Shoulder Relocation Maneuvers

Aka: Shoulder Relocation Maneuvers, Dislocated Shoulder Reduction, Shoulder Dislocation Management, Procedures for Shoulder Dislocation, Post-Reduction Management of Shoulder Dislocation

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II. Contraindications

  1. Do not attempt to reduce a Chronic Shoulder Dislocation present for >3-4 weeks
    1. Prolonged dislocations form adhesions between Humerus and axillary artery
    2. Risk of axillary artery rupture on relocation maneuvers
    3. Relocation should be by orthopedic surgery typically in the operating room
  2. References
    1. Herbert and Webley in Herbert (2015) EM:RAP 15(3): 1
    2. Verhaegen (2012) Acta Orthop Belg 78(3): 291-5 [PubMed]
    3. Sahajpal (2008) J Am Acad Orthop Surg 16(7): 385-98 [PubMed]

III. Precautions

  1. Reduction becomes more difficult as Muscles tighten
    1. Do not delay reduction
    2. Reduce on sideline in field if possible
  2. Check neurovascular exam before and after reduction
    1. Include axillary nerve function (Sensation lateral Shoulder, deltoid Motor Strength)
  3. Obtain AP and Axillary XRay prior to reduction

IV. Management: Premedications

  1. Some of the techniques may be effective without Anesthesia (e.g. Cunningham and Davos)
  2. Consider Intra-articular Injection
    1. Inject 20 ml of Lidocaine 1% into the glenohumeral joint
      1. Consider using 20 gauge spinal needle for adequate length
      2. Inject over 20-30 seconds and expect maximal effect at 10-15 minutes
    2. Approaches (lateral approach preferred)
      1. See Glenohumeral Joint Injection
      2. Posterior Shoulder intraarticular injection or
      3. Lateral Shoulder intraarticular injection
    3. As effective as analgesia, sedation for pain relief and successful Shoulder reduction
      1. Wakai (2011) Cochrane Database Syst Rev (4):CD004919 [PubMed]
      2. Jiang (2014) J Clin Anesth 26(5): 350-9 [PubMed]
  3. Interscalene Nerve Block (Brachial PlexusNerve Block)
    1. Complete Anesthesia for the Shoulder (as well as the elbow, Forearm and hand)
    2. Risk of nerve injury (up to 0.4% of cases) and phrenic nerve Anesthesia
  4. Supraclavicular Nerve Block (Supraclavicular Brachial Plexus Block)
    1. Regional Anesthesia of the upper arm, elbow, Forearm and hand, but incomplete Anesthesia of Shoulder
    2. Lower risk than Interscalene Block (as phrenic nerve is not in field)
    3. Consider for patients age >65 years old
  5. Anxiolytic alone (consider for Cunningham Technique)
    1. Ativan 0.5 to 1 mg IV
  6. Conscious Sedation
    1. Procedural Sedation
      1. Propofol or
      2. Ketamine or
      3. Etomidate or
      4. Versed 0.5 to 2 mg IV
    2. Analgesia
      1. Morphine Sulfate 1 to 6 mg IV or
      2. Fentanyl 100 mcg IV over 1 minute
        1. May repeat q5 min to total maximum of 3 mg/kg
    3. Precautions during Conscious Sedation
      1. See Procedural Sedation
      2. Supplemental Oxygen
      3. Capnography and Oxygen Saturation monitoring
      4. Naloxone at bedside
  7. General Anesthesia
    1. Indicated for failed reduction under Procedural Sedation

