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Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017
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Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
The shoulder, the body's most mobile joint, is the most commonly and easily dislocated. It is at highest risk for dislocation due to it having the greatest range of motion of any joint in the body. Shoulder dislocations account for 54.9% of sports-related dislocations in high school athletes.[1]
Shoulder dislocations are classified by the position of the humeral head (H) in relation to the glenoid cavity (G): most commonly anterior; occasionally posterior; and very rarely inferior, superior, or intrathoracic. More than 95% of shoulder dislocations occur in an anterior and inferior direction.[1] Anterior shoulder dislocations usually result from trauma with the arm in abduction, extension, and external rotation, such as when preparing for a volleyball spike. Posterior dislocations are less common (no more than 4% of all shoulder dislocations) and result from forceful internal rotation and adduction. Posterior dislocations are associated with significant force, such as in high-energy trauma.
Inferior (luxatio erecta), superior, and intrathoracic dislocations are rare and are usually associated with complications.[2,3]
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Shoulder dislocations affect approximately 1.7% of the US population and are most frequently secondary to trauma. The incidence of all traumatic shoulder dislocations has been estimated at 11.2 cases per 100,000 person-years, with a cumulative incidence rate of 0.7% for men and 0.3% for women up to age 70 years.[2] Gender distribution is bimodal, with peak incidence in men aged 20-30 years (with a male-to-female ratio of 9:1) and in women aged 61-80 years (with a female-to-male ratio of 3:1).
Adolescents have shoulder dislocations more frequently than younger children due to stronger epiphyseal growth plates that are more likely to dislocate rather than fracture. Almost half of dislocations occur between the ages of 15 and 29 years. Dislocation is more likely in older adults due to weaker joint capsules and supporting tendons and ligaments.
Anterior dislocation is most commonly seen in those aged 18-25 years and is typically due to sporting injury. The second most common age group to sustain anterior dislocation is the elderly. Falling on an outstretched hand is a common cause in older adults.
Image courtesy of Wikimedia Commons.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Most shoulder dislocations are straightforward and can easily be reduced in the ED by using one of several techniques. On initial evaluation, the patient with an anterior dislocation often resists moving the shoulder, and tends to hold the affected arm by his/her side supported by his/her other arm.
In most anterior shoulder dislocations, the humeral head can be felt anteriorly. This can be seen by comparing the unharmed side to the dislocated shoulder.
Posterior dislocations can be harder to physically diagnose since the patients usually keeps their arm in an internally rotated and adducted position as the arm is held against his or her abdomen. Direct inferior dislocations (luxatio erecta) lock the shoulder in abduction and can be especially difficult to reduce.[1,4]
For all suspected shoulder dislocations, first examine the regimental badge area for pinprick sensation to assess axillary nerve sensory function. This is accomplished by feeling for deltoid contraction and evaluating the patient's sensation to touch over the lateral upper arm.
Depending on the mechanism of trauma and the examination, radiography of a dislocated shoulder is usually indicated. It may be difficult via physical examination to differentiate between a dislocation and a proximal fracture of the humerus. A patient with a history of multple dislocations associated with either minor or no trauma may not require radiography.
Shown is an anterior dislocation of the shoulder.
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
The treatment of a dislocated shoulder is immediate relocation by a variety of maneuvers. Without immediate treatment, muscle spasm may occur thereby making it difficult to reduce the joint without anesthesia. The choice of method and the depth of anesthesia should be determined on a case-by-case basis, taking into account patient-related factors (eg, general medical condition; age; level of anxiety and cooperation; time since injury; history of shoulder dislocations; and history of adverse reactions to systemic analgesics, muscle relaxants, and sedatives).
The traction/countertraction technique is a commonly used method for reduction. It is the least traumatic and the most practical to perform in the field immediately following an injury.[1] It involves a force applied in one direction counteracted by a force applied in the opposite direction. An assistant may be helpful for applying countertraction.
One person applies longitudinal traction on the affected arm by tightly grasping the wrist, while another person uses a sheet or towel wrapped around the patient's torso and pulls in the opposite direction. The head of the humerus is disengaged from the glenoid by moving the affected arm slowly between external and internal rotations and maintaining steady traction and countertraction. Axillary nerve function should be assessed after this type of reduction.
