involves traction applied to the affected arm whilst the shoulder is in abduction, an assistant applies firm countertraction to the chest using a folded sheet. The surgeon can rotate the shoulder internally and externally to unhinge the dislocated humeral head (4, 18).
Spaso Technique begins with the patient in the supine position. The affected arm is grasped by the wrist or distal forearm and gently lifted vertically, whilst applying gentle traction. The shoulder is then externally rotated, reduction usually occurs spontaneously. Pushing the humeral head back into position may assist whilst maintaining traction (36).
Snowbird Reduction Technique involves the patient sat upright as straight as possible; an assistant helps maintain this position by standing on the opposite side with their arms clasped around the patient's chest into the axilla. The affected arm is flexed at 90º and a stockinette is placed around the proximal forearm, it is twisted once, so that the surgeon's foot can be placed in the distal loop and firm downward traction applied. The surgeon's hands are free to apply rotation or pressure as needed until reduction is successful (33).
Eskimo Technique begins with the patient lying on the nondislocated shoulder on the ground. Two people now lift the patient by the dislocated arm; holding onto the distal forearm or wrist. Keeping the opposite shoulder suspended a couple of centimetres off the ground, reduction is noted to occur usually within a few minutes. The surgeon can assist by exerting a slight direct pressure against the humeral head, which is usually palpable in the axilla (34).
This new method was invented after the author found that some of the older techniques were too traumatic for the elderly patient. After providing adequate analgesia and muscle relaxant the surgeon stands behind the patient and inserts their flexed forearm into the axilla of the affected shoulder. The surgeon's free hand is placed on the flexed forearm of the patient and gentle traction applied. The surgeon's forearm pulls in a proximal and lateral direction and levers the humeral head into the glenoid socket. Traction is then released (37).
Scapular Manipulation begins with the patient in the prone position on an examining table, the affected arm hangs vertically over the edge of the table at 90 forward flexion and externally rotated. At the wrist 5 to 10Ib of weights is used to maintain traction and secured using a wrist splint. One the patient begins to relax, reduction is then attempted by pushing on the tip of the scapula medially, with rotation of the superior aspect of the scapular laterally (35).
Click for video (wmv)
A range of success rates have been found for the above techniques. The table below summarises these findings from a range of studies.
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1 Hovelius L. Incidence of Shoulder Dislocation in Sweden. Clinical Orthopaedics 1982; 166:127-131.
2 Davy AR and Drew SJ. Management of Shoulder Dislocation- Are we doing enough to reduce the risk of recurrence? Injury, Int. J. Care Injured 2002; 33: 775 - 779.
3 Kazar B and Relovszky E. Prognosis of primary dislocation of the shoulder. Acta Orthop Scand 1969; 40: 216-24.
4 Christofi T, Kallis DA, Raptis M, Rowland and Ryan J. Management of Shoulder Dislocations. Trauma 2007; 9: 39-46
5 McNamara RM. Reduction of Anterior Shoulder Dislocations by Scapular Manipulation. Annals of Emergency Medicine 1993; 21: 1140 - 1144.
6 Anand J, Thakur, Ramachandran, Narayan. Painless Reduction of Shoulder Dislocation By Kocher's Method. The Journal of Bone and Joint Surgery 1990;72-B:524.
7 Simonet WT, Melton LJ, Cofield RH, and Ilstrup DM. Incidence of Anterior Shoulder Dislocation in Olmsted County, Minnesota. Clin Orthop 1984; 186: 186 - 191
8 Kroner K, Lind T and Jensen J. The Epidemiology of Sholder Dislocations. Arch Orthop Trauma Surg 1989; 108: 288 - 1290.
9 McRae R. Pocketbook of Orthopaedics and Fractures 2nd Edition. Churchill Livingstone Elsevier 2006: 276-280
10 Robert H, Whitaker & Borley N. Instant Anatomy 2nd Edition. Blackwell Science 2000: 154 - 176.
11 Moore KL and Dalley AF. Clinically Orientated Anatomy Fourth Edition. Lippincott Williams & Wilkins 1999: 665 - 795.
12 Brady JW, Knuth CJ, Ronald G and Pirrallo. Bilateral inferior Glenohumeral Dislocation: Luxatio Erecta, An Unusual Presentation of a Rare Disorder. The Journal of Emergency Medicine 1995; 13; 1:37 - 42.
13 Ceroni D, Sadri H, and Leuenberger A. Radiographic Evaluation of Anterior Dislocation of The Shoulder. Acta Radiologica 2000; 41: 658-61
14 Pasila M, Jaroma H, Kiviluoto O et al. Early complications of Primary Shoulder dislocations. Acta Orthop Scand 1978; 49:260 - 263.
15 Beeson MS. Complications of Shoulder Dislocation. American Journal of Emergency Medicine 1999; 17; 3: 288 - 294.
16 Mizuno K and Hirohata K. Diagnosis of Recurrent Traumatic Anterior Subluxation of the Shoulder. Clin Orthop 1983; 179: 160 - 167.
17 DePalma AF, Flannery GF: Acute Anterior Dislocation of the Shoulder. Am J Sports Med. 1973; 1: 6-15.
18 Cunningham NJ. Technique for Reduction of Anteroinferior Shoulder Dislocation. Emergency Medicine Australasia 2005; 17: 463 - 471
19 Baker DM. Fracture of the Humeral Shaft Associated with Ipsilateral Fracutre Dislocation of the Shoulder: Report of a Case. J Trauma 1971; 11: 532 - 534
20 Perron AD, Ingerski MS, Brady WJ, Erling BF, and Ullman EA. Acute Complications Associated with Anterior Dislocation at an Academic Emergency Department. J. Emerg. Med 2003; 24: 141 - 145.
