Which Shoulder Reduction Techniques Work Best, And Which Should You Avoid?

Marsena Collins NP-C

Shoulder dislocations are very common. In fact, they account for over 50 percent of all major joint dislocations. Further, the shoulder can dislocated in three difference ways:

• Anterior (~95%)
• Posterior (~4%)
• Inferior (less than 1%)

Reducing a dislocated shoulder requires an understanding of how the shoulder is dislocated. A successful reduction relies on choosing the correct technique. Fortunately, there are many successful reduction techniques reductions and methods that will work. This article will help you choose the simplest and quickest technique for your patient. These are all also aimed at avoiding further injury to their shoulder.

What is a Reduction?

Reduction maneuvers work by using abduction and also external rotation to disengage the humeral head from the glenoid. They also rely on axial traction to reduce the joint. “Axial traction” refers to a force directed along the length of the bone. For example, a force pushing the humerus towards the humeral head and glenoid.

The provider should feel a distinct clunk as the shoulder reduces regardless of technique used.

Reduction Techniques That Work Best for Anterior Dislocation

There is no clear evidence to support the superiority of one reduction technique over the other. I suggest starting with scapular manipulation, which is the least painful for the patient. If this approach is unsuccessful, next attempt the external rotation technique (with or without the Milch technique). Traction-countertraction techniques can be attempted If reduction is still unsuccessful after these attempts.

Scapular manipulation (Good First Maneuver !!)

• Quick, easy, and well tolerated by the patient 
• Employs rotation of the scapula to disengage the humeral head from the glenoid and also allow it to reduce into the glenoid. 
• Success rates range from 80 to 100%
• Takes one to five minutes
• It is easiest to perform with the patient upright or in a prone position (see next)

Upright Scapular technique 

• Place the head of the bed at 90 degrees. Have the patient also dangle their legs over the side of the gurney and rest their unaffected shoulder against the upright portion of the bed. Encourage the patient to relax their shoulder muscles. 
• Stand behind the patient and locate the scapula. Next, simultaneously push the tip medially and the acromion inferiorly using your thumbs, thereby rotating the scapula.
• While you are doing this, an assistant provides gentle forward or downward traction on the arm to exert downward traction, the assistant grabs the patient’s wrist with one hand and the already flexed elbow with the other hand and pushes down on the elbow while holding the wrist in place. Downward traction helps to prevent movement of the patient’s arm and may increase success rates.

Prone Scapular technique 

• Have the patient lie prone on a stretcher.
• Hang the arm off the side of the stretcher and allow it to drop towards the ground.
• Add About 10 to 15 pounds of weight to the distal wrist by pulling down on the forearm.
  • This can also be done by hanging a weight from the patient’s wrist.
• Manipulate the scapula in similar fashion to the upright approach.
• If scapular technique is unsuccessful, then proceed with external rotation

External rotation technique 

This technique reduces anterior glenohumeral dislocation by overcoming spasm of the internal rotators of the humerus, unwinding the joint capsule, and also enabling the external rotators of the rotator cuff to pull the humerus posteriorly. This method is also safe, easy to understand and teach, has no reported complications, and requires only one clinician. It is successful in 80 to 90 percent of patients with a simple anterior shoulder dislocation.

• Have the patient lie supine with their elbow flexed to 90 degrees (this relaxes the long head of the biceps and allows movement of the humeral head.
• Grasp the flexed elbow with one hand to maintain the adducted position of the arm and hold the wrist of the patient’s arm with your other hand.
• Ask the patient to let their arm fall to the side (ie, externally rotate) slowly (over 5 to 10 minutes) while you gently guide the hand. Whenever the patient feels pain or muscle spasm, stop and allow the muscles to relax.
• Reduction generally occurs with the arm externally rotated between 70 to 110 degrees Reduction is often subtle and the “clunk” of the humerus rearticulating with the glenoid.

Milch technique

Add the Milch technique if reduction is unsuccessful with the external rotation approach. This can be done even after the arm is fully externally rotated. To perform this technique, abduct the fully externally rotated arm into an overhead position, maintaining external rotation throughout the abduction. Apply gentle traction in line with the humerus and also direct pressure over the humeral head with the operator’s thumb in the axilla. The Milch technique aims to align the shoulder muscles in an overhead position that allows for simple reduction of the humeral head without other muscular interference.  The success rates of this technique range from 86 to 100 percent.