For an inferior dislocation, one operator applies axial traction to the abducted arm while an assistant applies parallel countertraction. Abduction is increased while applying pressure on the humeral head superiorly.
Image courtesy of Guler O, Ekinci S, Akyildiz F, et al. J Orthop Surg Res. 2015; 10: 80. [Open access.] PMID: 26016671, PMCID: PMC4448546.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Kocher method
First portrayed by Kocher in 1870, Kocher's method excludes traction using leverage alone. If not performed correctly, complications may occur. These include tearing of the subscapularis muscle, fractures of the proximal humerus, or neurovascular compromise.
In the Kocher method (shown), the affected arm is pulled in the direction of the arm's longitudinal axis, followed by external rotation of the limb. The arm is then adducted until a pop is heard or felt, signifying that the humeral head has relocated back to its normal position (into the glenoid fossa). After reduction, the arm is put in a sling to stabilize the joint; this allows the musculature to come back to its original place.[5]
Image courtesy of Guler O, Ekinci S, Akyildiz F, et al. J Orthop Surg Res. 2015; 10: 80. [Open access.] PMID: 26016671, PMCID: PMC4448546.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Spaso method
The Spaso technique requires the patient to remain supine, while the clinician grasps the affected arm by the wrist, lifting it up vertically, applying traction in the direction of the longitudinal axis of the arm while externally rotating the shoulder. The reduction is complete when an audible or palpable clunk is heard or felt.
Reduction will usually occur after a few minutes of gentle traction. If difficulty is experienced, the clinician may use his other hand to palpate the humeral head and push firmly posteriorly. When properly applied, the Spaso technique has a success rate of more than 87%.[5,6]
Image courtesy of Guler O, Ekinci S, Akyildiz F, et al. J Orthop Surg Res. 2015; 10: 80. [Open access.] PMID: 26016671, PMCID: PMC4448546.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Chair method
The chair method involves asking the patient to sit in a stable chair sideways and hang his/her affected arm over the backrest. A small pillow or folded bed sheet may be placed atop the backrest under the patient's armpit to provide more comfort and support. The physician squats down behind the chair, using one hand to hold the patient's elbow, and induces the patient's arm to gently flex. Traction is applied slowly and reduction usually occurs.[5]
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Stimson Maneuver
In the Stimson hanging arm technique, the patient lies prone and the affected arm dangles from the side of the stretcher without touching the floor. The patient may be tightly strapped down with a sheet to prevent sliding off the stretcher.
A 5 to 10-lb weight is securely fastened to the wrist of the affected arm to provide continuous traction. Reduction will occur spontaneously after 15-20 minutes. To facilitate reduction, the physician may apply gentle external rotation of the extended arm, flexion of the elbow 90°, or scapular manipulation.[7]
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
The scapular manipulation method fixes the humeral head in place and rotates the scapula to accommodate, and realign with, the humeral head.[6,8] With the patient prone or seated and the back exposed, the affected arm is placed in 90° of forward flexion at the shoulder. If the patient is prone, weights of 5-10 lbs may be secured to the patient's wrist to maintain traction. Then, reduction is attempted by manipulating the scapula. Manipulation of the scapula is carried out by stabilizing the superior aspect of the scapula with one hand and pushing the inferior tip of the scapula medially toward the spine.
If the patient is seated, an assistant should stand and face the patient and firmly grasp the wrist of the dislocated arm. The assistant should then apply steady forward traction parallel to the floor while applying countertraction with the other arm, which is outstretched and resting on the patient's clavicle.
Images courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
External Rotation
The external rotation method (ERM) is a modified version of the Kocher method and is reported to be safe and reliable for the reduction of acute anterior shoulder dislocation. Sedatives or analgesics are not typically required.
With the patient in the supine position, the treating physician uses one hand to adduct the affected arm tightly to the side of the patient's chest. With the other hand, the physician grasps the patient's wrist, bends the elbow to 90° of flexion, and gently rotates the upper arm externally, using the forearm as a lever, without force or traction. Reduction typically takes place between 70° and 110° of external rotation; sometimes, it takes place during return on internal rotation.
