_JAccid Emerg Med 1998;15:7-12 Anterior glenohumeral dislocations: what to do and how to do it A P Gleeson Anterior glenohumeral dislocation is the com- monest major joint dislocation seen in the acci- dent and emergency (A&E) department.' There is, however, no uniform agreement on which form of analgesia should be given before reduction, nor on the reduction manoeuvre of choice. In this review I shall outline the common approaches to shoulder dislocation reduction, attempt to dispel some common misconceptions about the condition, and set out a logical management strategy. Patient assessment HISTORY Anterior glenohumeral dislocations occur when the arm is forcibly abducted and externally rotated, the majority of patients sus- taining this injury in a fall. The two groups most commonly afflicted by shoulder disloca- tions are the young sporting male and the eld- erly female.2 The history should encompass questions about past medical history, medications, aller- gies and, if intravenous sedation/analgesia is to be given, when the patient last ate or drank. EXAMINATION Anterior dislocations can usually be recognised by the lack of the normal convex contour of the lateral aspect of the shoulder but this vital clue may be absent in obese patients and those with fracture-dislocations. Sensation in the arm, particularly in the area supplied by the axillary nerve, should be assessed before reduction as traction reduction manoeuvres may cause stretching of nerve trunks with resultant neur- apraxias. Distal pulses should also be sought and, if absent, a precipitous reduction follow- ing radiological confirmation of the dislocation is of the utmost importance. Patients with a significant history of cardiorespiratory disease should have both of these systems examined clinically, particularly if they are to be given intravenous medication. Accident and Emergency Department, St George's Healthcare NHS Trust, Blackshaw Road, London SW17 OQT, UK A P Gleeson Correspondence to: A P Gleeson, Consultant in Accident and Emergency Medicine. Accepted for publication 21 July 1997 RADIOGRAPHIC FEATURES An anteroposterior radiograph of the shoulder alone will normally show an anterior disloca- tion but axillary or trans-scapular views are usually performed in addition. Anterior gleno- humeral dislocations can be classified accord- ing to the position of the humeral head (fig 1): (a) subcoracoid; (b) subglenoid; (c) luxatio erecta; (d) subclavicular; (e) supraglenoid; (f) intrathoracic; (g) fracture-dislocation. This classification is very important as, con- trary to popular opinion,3 different reduction manoeuvres or variations on a particular manoeuvre are required for different disloca- tions. Treatment ANALGESIA Despite the considerable pain associated with this injury there is a vogue for reducing dislocations without any analgesia. This prac- tice has evolved mainly for the convenience of the physician. It requires only one operator, monitoring is not mandatory, and once reduc- tion has been effected the patient can be discharged promptly from A&E."8 A few patients will tolerate reduction without analge- sia, but they are in the minority and must be carefully selected. Patient comfort is para- mount and should not be compromised by a need to increase patient turnover in A&E. There are several options for pain control available to the emergency physician. Entonox is widely used as the sole means of analgesia during reduction,7 but elderly patients in particular have difficulty using it effectively. An excellent alternative is to deliver the N20:02 mixture through an anaesthetic circuit using flow meters, as no effort is required on the part of the patient to ensure delivery of the mixture. Regional anaesthesia-that is, suprascapular'° " and interscalene brachial plexus blocks,"-has been used with moderately good results. Intra-articular ligno- caine has also recently been shown to be as effective as intravenous sedation/analgesia.'3 '4 Intravenous benzodiazepine and opioid en- sures good analgesia and relaxation and is cur- rently the gold standard. It must be stressed, however, that all patients given intravenous sedation must be monitored with ECG and pulse oximetry, at a minimum, in an area where resuscitation equipment is at hand. Two doctors must be in attendance, one of whom is trained in advanced resuscitation and airway management. ' General anaesthesia is gener- ally reserved for cases where reduction manoeuvres have failed using the above analgesic techniques, or when open reduction and internal fixation are primarily indicated, as with certain fracture-dislocations.'6 REDUCTION MANOEUVRES A multitude of different reduction manoeuvres have been described. They can be divided into traction and leverage techniques. The Hippocratic method is the earliest described traction technique.3 Stimson'7 18 re- quired the patient to be prone, using a weight tied around the wrist to apply traction. Lacey and Crawford,'9 and later McNair,'0 employed manual traction, external rotation, elevation of the arm, and pressure over the humeral head with the patient prone, that is, a modification of the Milch manoeuvre. Pick2' and Lippert"2 used manual traction with elbow flexion to 7 on October 18, 2020 by guest. 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_JAccid Emerg Med 1998;15:7-12
Anterior glenohumeral dislocations: what to doand how to do it
A P Gleeson
Anterior glenohumeral dislocation is the com-monest major joint dislocation seen in the acci-dent and emergency (A&E) department.'There is, however, no uniform agreement onwhich form of analgesia should be given beforereduction, nor on the reduction manoeuvre ofchoice. In this review I shall outline thecommon approaches to shoulder dislocationreduction, attempt to dispel some commonmisconceptions about the condition, and setout a logical management strategy.
