July 2015 Shoulder Reduction Techniques

This month, JC kicks off our 2015-2016 academic year and we would like to extend a warm welcome to our new interns, PA's, Fellows & Attending staff. One of the most satisfying procedures in EM is the reduction of an acutely dislocated shoulder. That stated, it can also be one of the most frustrating when your usual “go-to” approach is unsuccessful. Despite a myriad of reduction techniques, the strength of the evidence in favor of any one technique is not great. Because of this, EBM teaches us to then rely upon  expertise and patient values.  We thought JC would be a great venue to solicit the expertise of our amazing community faculty so, who will be available to share their tricks with our newbies. I have included three articles that describe or compare techniques that are known to most, and a few that may not be. I also included a Humor in Medicine article for every intern from CJEM: Successful Hospitalization Of Patients With No Discernible Pathology and I expect our faculty will be able to provide additional advice in this regard as well.   

P: In patients with an acute anterior elbow dislocation                                                                                   

I: Does use of the FARES, Stimson, Milch, Kocher, chair, scapular, Eskimo (no kidding), self-reduction      

C: Compared to Hippocratic (sheets and toga’s)                                                                                           

O: Provide better outcomes (time to reduction, pain, attempts or perceived greatness of clinician)

Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success. J Shoulder Elbow Surg. 2012 Nov;21(11):1443-9

Resident Review

A new drug free technique for reducing anterior shoulder dislocations. Emerg Med (Fremantle). 2003 Oct-Dec; 521-4.

Resident Review

Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods.J Bone Joint Surg Am. 2009 Dec;91(12):2775-82

Resident Review

Group Consensus:  Clinical Bottom Line

1. The majority of procedures are variations on the same theme. You should find two or three you can be comfortable with.

2. Patient cooperation will likely drive which technique to use and whether the patient is appropriate candidate to forego analgesics/anesthetics.

3. Female JC participants saw an advantage to a weighted (Stimson) technique and note that Brut strength may play a bigger role with shoulder reductions than most articles would have you believe.

4. Don't accept an invitation to go skydiving if you have had a prior shoulder dislocation!