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Milch Technique
The Milch Technique may be used in cases of unsuccessful reduction using external rotation. In this method, the patient lies supine while the clinician slowly pulls the arm to a 90° abduction followed by a slow external rotation to 90°. This maneuver causes the muscles of the rotator cuff to relax and allows the humeral head to move back into its anatomic position within the glenoid fossa. The main advantage of this method is that it is nearly painless and thus generally does not require anesthesia or sedation. It has an estimated success rate in the range of 70-90%.[7]
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Axial (inline) traction and the two-step reduction are two techniques commonly used to reduce inferior shoulder dislocations.
For the axial (Inline) traction method, the patient is placed supine on a sturdy immobile surface (eg, a wheel-locked gurney). The physician applies axial traction to the abducted arm standing on the affected side at the patient's head (shown). An assistant applies parallel countertraction using a sheet wrapped diagonally over the affected shoulder.
During the application of axial traction, increasing the degree of abduction (if possible) and applying cephalad pressure to the displaced humeral head (marked by the star) can help make reduction easier. After successful reduction of the humeral head, the arm should be fully adducted against the chest wall and supinated and immobilized in that position.[7]
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
In the two step reduction technique, the inferior dislocation is converted to an anterior dislocation (step 1), which is subsequently reduced (step 2).
The patient is placed supine on a secure immobile surface (eg, wheel-locked gurney). The clinician places the hand closest to the patient on the lateral aspect of the midhumerus and places the other hand on the medial condyle.
Step 1 of the reduction may be divided into two parts. In part 1, the clinician pushes anteriorly with the hand on the midhumerus and pulls posteriorly with the hand on the medial condyle (left). This motion brings the humeral head to a position anterior to the glenoid (ie, the humeral head is now anteriorly rather than inferiorly dislocated). In part 2, the clinician adducts the arm and moves the hand on the medial condyle to grasp the wrist.
In step 2 of the two-step reduction, the clinician, while holding the arm in adduction against the chest wall, externally rotates the shoulder by pulling on the wrist (right).[7]
Image courtesy of Wikimedia Commons.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
When choosing a technique for the reduction of a shoulder dislocation, a clinician must debate the advantages of a technique against considerations such as sedation risks, whether they will have assistance, patient anxiety, and their skill level.[5] No single reduction method is successful in every case and sometimes more than one technique can be used for successful reduction.
Signs of a successful reduction include a palpable or audible clunk, a notable relief of pain by the patient, and a return of shoulder motion. The reduction can be assessed immediately by an axillary radiograph which can confirm proper alignment of the joint structures and evaluate glenoid rim fractures. The shoulder should be immobilized in a sling for 1-3 weeks. Whether to place the arm in external or internal rotation position in the sling has been a matter of debate.
Elbow, wrist and hand range of motion exercises should take place while the patient is in the sling as well as exercises for the parascapular muscles. Active and passive flexion, extension, abduction, and internal/external rotation begin at about the third week, when the patient comes out of the sling with the aim for the patient to return to athletic activities within 4 to 6 weeks after successful reduction.[1,9]
Shown is a posterior shoulder dislocation (left) and the same shoulder post reduction (right).
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Elbow dislocations are the second most common large joint dislocation in adults after shoulder dislocations and are the most common dislocation in children. Posterior elbow dislocations make up about 90% of elbow injuries.[1] Elbow dislocations occur after structural injury to the lateral collateral ligament followed by complete lateral collateral ligament disruption and damage to the anterior and posterior compartments. The posterior medial collateral ligament can then become damaged while leaving the anterior portion intact. The medial collateral ligament can be damaged as further force can allow the elbow to pivot about the anterior bundle.[10] The injury typically occurs after a fall onto an outstretched and abducted arm, such as attempting to break a backward fall.
Posterior elbow dislocations often have a very prominent olecranon and a forearm that appears foreshortened. Anterior elbow dislocations have the appearance of an elongated forearm, and the arm is held in extension. Neurovascular assessment is essential in any elbow dislocation before and after reduction because associated brachial artery and ulnar nerve injuries are frequent. Also common are median nerve injuries.[10]
Shown is the left elbow of a soccer goalie with a posterior and lateral dislocation. Also present is a small avulsion fracture of the olecranon.