Patient assessmentHISTORYAnterior glenohumeral dislocations occurwhen the arm is forcibly abducted andexternally rotated, the majority of patients sus-taining this injury in a fall. The two groupsmost commonly afflicted by shoulder disloca-tions are the young sporting male and the eld-erly female.2The history should encompass questions
about past medical history, medications, aller-gies and, if intravenous sedation/analgesia is tobe given, when the patient last ate or drank.
EXAMINATIONAnterior dislocations can usually be recognisedby the lack of the normal convex contour of thelateral aspect of the shoulder but this vital cluemay be absent in obese patients and those withfracture-dislocations. Sensation in the arm,particularly in the area supplied by the axillarynerve, should be assessed before reduction astraction reduction manoeuvres may causestretching of nerve trunks with resultant neur-apraxias. Distal pulses should also be soughtand, if absent, a precipitous reduction follow-ing radiological confirmation of the dislocationis of the utmost importance. Patients with asignificant history of cardiorespiratory diseaseshould have both of these systems examinedclinically, particularly if they are to be givenintravenous medication.
Accident andEmergencyDepartment, StGeorge's HealthcareNHS Trust, BlackshawRoad, London SW17OQT, UKA P Gleeson
Correspondence to:A P Gleeson, Consultant inAccident and EmergencyMedicine.
Accepted for publication21 July 1997
RADIOGRAPHIC FEATURESAn anteroposterior radiograph of the shoulderalone will normally show an anterior disloca-tion but axillary or trans-scapular views are
usually performed in addition. Anterior gleno-humeral dislocations can be classified accord-ing to the position of the humeral head (fig 1):(a) subcoracoid; (b) subglenoid; (c) luxatioerecta; (d) subclavicular; (e) supraglenoid; (f)intrathoracic; (g) fracture-dislocation.
This classification is very important as, con-
trary to popular opinion,3 different reductionmanoeuvres or variations on a particularmanoeuvre are required for different disloca-tions.
TreatmentANALGESIADespite the considerable pain associated withthis injury there is a vogue for reducingdislocations without any analgesia. This prac-tice has evolved mainly for the convenience ofthe physician. It requires only one operator,monitoring is not mandatory, and once reduc-tion has been effected the patient can bedischarged promptly from A&E."8 A fewpatients will tolerate reduction without analge-sia, but they are in the minority and must becarefully selected. Patient comfort is para-mount and should not be compromised by aneed to increase patient turnover in A&E.There are several options for pain control
available to the emergency physician. Entonoxis widely used as the sole means of analgesiaduring reduction,7 but elderly patients inparticular have difficulty using it effectively.An excellent alternative is to deliver theN20:02 mixture through an anaesthetic circuitusing flow meters, as no effort is required onthe part of the patient to ensure delivery of themixture. Regional anaesthesia-that is,suprascapular'° " and interscalene brachialplexus blocks,"-has been used withmoderately good results. Intra-articular ligno-caine has also recently been shown to be aseffective as intravenous sedation/analgesia.'3 '4Intravenous benzodiazepine and opioid en-sures good analgesia and relaxation and is cur-rently the gold standard. It must be stressed,however, that all patients given intravenoussedation must be monitored with ECG andpulse oximetry, at a minimum, in an areawhere resuscitation equipment is at hand. Twodoctors must be in attendance, one ofwhom istrained in advanced resuscitation and airwaymanagement. ' General anaesthesia is gener-ally reserved for cases where reductionmanoeuvres have failed using the aboveanalgesic techniques, or when open reductionand internal fixation are primarily indicated,as with certain fracture-dislocations.'6
REDUCTION MANOEUVRESA multitude of different reduction manoeuvreshave been described. They can be divided intotraction and leverage techniques.The Hippocratic method is the earliest
described traction technique.3 Stimson'7 18 re-quired the patient to be prone, using a weighttied around the wrist to apply traction. Laceyand Crawford,'9 and later McNair,'0 employedmanual traction, external rotation, elevation ofthe arm, and pressure over the humeral headwith the patient prone, that is, a modificationof the Milch manoeuvre. Pick2' and Lippert"2used manual traction with elbow flexion to
