Is there a time limit to attempting a relocation?
No, although there is a trend towards easier and quicker relocation if it is attempted sooner.
Once dislocated, the patient experiences a spasm/ pain cycle. If this persists, the muscle relaxation and patient comfort and cooperation components of your reduction are more difficult.
Bleeding from associated fractures into the joint itself may make your reduction more difficult over time due to increasing pain from capsule stretching.
Is the shoulder easier to reduce the sooner reduction is attempted?
Yes, with the caveat that you need to take the time to set the patient up properly, with both an explanation of the procedure, and appropriate positioning.
Should I X-ray prior to attempting reduction?
Yes – if there is doubt in the diagnosis or if there is any risk of a humeral shaft fracture.
No – if it is a spontaneous dislocation. There is a clinical decision algorithm which suggests that no x-ray is required for “a recurrent dislocator with atraumatic mechanism”, recommending x-rays for all other suspected dislocations.
However, there is a trade off between delaying the reduction for xrays versus early reduction for patient comfort, especially in a busy ED where the wait could commonly exceed 30-60 minutes. An experienced clinician with a good history of the mechanism, as well as clear examination findings may decide to reduce the shoulder prior to x-ray. However, any techniques involving traction should be immediately excluded from this decision making process.
The unavailability of x-rays (such as in field situations) may alter the decision to attempt reduction. Great care should be taken to confirm the diagnosis in the setting of reduction without x-ray.
What is the best technique to reduce the shoulder?
The best technique depends on the patient, the procedure and the environment.
Patient – the best technique for the patient is the one that involves: as little discomfort as possible; as little movement of the affected limb as possible; an explanation of the process and the reason why this option has been chosen. Have a look at our relocation techniques section for a guide on choosing the right method.
Procedure – the operator must choose a technique that they understand well and can execute carefully. Having some options if your default technique fails is also useful – most people have a favourite technique but none are infallible.
Environment – taking time to make the best of your environment can help you control your reduction attempt.
In a hospital setting this might mean a chair or bed in a well lit room with some assistants. Out of hospital this might mean finding a chair or a quiet area where you can communicate clearly and carefully to the patient in order to talk them through the reduction attempt.
Field environments can be unpredictable – one of my registrars reduced a shoulder of a boxer who had popped his shoulder out during a semi-professional bout. This was done on a chair, in the middle of the ring, the crowd cheered when the shoulder reduced!
Can posterior dislocations be reduced with the Cunningham Technique?
One of the authors has had 2 radiologically confirmed posterior dislocations, both of which were reduced painlessly using Cunningham Technique. ‘Zero Postion’ manoeuvres such as a Milch Technique would also seem to be an anatomically sensible approach.
What is the role of analgesia in shoulder relocations?
Before or during the reduction, analgesia may or may not be needed, depending on the success of the analgesic positions.
Following the reduction, simple analgesia may be all that is required. If significant pain is present and a concurrent injury has been excluded then oral opiate analgesia and a simple sling are a good early option. Early mobilisation (if planned) requires good analgesic control.
Does everyone need sedation to put a shoulder back in?
No. The use of drugs is widespread yet has been shown to be unnecessary in the majority of cases if an appropriate technique is correctly applied. Some anxious and uncooperative patients may require analgesia and/or sedation.
Some dislocations have physical barriers to reduction (such as a fracture fragment blocking the path of the humeral head back to the glenoid fossa) and these patients may need conscious sedation or general anaesthesia and an orthopaedic surgeon.
Is it worthwhile attempting relocation on the field?
Yes – if the expertise is available the sooner the better. But keep in mind there is a trade-off between clarity of diagnosis, patient comfort, proximity to medical services.
What concurrent injuries should I worry about?
Fractures occur in about 30% of cases, particularly Hill Sach’s lesions, greater tuberosity fractures and Bankart lesions. Click here to see a list of associated injuries.
Can I teach my patient relocation techniques?
Yes – especially for recurrent dislocators. If the patient has a reliable partner, then you may be able to teach them the first manoeuvre of Kocher’s,Cunningham or Milch techniques. There is also clever auto reduction technique (Boss-Holzach-Matter) that might be suitable for some patients.
Isn’t it unethical to withhold pain relief for patients with shoulder dislocations?
Primum non nocere – First, do no harm!
Benzodiazepines and opiates have traditionally been the drugs of choice when manipulating shoulder dislocations. Both classes of drug carry cardiovascular and respiratory risks, especially in the elderly – these risks should always be considered.
Intra articular and suprascapular nerve blocks have been used – there is a theoretical risk of joint infection with these techniques. If a patient can cooperate long enough to allow one of these blocks then the shoulder almost certainly could have been reduced in the time it takes to perform the block.
Some operators feel that chemical sedation or analgesia should usually or always be given. However there are a number of studies using a variety of techniques where the standard use of drugs has been shown to be unnecessary.
What are the “analgesic positions?”
Certain positions can provide immediate relief of pain for the patient. Providing gentle support in the opposite direction to the spasming muscles can help to reduce joint stretching, bringing the humeral head closer to its normal anatomical position, and relieving pain.
Click Here for Analgesic Position 1 for patients presenting in adduction.
Click Here for Analgesic Position 2: for patients presenting in abduction.