21 Laat EA, Visser CP, Coene LN, Pahlplatz PV and Tavy DL. Nerve Lesions in Primary Shoulder Dislocations and Humeral Neck Fractures. The Journal of Bone and Joint Surgery 1994; 76B; 3 381 - 383.
22 Graham JM, Mattox KL, Feliciano DV, DeBakey ME. Vascular Injuries of the Axilla. Ann. Surg. 1982; 195; 2: 232 - 237.
23 McLaughlin H. Injuries of the Shoulder and Arm. Trauma 1959: 233 - 296.
24 Stayner LR, Cummings J, Anderson J, and Jobe C. Shoulder dislocations in patients older than forty years of age. Orthop. Clin. North Am 2000; 31: 231 - 239.
25 McLaughlin HL and Cavallaro WU. Primary Anterior Dislocation of the Shoulder. American Journal of Surgery. 1950; 15: 615 - 621.
26 Parvin RW. Closed Reduction of Common Soulder and Elbow Dislocations Without Anaesthesia. Arch Surg 1957; 75: 972 - 975.
27 Aronen JG and Chronister RD. Anterior Shoulder Dicloations: Easing Reduction by Using Linear Traction Techniques. Phy Sports Med 1995; 23: 65 - 69.
28 Kocher T. Eine neue. Reductionsmethode fur Schultetrverrenkung. Berliner Klin Wehnschr 1870; 7: 101-105.
29 Wilson JN. Fracture and Joint Injuries Volume Two. Churchill Livingstone 1976: 559 - 565.
30 Kirker JR. Dislocation of the Shoulder Complicated by Rupture of the Axillary Vessels. Repeat of a Case. J Bone Joint Surg 1952; 34B: 72 - 73
31 Lacey T and Crawford HB. Reduction of Anterior Dislocations of the Shoulder by Means of the Milch Abduction Technique. J Bone Joint Surg (Am) 1952; 34: 100 - 109.
32 Mirick MJ, Clinton JE, and Ruiz E. External Rotation Method of Shoulder Dislocation Reduction.
JACEP 1979; 8; 528 - 531.
33 Westin CD, Gill EA, Noyes ME, and Hubbard M. Anterior Shoulder Dislocation; A Simple and Rapid Method for Reduction. The American Journal of Sports Medicine 1995; 23; 3: 369 - 371
34 Sven, Refslund, Poulsen. Reduction of Acute Shoulder Dislocation Using the Eskimo Technique: A Study of 23 Consecutive Cases. The Journal of Trauma 1988; 28; 9: 1382 - 1383.
35 Kothari RU and Dronen SC. Prospective Evaluation of the Scapular Manipulation Technique in Reducing Anterior Shoulder Dislocation. Annals of Emergency Medicine 1992; 21: 1349 - 1352.
36 Yuen MC, Yap PG, Chan YT and Tung WK. An Easy Method to Reduce Anterior Shoulder Dislocation: the Spaso Technique. Emergency Medicine Journal 2001; 18: 370 - 372.
37 Manes HR. A New Method of Shoulder Reduction in the Elderly. Clin Orthop 1980; 147: 200 - 202.
38 British National Formulary 55. March 2008.
39 Cortes VC, Checa GD and Vela JR. Reduction of Acute Anterior Dislocation of the Shoulder Without Anaesthesia In the Position of Maximum Muscular Relaxation. International Orthopaedics 1989; 13: 259 - 262.
40 Clinical Effectiveness Committee. Standards for Emergency Departments. British Association for Emergency Medicine. January 2006.
41 Russell JA, Holmes EM, Keller DJ and Vargas JH. Reduction of Acute Anterior Shoulder Dislocations Using the Milch Technique: A Study of Ski Injuries. J Trauma 1981; 21: 802 - 804.
42 Bakal B, Sener S, and Turkan H. Scapular Manipulation Technique for Reduction of Traumatic Anterior Shoulder Dislocations: Experiences of an Academic Emergency Department. Emergency Medical Journal 2005; 22: 336 - 338.
43 Anderson D, Zvirbulis R and Ciullo J. Scapular Manipulation for Reduction of Anterior Shoulder Dislocations. Clinical Orthopaedics and Related Research 1982; 164: 181 - 183.
44 Doyle WL and Ragar T. Use of the Scapular Manipulation Method to Reduce an Anterior Shoulder Dislocation in the Supine Position. Annals of Emergency Medicine 1996; 27: 92 - 94.
45 Williamson A and Hoggart B. Pain Rating Scales. Journal of Clinical Nursing 2005; 14: 798 - 804.
46 Hussein MK. Kocher's Method is 3,000 years old. The Journal of Bone and Joint Sugery 1968; 50B; 3: 669 - 671.
47 Dunn MJG, Mitchell R, Souza CD and Drummond G. Evaluation of Propofol and Remifentanil for intravenous sedation for reducing shoulder dislocations in the emergency department. Emergency Medicine Journal 2006; 23: 57 - 58.
48 Paudel K, Pradhan RL, and Rijal KP. Reduction of Acute Anterior Shoulder Dislocations under Local Anaesthesia - A Prospective Study. Kathmandu University Medical Journal 2004; 2; 1: 13 - 17.
49 Peck C, McCall M, and Rotem T. Continuing Medical Education and Continuing Professional Development: International Comparisons . BMJ 2000; 320: 432 - 435.
50 The Trauma Audit and Research Network; An Overview.
51 Ahmed SMY, Mansingh R, Laxmanan P and Nicol MF. What is The Preferred Method of the Anterior Shoulder Dislocation Among European Surgeons? Is There a Need to Change The Practice?J. Injury 2006; 12: 94.