In their report of a young man who had dislocated his shoulder during a fight,
Drs Gary Quick and Gale Joslin described a well-known technique for reduction of
the dislocation (CONSULTANT, July 2001, page 1100y). This method is very laborintensive
(especially in muscular persons) and can be frightening for patients because
of the blood pressure cuff, IV line, oxygen cannula, and the efforts of 2 people
pulling against each other (Figure).
A much simpler method involves
no strain, no drugs, and little--if
any--pain. No strength is required, so
it can be used by even very slight practitioners.
In more than 50 reductions
in patients with all types of body habitus,
this approach has never failed me.
Here is the method I use:
Isolate the patient in a room or on a
stretcher with curtains drawn. Turn
the lights down low, or off if possible.
Calmly explain the technique to the patient,
and instruct him or her to relax.
Having the patient relaxed is the key to
Extend the arm fully, hold it gently, and
slowly abduct the shoulder. The shoulder
will slide back in place once the humeral
head nears the rent in the capsule.
In some settings you may want to
apply gentle pressure on the anterior
surface of the humeral head with your
free hand during the abduction. This can aid reduction, particularly in large
or muscular patients.
Never use the method known as the Kocher maneuver. This technique has
occasionally resulted in fractures of the humerus and is very painful for patients.
---- Charles Cusumano, PA-C, FMP
Thank you for your comments on the shoulder reduction technique
most commonly known as the external rotation method. There are at
least 5 other successful, well-accepted methods for the reduction of
an anterior shoulder dislocation:
- Stimson maneuver.
- Scapular manipulation.
- Milch technique.
- Traction-countertraction (used in our patient).
- Eskimo technique.
Each of these offers different advantages and disadvantages to the patient
and the physician. Practitioners should learn at least 2 or 3 different techniques
so that they are prepared for a variety of circumstances.
Our patient was both anxious and
in significant pain (rated as 8 on a
scale of 1 to 10) before the reduction.
Thus, we believed that premedication
and intravenous conscious sedation
with monitoring was the most appropriate
approach. To ensure patient safety, we always use a
conscious sedation protocol whenever we administer drugs
during a procedure. This patient genuinely welcomed the
analgesia and amnesia that conscious sedation can provide.
If we had elected to try the procedure without premedication,
we would have been obliged to limit our attempts
to a single effort. If that failed, we would then have premedicated
the patient and applied monitoring equipment.
We could have used a method other than the traction-
countertraction technique. Indeed, if we had not
been successful by the second attempt, we would have
switched to an alternative technique. The flexibility that
comes from knowing several approaches is sometimes
the key to success.
-- Gary Quick, MD
Muskogee Regional Medical Center