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Discourse About Dislocation

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 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 success.
  • 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
            Campbellsville, Ky
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
            Muskogee, Okla
 
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