V. Management: Post-Reduction

  1. Immobilize Shoulder with sling
    1. Age under 40 years old
      1. Sling for 1 week
    2. Age over 40 years old
      1. Sling for only 2 to 3 days (no longer than 1 week)
      2. Risk of Frozen Shoulder
  2. Consider orthopedic referral
    1. Indicated for consideration of surgical management (esp. young or athletic patients)
      1. Consider after first anterior dislocation in active patients age <25 years
      2. Complicated dislocation (large Bony Bankart lesion, or osseous defect at glenoid or humeral head)
    2. Stabilization surgery prevents recurrent injury
      1. Bottoni (2002) Am J Sports Med 30:576-80 [PubMed]
  3. Restrictions
    1. Avoid overhead activity
    2. Avoid external rotation
    3. Exercise caution with Shoulder Abduction and Shoulder extension
  4. Return to Play
    1. May be as early as 2 to 3 weeks after dislocation
    2. Athlete should have painless, full symmetrical Shoulder Range of Motion at time of return
    3. Should be able to perform sport specific activities
  5. Shoulder Range of Motion Exercises as symptoms allow
    1. Pendulum Exercises and Circumduction at 5-10 days
      1. Start with arm in sling
        1. Bend at waist
        2. Allow arm to fall toward floor
        3. Rotate arm in circle
      2. Advance Exercise
        1. Arm out of sling
        2. Circles of greater diameter
    2. Advanced range of motion at 2-3 weeks
      1. Abduction via wall walking with fingers
      2. Internal rotation
        1. Start by touching hip
        2. Progress to touching mid-back
      3. Flex and extend elbow out of sling as tolerated
    3. Additional Exercises
      1. See Shoulder Strengthening Exercises
      2. Consider physical therapy starting at 2-4 weeks after dislocation
    4. Return to activity
      1. Shoulder strength and range of motion equal to the opposite side

VI. Procedure: Reduction by Self-Reduction Method (Anterior and Posterior Dislocation)

  1. Known as Davos reduction maneuver or Boss-Holzach-Matter Technique
  2. Efficacy
    1. Very effective for reduction, even in the emergency department without sedation
  3. Position
    1. Sit on floor with knees flexed
    2. Wrap both arms around ipsilateral knee
      1. Interlace fingers of each hand with one another
      2. Ace wrap wrists together
  4. Traction
    1. Lean backward, extend arm at elbow and extend head and neck backward
    2. Applies traction at Shoulder for reduction
  5. Resources
    1. Instructional Video
      1. https://www.youtube.com/watch?v=u2MsnjVNoPM
  6. References
    1. Stafylakis (2016) J Emerg Med 50(4):656-9 +PMID:26899512 [PubMed]

VII. Procedure: Reduction by Cunningham Technique (Anterior Dislocation)

  1. Preferred method for Anterior Shoulder Dislocation
    1. Requires no Conscious Sedation (in fact, requires an awake patient)
    2. Consider Ativan 0.5 to 1 mg prior to procedure
  2. Patient position
    1. Performed in awake, sitting patient
    2. Patient and examiner sit opposite one another eye to eye
    3. Patients arm position (Analgesic position, most comfortable)
      1. Held adducted at side
        1. Critical to success (may be difficult in Obesity)
      2. Elbow flexed to 90 degrees
      3. Patients palm rests against examiners Shoulder
    4. Examiner position
      1. Examiner's hand rests firmly on top of the patient's dorsal Forearm, applying downward pressure
  3. Technique
    1. Examiner applies gentle, steady pressure downward on dorsal Forearm (2-5 pounds of pressure)
    2. With free hand, examiner massages upper extremity proximal Muscles
      1. Start at deltoid
      2. Move distally to biceps and triceps
    3. As patient begins to feel relaxation (expect some apprehension at this point)
      1. Premedication with Ativan prior to procedure may facilitate this transition
      2. Patient shrugs Shoulders up and back
      3. Patient pushes chest outward
    4. Anticipate Shoulder to spontaneously relocate
      1. May take as long as 15 minutes to relocate
  4. References
    1. Orman (2011) EMRap.tv, EMRAPTV-122-Cunningham-Technique
    2. Shoulder Dislocation Site
      1. http://shoulderdislocation.net/relocation/cunningham

VIII. Procedure: Reduction by Hennepin Maneuver (Anterior Dislocation)

  1. Premedication
    1. May be attempted without premedication
    2. Typically requires good Muscle relaxation, although me be attempted with significant anxiolysis (e.g. Ativan 0.5 to 1 mg IV)
    3. Consider Opioid Analgesics or Conscious Sedation
  2. Patient position
    1. Patient supine
  3. Technique
    1. Examiner flexes patient's elbow to 90 degrees
    2. Examiner externally rotates Shoulder to 90 degrees (relocates the humeral head under glenoid)
      1. Relocation may occur spontaneously at this time
      2. Consider maintaining this position until Muscles Fatigue and ultimately relax
    3. Milch Technique (added to above technique)
      1. Indicated if external rotation alone does not relocate Shoulder
      2. Continue to maintain 90 degrees of external rotation
      3. Examiner slowly abducts arm
  4. References
    1. Simon (1984) Ann Emerg Med 13:981 [PubMed]
    2. Garnavos (1992) J Trauma 32:801 [PubMed]