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reduce the stretch on the biceps tendon andneurovascular structures. The newer techniqueof scapular manipulation" also requires thepatient to be in the Stimson position with a
hanging weight before reduction. TheKocher,'4 Milch,'5 and external rotation'6methods are leverage techniques; however,traction is added by many operators, althoughnot included in any of the original descriptions.An analysis of the most commonly used
manoeuvres reveals that external rotation is thekey movement in effecting reduction. Itovercomes spasm of the internal rotators of the
humerus, unwinds the joint capsule,"4 andshortens the rotator cuff muscles which theneffect a posterior pull on the humeral head.Traction, although employed in many tech-niques, is not necessary for reduction in a greatnumber of cases.
Before attempting reduction, radiographicassessment of the dislocation is essentialbecause the reduction manoeuvre of choiceshould be dictated by the subtype of anteriordislocation.
SUBCORACOID DISLOCATIONSubcoracoid dislocations account for 90% ofanterior dislocations.2" The humeral head iswedged by the spasm of subscapularis and theother internal rotators of the humerus. Thisimpingement causes the Hill-Sachs lesion seenon the posterolateral aspect of the humeralhead in up to 40% of patients.6 The threemanoeuvres most commonly used for subcora-coid dislocations are the Kocher technique, theMilch manoeuvre, and the external rotationmethod.The Kocher technique is probably much
older than its initial description."8 This man-oeuvre has high success rates'9 '0 (table 1), buthas been labelled as being unphysiological,brutal, and dangerous because of its associ-ation with fractures of the surgical neck ofhumerus." Most adverse reports, however, arefrom the early part of this century, whenanaesthetic and analgesic techniques were intheir infancy." " Fractures with this techniqueonly occur when the operator forcibly tries toovercome muscle spasm, the elderly osteo-porotic patient being at most risk. If resistanceto reduction is met, then the patient eitherrequires supplemental sedation/analgesia or adifferent reduction manoeuvre.Many variations of the Kocher manoeuvre
are used but, in his original description of thetechnique, Kocher described "pressing thearm, with elbow flexed, close to the side of thebody, outward rotation until a resistance isencountered, elevation forward of the exter-nally rotated arm in the sagittal plane as far asit will go, and finally slow inward rotation" (fig2A-D). Traction was not described at anystage,'4 but was added later by proponents ofthe technique.'5 In fact, axial traction insubcoracoid dislocations serves no purposebefore external rotation apart from moving thehumeral head more inferiorly, thereby causingpain and inducing muscle spasm.36There is considerable logic in the individual
movements as described by Kocher. Flexion atthe elbow is thought to relax the hold of thelong head of biceps on the humeral head.'7Adduction of the arm moves the humeral headlaterally, thereby stretching subscapularis. Ex-ternal rotation stretches the internal rotatorsfurther and moves the head over the glenoidrim. At this point the head may fall into posi-tion, facilitated by the pull of the rotator cuffmuscles. If not, elevation of the externallyrotated arm in the saggital plane presents thesmallest area of the humeral head to theglenoid'0 with reduction being further aidedby adduction of the externally rotated arm
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across the chest before internal rotation(fig 2E).The Milch manoeuvre was described in
1938 for subcoracoid dislocations. The opera-tor abducts and elevates the arm while fixingthe humeral head with his contralateral thumb.At the point of maximum abduction, firmpressure is exerted over the head of thehumerus to effect reduction (fig 3A). Tractionon the abducted arm was not described
originally and has been added by otheroperators.19 20 30 The theory behind this man-oeuvre is that in the fully abducted position themuscles acting about the shoulder joint arealigned in the same plane and are thus notworking against each other. As a result, there isless chance of causing a fracture duringmanipulation. It is a safe procedure with noreported complications and is thought to berelatively painless7 20 30; however, no prospec-tive trial to date has compared pain scores fordifferent reduction manoeuvres based onobjective assessment.