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
For reduction of a posterior elbow dislocation, multiple approaches may be required. The prone approach allows for more muscular relaxation and should be the initial approach.[11] In this one-person technique, the patient may lie prone with the humerus supported by the examination table (shown). The operator applies downward traction with one hand while the other hand applies force axially down the humerus along the olecranon process, guiding it over the capitellum. Alternatively, in the supine approach, an assistant stabilizes the humerus against the stretcher as the clinician grasps the wrist, and applies slow, steady, inline traction, while keeping the elbow slightly flexed and the wrist supinated.[11]
Image courtesy of Martin JR, Mazzini JP. Cases J. 2009; 2: 6603. [Open access.] PMID: 19829829, PMCID: PMC2740197.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Post reduction, radiographic evaluation of the elbow should be obtained to determine alignment and to reveal any associated fractures.[1,11] Assess the stability of the elbow by gently moving the joint through its full range of motion, watching especially for instability upon elbow extension.[11] The elbow should be placed in a posterior splint and neurovascular assessment is indicated, including evaluation and documentation of median nerve function, ulnar nerve function, and distal pulses.
Shown are post closed-reduction radiographs. On the left, the radiograph shows incongruity of the elbow joint. On the right, a bone fragment into the joint can be seen.[12]
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Carpal dislocations represent a continuum of wrist injury that can lead to lunate or perilunate dislocation.[13] Because of the mechanism of injury, the lunate cup commonly is directed in a volar direction in dislocation. Perilunate dislocations result from dislocation of the distal carpal row.[13] Normally, the capitate rests within the lunate cup. In a perilunate dislocation, there is dislocation of the midcarpal joint. Most commonly, the capitate dislocates dorsally from the appropriately seated lunate.
Scaphoid fractures are often associated with perilunate dislocation because of the stresses involved. The many forms of carpal instability include scapholunate dissociation, lunate and perilunate dislocations, scaphoid fracture, and other intercarpal instabilities.[13]
Shown is the classic teacup sign in a lateral view of a lunate dislocation.
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
A wrist injury is usually a result of a fall onto an outstretched hand with hand rotation. Injuries can range from scapholunate strain to carpal dislocation to scaphoid fracture. A large percentage of wrist injuries are not diagnosed in the ED and the injury can lead to chronic pain and wrist instability.[13]
Wrist injuries account for as many as 2.5% of all emergency department visits.[14,15] Wrist dislocations represent a small number of those injuries. 10% of carpal injuries consist of subluxations and dislocations; perilunate dislocation is the most common type of dislocation.
Shown is an anteroposterior view of a lunate dislocation.
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Perilunate dislocation and perilunate fracture dislocation is an emergency and patients should undergo open reduction and internal fixation (ORIF) as soon after the injury as possible in order to achieve the best results.[16] Reduction may be performed in the emergency department, with delay of the definitive procedure, as any fracture associated with perilunate dislocations typically requires stabilization with small compression screws or percutaneous pins. It is sometimes necessary to delay the definitive procedure because of the patient's overall condition, excessive swelling of the wrist and hand, or the need for appropriate surgical assistance.[16]
Shown is a posteroanterior radiograph of a perilunate dislocation. Crowding is seen between the proximal and distal carpal bones.
Image courtesy of Medscape/ David T. Schwartz, MD.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Approximately 9% of all sports injuries involve the hand and fingers.[1] Finger/phalanx dislocations commonly occur during sporting events when the finger comes into swift, blunt contact with the body or equipment of another player. Although sometimes viewed as a minor injury, finger dislocations can also be associated with hand and wrist injuries.[1] Dislocation nomenclature is based on the position of the more distal bone in relation to the more proximal bone: dorsal, volar, medial, or lateral.
Shown is a thumb metacarpophalangeal (MCP) joint dislocation.
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Some orthopaedists recommend that volar dislocation of the PIP joint should not be reduced in the field and may benefit from surgical reduction given the high prevalence of soft tissue interposition that can prevent reduction. If the reduction is not successful, multiple attempts should not be performed.
