Skill Checkup: Reduction of Shoulder Dislocation

Shoulder dislocation is the most common large-joint dislocation seen in the emergency department (ED). Reduction techniques can vary in terms of required force, time, equipment, and staff. No single reduction method is successful in every instance; therefore, the clinician should be familiar with several reduction techniques. For a more thorough discussion, along with advantages and disadvantages of each technique, read here.

Scapular Manipulation

A 2017 study found that scapular manipulation was the most successful and fastest technique for closed reduction of anterior shoulder dislocations. With the patient prone or seated and the back exposed, the affected arm is placed in 90° of forward flexion at the shoulder, and slight traction is applied. If the patient is prone, weights are used, or manual downward traction is applied by an assistant. If the patient is seated, an assistant should stand, facing the patient, and use one arm to 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.

The treating physician then stands lateral to the affected shoulder and stabilizes the scapula by placing the palm of one hand on the lateral aspect of the shoulder with the thumb securely on the superior lateral border, then placing the other palm over the inferior tip of the scapula and positioning the thumb on the inferior lateral border of the scapula. The physician then uses both hands to rotate the inferior tip of the scapula medially and the superior aspect laterally with slight dorsal displacement. The goal is to move the glenoid fossa back into the correct anatomic position. To facilitate reduction, the assistant may apply, along with traction, slight external rotation of the humerus, elbow flexion in 90°, or both.

FARES Technique

The Fast, Reliable, and Safe (FARES) method was found to be the best alternative to scapular manipulation for closed reduction of anterior shoulder dislocations. The treating physician should stand on the same side as the dislocated arm and face the patient, evaluating for fractures and assessing neurologic status and circulation before reduction is attempted. While grasping the patient's wrist with both hands, the patient's elbow is extended and the forearm is neutral. The physician should then slowly abduct the shoulder, applying longitudinal traction. The clinician then applies continuous, vertical oscillations that last 2-3 seconds while continuing slow arm abduction. Once the arm reaches 90°, the clinician slowly externally rotates the arm while continuing traction, oscillations, and abduction. Typically, the shoulder reduces at about 120° of abduction. Once reduced, the physician internally rotates the shoulder and gently lays the forearm on the chest wall.

External Rotation

The patient is placed supine on a stretcher. The treating physician adducts the affected arm tightly to the patient's side with one hand, and then, with the other hand, 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 (see the video below).

If the patient experiences pain, a short pause should be taken to allow the muscles of the upper arm to relax. After the pain has subsided, rotation continues until the forearm is in the coronal plane. Reduction typically takes place between 70° and 110° of external rotation; sometimes it takes place during return on internal rotation.

Milch Technique

The patient may be supine or prone, with the shoulder close to the edge of the stretcher. The affected arm is placed in full abduction overhead, or the patient is instructed to raise the arm laterally and behind the head. The operator may assist abduction gently. With the patient's arm in full abduction, the physician gently applies longitudinal traction and external rotation with one arm (see the video below).

If reduction is not completed, the physician uses the thumb or fingers to push the humeral head up into the glenoid fossa, with gradual adduction of the extended arm still held in traction.

Spaso Technique

With the patient supine on a stretcher, the physician grasps the affected arm around the wrist or distal forearm and lifts it vertically to the ceiling, applying upward traction and gentle external rotation (see the video below).

If the patient experiences pain, the physician should stop and wait until the muscles relax; this may take several minutes. Once the muscles have relaxed, the physician may continue gently. If an audible or palpable clunk is not heard, direct pressure should be applied to the humeral head with the other hand. An alternative to the standard Spaso technique is the Waldron variation. In this approach, while the elbow is maintained in a flexed position, the physician firmly holds the epicondyles and applies vertical traction on the humerus while moving the forearm through an arc extending from 10° of external rotation to 10° of internal rotation.

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