Like any other dislocation acute dislocations of the glenohumeral or shoulder joint should be reduced as quickly and gently as possible. There are many advantages of early reduction of shoulder dislocation.
- Eliminates the stretch and compression of neurovascular structures
- Reduces amount of muscle spasm that must be overcome to effect reduction
- Prevents further insult to humeral head and glenoid labrum
If patient reports within short time, some dislocations can be reduced without medication especially in thinly built patients. Reduction is difficult without medications if patient is very muscular , dislocation is of a long standing duration, the dislocation is locked in soft tissue.
In such cases, it is wise to use general anaesthesia .
Narcotics and muscle relaxants can be used to aid in the reduction of shoulder dislocations if appropriate. However there is a danger of respiratory depression after pain is relieved after reduction of the dislocated shoulder. EIther one should opt for GA or appropriate resuscitation measures should be kept ready before hand.
An intravenous access should be in place before reduction procedure is begun.
Techniques of Reduction
Two different principles have been used in the reduction of shoulder dislocation—traction and leverage.
Hippocratic Technique
Not used commonly but Hippocrates’ original technique can be used when only one person is available to reduce the shoulder. Dislocated limb of the patient is held in traction and stockinged foot of the physician is used as countertraction.
The heel should not go into the axilla but should extend across the folds and against the chest wall.
With a gentleTraction should the arm may be gently rotated internally and externally to disengage the head
Due to associated complications, Hippocratic method is not widely used.
Stimson’s Technique
The patient is placed prone on the edge of the examining table while downward traction is gently applied Appropriate weights depending on the size of the patient are taped to the wrist of the dislocated shoulder, which hangs free off the edge of the table.
One should be patient since it may take 15 to 20 minutes for the reduction to occur when using this technique.
Milch’s Technique
With the patient supine, the arm is abducted and externally rotated, and the thumb is used to gently push the head of the humerus back in place.
Kocher’s Technique
In this maneuver, the humeral head is levered on the anterior glenoid and the shaft is levered against the anterior thoracic wall until the reduction is completed. We do not recommend it for routine use because undue forces used in rotation leverage can fracture the humerus or damage the soft tissues of the shoulder joint, the vessels, and the brachial plexus.
Open Reduction
Need for this is very rare in acute dislocation but can arise in long standing dislocations and difficult reductions.
Postreduction Care
After reduction the protocol is [This applies to all dislocations]
- Patient’s neurologic status is checked, including the sensory and motor functions of all major nerves
- Strength of the pulse is verified
- Evidence of bruits or an expanding hematoma is looked for.
- Radiographic check films are done immeditely to checkfor reduction of the dislocation.This also provides an additional opportunity to detect fractures of the glenoid and proximal humerus.
Recurrent glenohumeral instability is the most common complication of glenohumeral dislocation, therefore stress is on optimum rehabilitation.
The shoulder is immobilised for 2 to 5 weeks in position of adduction and internal rotation. This position relaxes the injured anterior structures. The patient is encouraged to extend the elbow several times a day.
Persons older than 30 years tend to develop stiffness quickly and in these people gradual mobilization may be begun within a week.
The patient also is instructed to do progressive isometric exercises, particularly of the internal and external shoulder rotator muscles t prevent atrophy of these muscles. Vigorous rotator strengthening exercises are done after immobilization stopped.
Swimming enhances endurance and coordination of shoulder and is recommended.
Important
The injured should not be used in sports or for over-the-head labor until normal rotator strength and nearly full forward elevation are achieved.
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