Dislocated shoulder - 3
Important Good preparation and adequate sedation/analgesia make these easy.
Assuming an isolated injury:
1. Place a pillow between the patients arm and torso to increase comfort
2. Offer analgesia.(morphine, ketorolac)
3. Prereduction and postreduction radiographs are recommended. Patients with frequent recurrent dislocations rarely need X-rays.
4. Conscious sedation helps relax surrounding musculature, making reduction easier.
5. The key to successful reduction is slow and steady application of a maneuver with adequate analgesia and relaxation.
6. Successful reduction is evinced by a palpable or audible relocation, marked reduction in pain, and increased range of motion. The patient may be asked to touch the uninjured shoulder to safely demonstrate a successful reduction.
7. After all reductions, apply a shoulder immobiliser and perform a careful neurovascular examination.
Anterior dislocation - how to reduce?
There is usually plenty of debate about the optimum method of shoulder dislocation, with local customs.
Choice of method is discussed below.
Patient lies prone on the bed with the dislocated arm hanging over the side.Traction is provided by up to 5kg weight attatched to the wrist or above the elbow. Apply gentle internal/external humeral rotation. Reduction may take 20-30 minutes.
Modified Kocher's technique
While the patient lies on their back, adduct the arm and flex it to 90 degrees at the elbow.
VERY SLOWLY rotate the arm externally, pausing for pain. The purpose of this is to slowly overcome the pull of the pectorals.
When the arm reaches the coronal plane, reduce the shoulder by then drawing (adducting) the whole elbow forward across the chest.
Link to ShoulderDislocation.net - modified Kocher images
Traction / Countertraction
While the patient lies supine, apply axial traction to the arm with a sheet wrapped around the forearm and the elbow bent 90 degrees. An assistant should apply countertraction using a sheet wrapped under the arm and across the chest.
With the patient lying prone, apply manual traction of 5-15 lb of hanging weight to the wrist. After relaxation, rotate the inferior tip of the scapula medially and the superior aspect laterally.
Alternatively, the patient can be seated while an assistant provides traction/countertraction by pulling on the wrist with one hand and bracing the upper chest with the other. The same scapular rotation is then performed.
1) With the patient on their back hold their arm around the wrist and gently lift it vertically (extend).
2) When the affected arm is in the vertical position, apply traction.
3) While maintaining vertical traction, rotate the shoulder externally.
4) It may be helpful to push on the head of humerus to assist reduction, while maintaining traction with the other hand.
Abduct pt's arm with one hand, pushing the humeral head with the other.
When fully abducted, traction and external rotation lift the head of the humerus into the socket.
Link ShouldeDislocation.net Milch technique
The tradional method describes putting the physician's 'stockinged feet' in the patient's axilla, and then using traction, with a little internal/ external rotation to ease the humeral head into the glenoid.
Which method should I use?
A randomised control trial would be useful, but would need to be large (several thousand patients) to have sufficient power to detect significant differences in complications.
All methods have their proponants. Success rates are not particularly helpful, as the methodology used to asses these is usually poor/inconsisant/lacks control populations/has no randomisation. Techniques successful in an asian population may be less helpful with the 160kg Hells Angel you are dealing with.
It is a good idea to try a few different methods, supervised by someone who knows them, and then concentrate on the one that seems to work best for you.