If reduction has not been successful usingthe standard Milch manoeuvre, one can applytraction on the abducted arm accompanied byfirm pressure over the humeral head with thefingertips. The arm is then abducted whilemaintaining traction and pressure over thehumeral head. The operator's fingers in thisinstance act as a fulcrum over which thehumeral head can move (fig 3B).The external rotation method, as described
by Leidelmeyer,"6 is essentially the initialmovements of the Kocher manoeuvre, that is,adduction and external rotation with thepatient in a supine position (fig 2A and B).
Figure 2 (A) Kocher manoeuvre; adduction with theelbow flexed. (B) Kocher manoeuvre; external rotation.(C)Kocher manoeuvre;forward elevation of the externallyrotated arm. (D) Kocher manoeuvre; internal rotation. (E)Kocher manoeuvre; adduction of the externally rotatedarm.
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Figure 3 (A) Milch manoeuvre. (B) Traction, adduction and pressure on the humeral head.
External rotation, aided by gravity, shouldoccur over several minutes to minimise musclespasm. This is an atraumatic method which hasachieved success rates of up to 80% forsubcoracoid dislocations."8 39 Failure to achievereduction with this technique occurs mostcommonly in the elderly and may be due toabsence of the pull of the rotator cuff muscleson the humeral head when there is a completetendon tear. In one review of patients over 40years of age with anterior dislocations, 90%had full thickness tears.40The scapular manipulation manoeuvre has
achieved popularity in north America, but isnot widely used in the United Kingdom.Originally described by Bosley and Miles,2" ithas high success rates.4l"" Patients are placedprone, with the affected arm hanging verticallyfrom a trolley with a 5 or 15 pound weightattached to the wrist. After five minutes theoperator manipulates the scapula by pushingits inferior angle medially (fig 4). Thereduction may be facilitated by applying trac-tion and externally rotating the arm. Thistechnique has the disadvantage of being diffi-cult in obese individuals and of requiring thepatients to be prone. This position can posedifficulties for certain patients, particularly ifthey require intravenous sedation/analgesiaand airway management is a priority. It hasbeen performed in the seated4' and supinepositions44 but under these circumstances it is
Figure 4 Scapular manipulation.
recognised as being technically difficult andpainful.
SUBGLENOID DISLOCATIONThese dislocations often have an associatedfracture of the greater tuberosity of thehumerus and are seen more commonly in olderpatients. Because of the inferior position of thehead in relation to the glenoid, traction isessential for reduction. The Hippocraticmethod, where the operator applies traction onthe arm while providing countertraction withhis foot in the patient's axilla45 (fig 5A), wasthought to have been introduced specificallyfor subglenoid dislocations.27 Additional exter-nal rotation of the arm will facilitate reduction.Alternatively, countertraction can be employedusing a sheet and an assistant (fig 5B). TheHippocratic method is reported as carrying asignificant risk of neurovascular damage andthus many operators prefer to use the Milchmanoeuvre with added traction.
LUXATIO ERECTAThis uncommon form of dislocation, firstdescribed in 1859 by Middledorff andSchram," accounts for 1% of all shoulderdislocations.47 It occurs when the humerus dis-locates with the arm in full abduction and isassociated with rotator cuff tears and greatertuberosity fractures in 50% of cases.48 Luxatioerecta is ideally suited for the latter movementsof the Milch manoeuvre with countertractionover the shoulder assisting reduction. Consid-erable traction is usually required to dislodgethe humeral head from under the glenoid, andthe arm may have to be adducted while main-taining traction and pressure on the humeralhead to effect reduction.
SUBCLAVICULAR DISLOCATIONReduction is effected by a combination of trac-tion and external rotation on the slightlyabducted arm, that is, the Hippocratic tech-nique.
