Discourse About Dislocation

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 ofthe dislocation (CONSULTANT, July 2001, page 1100y). This method is very laborintensive(especially in muscular persons) and can be frightening for patients becauseof the blood pressure cuff, IV line, oxygen cannula, and the efforts of 2 peoplepulling against each other (Figure).A much simpler method involvesno strain, no drugs, and little--ifany--pain. No strength is required, soit can be used by even very slight practitioners.In more than 50 reductionsin 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 astretcher with curtains drawn. Turnthe 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 tosuccess.Extend the arm fully, hold it gently, andslowly abduct the shoulder. The shoulderwill slide back in place once the humeralhead nears the rent in the capsule.In some settings you may want toapply gentle pressure on the anteriorsurface of the humeral head with yourfree hand during the abduction. This can aid reduction, particularly in largeor muscular patients.Never use the method known as the Kocher maneuver. This technique hasoccasionally resulted in fractures of the humerus and is very painful for patients.
---- Charles Cusumano, PA-C, FMP
      Campbellsville, KyThank you for your comments on the shoulder reduction techniquemost commonly known as the external rotation method. There are atleast 5 other successful, well-accepted methods for the reduction ofan 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 patientand the physician. Practitioners should learn at least 2 or 3 different techniquesso that they are prepared for a variety of circumstances.Our patient was both anxious andin significant pain (rated as 8 on ascale of 1 to 10) before the reduction.Thus, we believed that premedicationand intravenous conscious sedationwith monitoring was the most appropriateapproach. To ensure patient safety, we always use aconscious sedation protocol whenever we administer drugsduring a procedure. This patient genuinely welcomed theanalgesia 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 attemptsto a single effort. If that failed, we would then have premedicatedthe patient and applied monitoring equipment.We could have used a method other than the traction-countertraction technique. Indeed, if we had notbeen successful by the second attempt, we would haveswitched to an alternative technique. The flexibility thatcomes from knowing several approaches is sometimesthe key to success.

-- Gary Quick, MD
      Muskogee Regional Medical Center
      Muskogee, Okla