OTHER COMMONLY Used Anterior Reduction Techniques 

Traction countertraction

Traction-countertraction uses a sheet wrapped under the axilla. While the operator provides gentle continuous traction at the wrist or elbow, the assistant provides countertraction with the sheet from the opposite side of the patient. This multiplies the necessary force to move the humeral head into a position for reduction.

Stimson technique

If the above techniques are unsuccessful, one alternative method is Stimson’s technique, which involves placing the patient prone and hanging the affected extremity off the edge of the bed with 10 to 15 pounds of weight. This is similar to the prone scapular technique without manual rotation of the scapula. This usually spontaneously reduces the shoulder within 30 minutes.

Spaso technique

The Spaso technique employs gentle vertical traction and external rotation in the supine patient to reduce the dislocation, usually within one to two minutes.

FARES (Fast, Reliable, and Safe) technique

In this technique, the patient lies supine on a stretcher with the affected upper extremity at their side. The clinician also grasps the patient’s wrist and gently pulls the arm to provide traction. Counter-traction is not necessary. Gradually abduct the arm while the clinician continuously moves the arm up and down in an arc of approximately 10 cm. The up and down motion helps relax the shoulder musculature. External rotation should be added if the shoulder has not reduced by 90 degrees of abduction.

Cunningham technique

To perform this technique, the clinician sits in front of the patient, who assumes a comfortable sitting position. The patient places the hand on the affected side atop the clinician’s shoulder. The clinician rests one arm gently in the patient’s elbow crease while the other hand gently massages the patient’s biceps, deltoid, and trapezius muscles to help them relax. While encouraging the patient to relax, the clinician instructs the patient to pull their shoulder blades together and straighten their back. This maneuver moves the scapula medially and removes the major obstacle preventing reduction of the humeral head. 

Posterior shoulder dislocation reduction 

Posterior shoulder reductions rely on moving the humeral head anteriorly from a posteriorly dislocated position. This reduction maneuver involves axial traction on the adducted arm with the elbow flexed. Interally rotate and adduct the arm while applying traction. Sheets may also be used similar to the traction-countertraction method above. Direct pressure on the posterior aspect of the dislocated humeral head, directing it anteriorly, or gentle lateral traction using a sheet looped under the axilla to unlock the glenoid rim may also assist reduction.  Immobilize the arm in a neutral position when completed.

Inferior shoulder dislocation reduction 

Inferior dislocations result from a significant axial loading force that impacts the humerus underneath the glenoid and/or clavicle. These dislocations require a tremendous amount of force. Often times these patients are unable to rotate their shoulder, and also present with an outstretched arm that appears to be waving. This position is known as luxatio erecta. Reduction is achieved by traction-countertraction in line with the abducted humerus. Gentle, gradual adduction of the arm reduces the dislocation.  Closed reduction attempts work in most cases, unless a “buttonhole” deformity exists. This deformity is caused by the humeral head being trapped in a tear of the inferior capsule. These cases require open surgical reduction.

Techniques to Avoid

Avoid the wrestling technique, chair technique, Eskimo technique, Hippocratic technique, and Kocher’s method, these techniques are more complex and also associated with undesirable complications!!

The Hippocratic Technique

The Hippocratic technique involves traction-countertraction with the clinician’s foot placed in the patient’s axilla. This movement can cause undue stress to the patient’s shoulder joint and cause more damage.

Kocher’s Method

This technique required abducting the arm 45 degrees while applying in-line traction of the patient’s arm. Then, the following steps are taken:

• Externally rotate the arm
• Bring the elbow across the chest to the midline
• Internally rotate the arm until the patient’s hand touches their shoulder

Both the Hippocratic and Kocher techniques have a high rate of fractures, brachial plexus injury, and vascular injury. For these reasons, these techniques should be avoided.

Post Reduction

• Immobilize the arm and place in a sling. The patient should wear this for approximately 3 weeks.
• Confirm reduction with AP and lateral (y-view) radiographs. These images also ensure that no iatrogenic fractures have occurred during reduction maneuvers.
• Direct patient to Follow-up outpatient Orthopedics

References 

Sherman, S. Shoulder dislocation and reduction: (Sept 2020). UpToDate (Retrieved December 2021) from https://www.uptodate.com/contents/shoulder-dislocation-and-reduction#h28

Learn more about this and other important topics. Check out our Advanced Practice Provider Clinical Skills and Procedure Workshop!