New Method to Reduce Shoulder DislocationOrthopedic surgeons from Greece think they may have found a new way to quickly reduce an anterior shoulder dislocation with far less pain than two other methods commonly used. Reducing the shoulder joint simply means to put the head of the humerus (upper arm bone) back in the shoulder socket.
An anterior shoulder dislocation indicates that the head of the humerus has popped out of the socket in a forward direction. These injuries are most common with falls onto the extended arm/hand. Car accidents and sports activities are the two other ways in which this injury occurs.
The new technique is called the FARES method, which stands for fast, reliable, and safe. It is done with the patient lying on his or her back. The doctor faces the patient and holds the patient's hand while the patient's arm is down at his side. The elbow is straight and the thumb is pointing up. This position puts the forearm is in a neutral or midline position. A gentle traction force is placed on the hand to pull the arm down away from the patient's head.
Then the arm is slowly moved away from the body, a movement called abduction. The clinician continues to pull the arm gently downward toward the feet while applying a vertical (up and down) oscillating movement. When the arm is abducted to about 90 degrees, the examiner gently rotates the patient's arm into a position of external (outward) rotation. Now the palm is facing the ceiling.
The arm is gently pulled up toward the patient's head with continued traction and oscillating motions. When the arm is abducted about 120 degrees away from the side of the body, the humeral head slips back into the socket and the shoulder is reduced.
In this study, they compared how well the FARES technique for anterior shoulder reduction compared with two other methods commonly used (the Hippocratic method and the Kocher method). Each of these other methods are similar to the FARES method but with slight differences.
Most of the time, one method works but sometimes the physician has to try a different approach. Each attempt to relocate the shoulder without doing surgery causes additional pain and apprehension on the part of the patient. The goal is to find the safest, easiest, most painless way to relocate a dislocated shoulder and avoid surgery whenever possible.
The Hippocratic method is done with the patient on his or her back. A sheet is placed around the patient's chest and under the armpits. One person uses the sheet to apply traction toward the uninvolved shoulder. The other person applies a downward traction force to the dislocated arm while rotating the arm slightly.
The Kocher method is done with the elbow on the involved side in a flexed (bent) position (about 90 degrees of flexion). Instead of moving the arm away from the body, it is moved toward the body -- a movement called adduction. The forearm is rotated outward as far as it will go comfortably (palm up). Then the arm is lifted up as far as it will go and the clinician internally rotates the arm until it reduces.
Patients in the study had their first anterior shoulder dislocation. They were divided into three groups based on assignment to one of the three reduction methods described. The maneuvers were done by first and second-year orthopedic surgery residents. All patients were awake and without sedation (medication to relax them or put them to sleep). The reduction procedures were done even if the shoulder was dislocated and there was a fracture of the greater tuberosity. The greater tuberosity is a bump on the head of the humerus where muscles attach.
The results were measured by 1) whether the first attempt was successful, 2) how long the reduction took to complete (in minutes), and 3) by using the visual analog scale (VAS) to measure patients' pain levels during the reduction procedure. They found that the FARES method took half the time with much less pain.
For example, 88.7 per cent of the patients in the FARES group had a successful reduction. This compared with 72.5 per cent for the Hippocratic method and 68 per cent for the Kocher method. The time it took to reduce the dislocated shoulder using the FARE method ranged from slightly more than a minute up to three and a half minutes. The other two methods took at least two minutes (up to seven minutes) with quite a bit more pain reported by the patients.
The patients in this study who did not have a successful response to these techniques were taken to the operating room and sedated (put to sleep). While in this relaxed state without pain and without muscle guarding (tension), the same reduction method used in the clinic was repeated successfully in all cases.
The authors concluded that the FARES method of anterior shoulder dislocation reduction is safe and reliable while being faster and less painful than two other methods tested. The Kocher method was faster than the Hippocratic method but more painful for the patient. The FARES method can be done by medical students and residents who don't have a lot of practice yet. It is a simple technique that can be done by one person. And it can be used without the expense of medications (pain relievers or muscle relaxers) or an operation.
More studies are needed to confirm these findings and to compare the FARES method of shoulder reduction with other techniques that were not considered in this study. As common as anterior shoulder dislocations are, finding the best method to reduce it that can be used in the emergency department or outpatient clinics is an important goal.
Fares E. Sayegh, MD, et al. Reduction of Acute Anterior Dislocations: A Prospective Randomized Study Comparing a New Technique with the Hippocratic and Kocher Methods. In Journal of Bone and Joint Surgery. December 2009. Vol. 91-A. No. 12. Pp. 2775-2882.
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