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Youm2014 PDF
Abstract
Thomas Youm, MD The shoulder joint has the greatest range of motion of any joint in the
Richelle Takemoto, MD body. However, it relies on soft-tissue restraints, including the
capsule, ligaments, and musculature, for stability. Therefore, this joint
Brian Kyu-Hong Park, MD
is at the highest risk for dislocation. Thorough knowledge of the
shoulders anatomy as well as classification of dislocations,
anesthetic techniques, and reduction maneuvers is crucial for early
management of acute shoulder dislocation. Given the lack of
comparative studies on various reduction techniques, the choice of
technique is based on physician preference. The orthopaedic
surgeon must be well versed in several reduction methods and
ascertain the best technique for each patient.
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Acute Management of Shoulder Dislocations
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Thomas Youm, MD, et al
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Acute Management of Shoulder Dislocations
Table 2
Reduction Techniques for Anterior Dislocations
Patient Success Rate
Method Type Position Description (%)
we describe 11 reduction techniques placed supine. A sheet wrapped supinated forearm stationary and the
for management of anterior shoulder around the patients chest and within patient slowly stands (Figure 2). A
dislocations (Table 2). the axilla is pulled away from the 73% success rate was reported in the
affected side by an assistant while the original description of this tech-
Hippocratic affected limb is pulled inferiorly and nique.23 Westin et al24 modified the
Hippocrates described the earliest laterally at a 45 angle (Figure 1). technique by tying a loop of stocki-
reduction technique. The physician Alternatively, the sheet may be tied to nette about the forearm, flexing the
places a foot in the patients axilla the railing of the stretcher if no elbow 90, and using the loop as
while applying traction to the assistant is available. Slight external a pedal. The authors reported a suc-
affected arm with alternating inter- rotation of the humerus may aid the cess rate of 97%, and anesthesia was
nal and external rotation to disen- humeral head in clearing the anterior not required in 110 of 118 reductions
gage the humeral head. This method glenoid rim. Once the humerus is (93%).
is largely historical and has been disengaged, slight lateral traction on
abandoned because of the high rate the proximal humerus may be Kocher
of traction injury to the brachial necessary. The Kocher technique was first
plexus. described in 1870.25 With the patient
Chair supine or seated, the operator grasps
Traction-Countertraction In another traction-based maneuver, the patients forearm on the affected
The traction-countertraction method the patient is seated sideways in a chair side and flexes the elbow 90. The
uses longitudinal traction to disen- with the affected arm hanging over patient adducts the affected arm and
gage the humeral head. The patient is the backrest. The clinician holds the actively externally rotates to 70 to
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Thomas Youm, MD, et al
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Acute Management of Shoulder Dislocations
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Thomas Youm, MD, et al
Figure 7 Figure 8
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Acute Management of Shoulder Dislocations
Figure 9 Figure 10
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Thomas Youm, MD, et al
Table 3
Comparison of Reduction Maneuvers
No. of
Study (Design) Patients Maneuver Outcomes (P Value) Comments
Sayegh et al26 154 FARES versus Hippocratic Reduction on first or second FARES method is more
(RCT level I) versus Kocher attempt: FARES 88%, effective, faster, and less
Hippocratic 72.5%, Kocher painful than Hippocratic or
68% (P = 0.033) Time to Kocher methods.
reduction: FARES 2.3 min,
Hippocratic 5.5 min, Kocher
4.3 min (P ,0.001 )
Maity et al33 160 FARES vs ER Reduction on first or second FARES method is faster, less
(RCT level I) attempt: FARES 95%, ER painful and requires fewer
91% (P = 0.53) Number of attempts than ER. It is an
reduction attempts: FARES ideal first-line method.
1.14, ER 1.46 (P ,0.0001)
Time to reduction: FARES
2.1 min, ER 3.2 min
(P ,0.0001)
Beattie et al51 111 Milch versus Kocher Reduction on first attempt: No difference overall. Milch
(RCT level II) Milch 70%, Kocher 72% (NP) may be better for patients
aged ,40 years. Kocher may
be better in obese patients.
Amar et al52 60 Milch versus Stimson Reduction on first attempt: Milch technique superior to
(RCT level I) Milch 82%, Stimson: 28% Stimson technique in terms of
(P ,0.001) success rate and speed of
Time to reduction: Milch reduction.
4.6 min, Stimson 8.8 min
(P 0.007)
ER = external rotation, FARES = fast, reliable, and safe; NP = not published, RCT = randomized control trial
Age and sex are predictive factors for dislocation is highest in patients who recurrent dislocations as only a nui-
recurrent shoulder dislocation after sustained significant rotator cuff tear sance. Although recurrent dislocations
primary traumatic anterior dislocation. and/or associated fracture resulting in in highly competitive athletes or la-
Recurrent dislocations are most com- severe damage to the dynamic and/or borers may threaten the patients live-
mon in patients aged #20 years.3 The static stabilizers.53 lihood, in lower demand patients,
incidence of recurrent shoulder dislo- Traditionally, participation in athlet- surgery may not be indicated. Sachs
cation decreases precipitously after ics has been thought to predispose the et al54 reported that, over a 4-year
age 50 years.3 In a study of 252 pa- patient to recurrent dislocation. How- follow-up period after initial acute
tients treated for primary anterior ever, conflicting evidence has been re- traumatic anterior shoulder disloca-
shoulder dislocation, 56% of younger ported on this point. Robinson et al13 tion, 18 of 37 patients (49%) in the
patients developed instability over 2 found that, among patients younger highest risk group for redislocation
years and 66.8% developed instability than 25 years, participation in athletics requested surgery.
over 5 years.13 Men were found to did not yield a significant difference in
have a greater risk of recurrent insta- the rate of recurrence. In contrast,
bility than women. Sachs et al54 found that participation Summary
The degree of trauma associated in contact sports or occupational use of
with the initial dislocation also affects overhead motion increases the fre- Dislocations should be tended to
outcome. Mechanism of injury, asso- quency of recurrent dislocation after promptly for the easiest possible
ciated fractures, nerve injury, and the acute traumatic anterior dislocation. reduction and to minimize damage
difficulty of reduction are all deter- Many surgeons consider recurrent to surrounding neurovascular struc-
minants of outcome. Relative risk for dislocation an indication for surgery. tures. For anterior dislocations, we
redislocation after primary anterior However, the patient may consider recommend the use of an intra-
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Acute Management of Shoulder Dislocations
articular block as a first-line method 6. Soslowsky LJ, Flatow EL, Bigliani LU, with narcotics and benzodiazepines for
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