IX. Procedure: Reduction by Stimson's Method (Anterior dislocation)

  1. Patient position
    1. Patient lies prone on table
    2. Affected arm hangs over side of table
  2. Downward traction applied
    1. Assistant applies downward traction on arm or
    2. Attach 5 to 10 kg weight (10 to 15 pounds) to wrist
      1. Weight should hang freely and not touch floor
  3. Reduction
    1. Spontaneous reduction as ShoulderMuscles relax
    2. Pushing humeral head in caudal direction may assist
    3. Scapular Manipulation may also be attempted (see below)

X. Procedure: Reduction by Scapular Manipulation

  1. Patient position (same positioning at Stimson Method)
    1. Patient lies prone on table
    2. Affected arm hangs over side of table
  2. Downward traction applied
    1. Assistant applies downward traction on arm
    2. May also gently internally and externally rotate the Humerus while performing reduction
  3. Reduction
    1. Grasp the inferior Scapula and rotate it medially

XI. Procedure: Reduction by Traction (Anterior and Posterior Dislocation)

  1. Patient positioning
    1. Patient sitting or prone
    2. Shoulder adducted and internally rotated
  2. Traction at wrist by one provider
    1. Gentle, slight straight (parallel to body) traction
    2. Apply from patient's wrist
  3. Countertraction by second provider
    1. Apply with 4-5 inch sling (e.g. sheet) under axilla
    2. Pull transverse across patient's chest
    3. Consider pulling upward at 30 degrees
  4. Direct pressure
    1. Apply posterior to anterior pressure against humeral head

XII. Procedure: Reduction by Hippocratic Method (Anterior Dislocation)

  1. Precautions
    1. No longer recommended
    2. Axillary pressure risks Humeral Fracture and neurovascular injury
  2. Patient lies supine
  3. Single provider reduction method
    1. Counter-traction
      1. Place one foot on patient's chest wall
    2. Traction
      1. Grasp patient's wrist
      2. Apply traction at 45 degree angle

XIII. Procedure: Reduction by Modified Traction (Anterior dislocation)

  1. Patient prone, arm at side with elbow flexed 90 degrees
  2. Technique
    1. Traction toward patient's feet (parallel to body)
    2. Externally rotate Shoulder by moving wrist laterally

XIV. Procedure: Reduction by Strap Method (Anterior dislocation)

  1. Patient in sitting position
  2. Countertraction
    1. Second strap placed under axilla and across chest
    2. Assistant pulls strap across chest
  3. Traction
    1. Patient's elbow flexed at 90 degrees
    2. Strap placed around patient's Forearm
    3. Other end of strap placed under examiner's foot
    4. Downward traction applied to Forearm via strap
    5. Examiner externally rotates arm 20 degrees
    6. Spontaneous reduction often occurs

XV. Procedure: Reduction by Traction/Counter-Traction (Inferior dislocation)

  1. Requires Procedural Sedation
  2. Patient supine
  3. One examiner pulls traction in the direction of the abducted arm
  4. Second examiner examiner pulls counter-traction on a rolled sheet across the top of Shoulder

XVI. Procedure: Conversion of Inferior Dislocation to Anterior Dislocation by Rotation (Inferior dislocation)

  1. Patient supine
  2. Examiner stands beside patient on side of dislocation, beside the patient's head
    1. One hand on the lateral Humerus at mid-shaft
      1. Apply pressure toward the anterior Shoulder (anterior to glenoid)
    2. Other hand over the medial epicondyle
      1. Apply gentle superior or upward force
  3. Maneuver rotates the Humerus from the inferior position to anterior position (in relation to glenoid)
    1. Converts an inferior dislocation to an anterior dislocation
  4. Use other techniques above to reduce the anterior dislocation

XVII. Resources

  1. Ten Ways to reduce a Shoulder Dislocation (Dr. Larry Mellick, YouTube)
    1. https://www.youtube.com/watch?v=HtOnreM7heg

XVIII. References

  1. Chan and Huang (2022) Crit Dec Emerg Med 36(2): 16-7
  2. Dolbec (2019) Crit Dec Emerg Med 33(1): 17-25
  3. Wirth in Greene (2001) Musculoskeletal Care, p.151-2
  4. Burra (2002) Orthop Clin North Am 33:479-95 [PubMed]
  5. Simon (2023) Am Fam Physician 107(5): 503-12 [PubMed]

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