Shoulder Dislocation

August 8th 2007

Dr. Gilbert Boucher
FRCP, CSPQ, ABEM
MGH ED
Goal
z Review techniques of shoulder reduction
Shoulder dislocations
z 95% are anterior
z 25% are recurrent
z Mechanism:
z Abduction and external rotation
z 5-10% of dislocations cannot be reduced in
the ED.
Subglenoid
(30%)

Subcoracoid
(70%)

Subclavicular
(rare)
AP view Scapular view
Pre-reduction exam
z Axillary nerve: 8% palsies
z Deltoid muscle innervation: cannot test
z Sensory over cadet’s patch: lower deltoid
z Brachial artery: radial pulse
z Radial nerve: extension of wrist
z Sensation dorsum of hand.
z Share posterior aspect of brachial plexus
Analgesia
z None: fast
z Local infiltration: poor muscle relaxation
z Procedural anesthesia: preferred but time
and ressource consuming
z General anesthesia: for muscular/obese
patients.
Potential bone abnormalities
z Bankart’s lesion
z Fracture of anterior rim of glenoid fossa
z High incidence of recurrent dislocations
z Hill-Sach’s lesion
z Compression fracture causing groove on
posterolateral aspect of humeral head
z Hatchet deformity
z Avulsion fracture of greater tuberosity (10-
16%)
z Coracoid process damage
Forces
z Leverage: Koscher, Hippocratic
z Risk of humeral neck fracture
z Traction: Milch, Spaso, Stimson, traction
counter-traction
z Rotation: scapular manipulation
External rotation (partial
Kocher)
z External rotation of adducted arm until 70-80
degres
z Over 4-5 minutes
z Initial method, no analgesia.
z Up to 80% success
Traction Counter-Traction
(Matsen’s)
z 2 sheets:
z below axilla, toward opposite shoulder
z Wrapped around reductor + patient elbow
z Gentle « water skiing » with rotation of
humerus
z Wait
z Can add local pressure on humeral head.
Kosher’s method
z 1. External rotation of adducted arm
z 2. Elbow to midline of chest: leverage of
humerus onto thorax.
z 3. Internal rotation towards opposite shoulder
Lever humeral neck against
thorac
Stimson method
z Prone patient
z 10lbs weight attached to wrist
z Difficult monitoring, risk of falling.
z Limited time involvement
z Can use scapular manipulation, external
rotation, flexion of elbow.
z Can take up to 15-20 minutes
Scapular rotation
z Want to bring the socket onto the ball.
z Stabilized top scapula
z Push tip medially
z Apply traction to humerus, slight external
rotation
z Success up to 85%
Milch Method
z Bring arm to overhead baseball throwing
position
z Prevent humeral head movement downward
with thumb
z Abduction of arm (flexed or straight arm) with
external rotation
z Scratching of back of head.
z Can applied longitudinal traction
z Success 70-95%
Spaso method
z Described in 1998
z Full flexion – pointing toward the ceiling.
z External rotation at the end while maintaining
traction (palm up)
z Can push humeral head from posterior
approach.
z Can flex the arm and rock.
z Success rate 87.5%
Eskimo technique
z Used in Greenland
z Patient lies on unaffected shoulder
z Pull up by the dislocated arm until other
shoulder is off a few centimeters.
z Push on humeral head.
z Strain on brachial plexus
Self-reduction technique
(Aronen’s)
z Hands locked together around ipsilateral
knee
z Patient leans backward slowly
Resume
z 1st vs recurrent
z ?need for x-ray
z Try without sedation prior to x-ray
z If sedation required, likely safe to x-ray
z Gentle methods prior to traction-counter-
traction.
Posterior shoulder dislocation
z Electrical shock
z Seizure
z Trauma:
z Internal rotation
z Adduction
z Flexion
Light bulb effect
Wide glenoid space
Reduction
z Traction
z Adduction
z Internal rotation
z Pressure over humeral head: push from
behind.
Luxatio Erecta
z Fall on abducted arm
z Locked arm in abduction
z Rx: Mitch traction