SUPRAGLENOID DISLOCATIONSuch dislocations usually result from anupward axial force applied to the flexed elbowin an adducted arm.'7 They are commonlyassociated with rotator cuff tears, long head ofbiceps rupture, and fractures of the greatertuberosity, acromium, and coracoid process.Traction on the externally rotated adductedarm will usually suffice for reduction.49
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Figure 5 (A) Hippocratic technique; the foot can be used to exert pressure on the humeral head. (B) Hippocratictechnique using sheetfor countertraction.
INTRATHORACIC DISLOCATIONThis is rare and is beyond the scope of normalA&E practice.
FRACTURE-DISLOCATIONClassification is into three types,50 two part,three part, and four part.
Two partA fracture of the greater tuberosity occurs inapproximately 10% of dislocations and is usu-ally associated with the humeral head in a sub-glenoid, low subcoracoid, or subclavicularposition. The reduction manoeuvre used willdepend on the position of the humeral head.Dislocations associated with a humeral neckfracture, whether displaced or not, shouldprobably be reduced under general anaesthesiawith image intensification in order to diminishthe risk of neurovascular damage. Apparenttwo part fractures may inadvertently be con-verted to three part with closed reduction inA&E when undisplaced neck fractures are notseen on the original films.'6 If reduction is
ANTERIOR DISLOCATION
attempted in A&E, external rotation shouldnot form part of the procedure. Reduction maybe effected by traction and pressure over thehumeral head.
Three partOpen reduction and internal fixation is thetreatment of choice.5' Avascular necrosis of thehumeral head may ensue but, it may be avertedby the blood supply to the head from the ante-rior capsule and subscapularis. If the displace-ment is severe a hemiarthroplasty is indicated.
Four partThese should allhemiarthroplasty.5'
be managed by
Failed reductionThe majority of anterior glenohumeral disloca-tions can be reduced in A&E. There are, how-ever, a few cases where reduction cannot beachieved despite the use of several manoeuvresand adequate sedation and analgesia. Delayedpresentations or very muscular individuals fre-quently fall into this group. Reductions mayalso be impeded by interposed bicepstendon,52 54 subscapularis,5 labrum, or agreater tuberosity fragment."o General anaes-thesia is indicated for these "failures."
Subcoracoid Subglenoid/luxatio erecta
External rotation
; failureKocher
; failureMilch
; failureHippocratic
; failureRefer ortho
Milch
; failureHippocratic
; failureRefer ortho
Subclavicular/suprag lenoid
Hippocratic
; failureRefer ortho
c
Fractu re-dislocati
Greater tuberosityalone
Reduction methoddepends uponposition of humeralhead (see above)
Figure 6 Flow diagram for reduction manoeuvres.
AftercareIntrathoracic Successful reduction should be confirmed
radiologically and the neurovascular status inthe affected arm should be rechecked. Patients
Refer can then be discharged in a collar and cuff withOrtho/thoracics a body bandage and suitable oral analgesia.
Patients who have received intravenoussedation/analgesia should be monitored bynursing staff in A&E until they are alert andcan walk unaided, and before their discharge tothe care of a responsible adult they should bealerted to the risks of driving, working machin-
ion ery, and drinking alcohol in the subsequent 24hours. Follow up within a few days in the
Fratursurg orthopaedic clinic is appropriate.Fracture surgicalneck or 3/4 part Conclusion
A&E doctors should tailor their approach to a
Refer ortho dislocated shoulder depending on the require-ments of individual patients. No one techniquewill work for all dislocations. The two mostimportant factors determining a successfulreduction are the relief of pain and muscle
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spasm and the correct selection and executionof a reduction manoeuvre. Before reduction,patients should be offered Entonox for relief oftheir pain. After several minutes they should bereassessed and, if they are still significantlyuncomfortable and insufficiently relaxed toallow an atraumatic reduction, intravenoussedation/analgesia should be given. Resistanceduring reduction should not be met with force.Supplemental analgesia or a different reduc-tion manoeuvre should be employed. The flowdiagram (fig 6) outlines the sequence of reduc-nion manoeuvres that I would recommend inthe approach to anterior dislocation reduction.
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