In general, finger dislocations are reduced using a combination of gentle longitudinal traction and force in the direction opposite of the dislocation. To reduce a dislocated distal interphalangeal (DIP) joint, apply gentle longitudinal traction with hyperextension (if dislocation is dorsal) or hyperflexion (if dislocation is volar), followed by pressure to the base of the distal phalanx in the direction that realigns the phalanges.[17]
To reduce a dorsal dislocation of the proximal interphalangeal (PIP) joint, apply longitudinal traction with hyperextension, followed by pressure to the dorsal aspect of the base of the middle phalanx as the finger is brought into flexion.[17]
Shown is a lateral view of a dorsal distal interphalangeal (DIP) joint finger dislocation. Note small fracture fragments.
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
Splint a volar dislocation without a tendon injury by applying a dorsal splint in mild flexion. To splint a dorsal dislocation without a tendon injury, use a dorsal splint in extension. Consult a hand surgeon if the finger cannot be sufficiently reduced.[17]
Apply a dorsal splint with 20-30° of flexion. If an associated fracture of the volar lip affects more than 33% of the joint surface, a closed reduction will be unstable and operative repair is necessary because the collateral ligament is attached to the bony fragment.[17]
Shown is a proximal interphalangeal (PIP) joint dorsal splint.
Image courtesy of Medscape.
Best Practices: Successful Reduction Techniques for Upper Extremity Dislocations
Mark P. Brady, PA-C; Melisa W. Lai Becker, MD | January 5, 2017 | Contributor Information
For lateral dislocations, apply longitudinal traction and ulnar or radial stress to the finger, depending on the initial direction of injury. Partial tears can be buddy-taped however reduced dislocations (ie, complete tears) should be splinted.[17]
For volar dislocations, apply mild traction with the PIP and metacarpophalangeal (MCP) joints flexed. Splint only the PIP joint in full extension. Consultation with a hand surgeon before intervention is recommended as some studies recommend that all volar PIP joint dislocations be reduced in the operating room because the entrapment of the lateral band around the head of the proximal phalanx may block reduction.[17]
Lumbar puncture is a procedure frequently used for diagnostic purposes to rule out potential life-threatening conditions. Are you using best practices?Slideshows, July 2016
Shoulder dislocation is the most common large-joint dislocation seen in the emergency department (ED). The muscular, ligamentous, and bony anatomy of the shoulder (glenohumeral joint) gives it the most extensive range of motion of any joint in the human body.Procedures, Diseases/Conditions, September 2016
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Contributor Information
Authors
Mark P. Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Melisa W. Lai Becker, MD
Instructor, Harvard Medical School
Director, Division of Medical Toxicology
Attending Physician, Department of Emergency Medicine
Cambridge Hospital
Cambridge, Massachusetts
Disclosure: Melisa W. Lai Becker, MD, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
Associate Professor
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Joseph U. Becker, MD
Assistant Professor, Department of Emergency Medicine
Stanford University School of Medicine
Stanford, CA
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References
Skelley NW, McCormick JJ, Smith MV. In-game Management of Common Joint Dislocations. Sports Health. 2014 May; 6(3): 246–255. PMID: 24790695
Yamamoto T, Yoshiya S, Kurosaka M, et al. Luxatio erecta (inferior dislocation of the shoulder): a report of 5 cases and a review of the literature. Am J Orthop (Belle Mead NJ). 2003 Dec. 32(12):601-3. PMID:14713067
Groh GI, Wirth MA, Rockwood CA Jr. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg. 2010 Apr. 19(3):423-6. PMID: 19836975
Guler O, Ekinci S, Akyildiz F, et al. Comparison of four different reduction methods for anterior dislocation of the shoulder. J Orthop Surg Res. 2015 May 28;10:80. PMID: 26016671
Baykal B, Sener S, Turkan H. Scapular manipulation technique for reduction of traumatic anterior shoulder dislocations: experiences of an academic emergency department. Emerg Med J. 2005 May;22(5):336-8. PMID: 15843700
Martin JR, Mazzini JP. Posterolateral elbow dislocation with entrapment of the medial epicondyle in children: a case report. Cases J. 2009; 2: 6603. [Open access.] PMID: 19829829
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