A man with this X-ray after a fall. Unable to move with right upper limb
Treatment plan Consent Pain relief Close reduction Post reduction check Post reduction Xray Discharge Advice/ FU care
Options for pain relief Fentanyl/midazolam (shorter acting) Etomidate 0.1 mg/kg Propofol Pethidine/valium (look out for complications) Intra-articular LA Entonox
Reduction methods Non-traction options Spaso External Rotation (Hennepin) Scapular manipulation Stimsons method Traction options Traction-counter traction Hippocrates Kocher The new FARES method Neurovascular exam before CR!
Spaso technique Maintain gentle traction perpendicular to table When patient has relaxed, gently external rotate A clunk signifies reduction http://www.youtube.com/watch?v=8xibzOM7Hp0 ( from 3:05 to 3:50 )
External Rotation Arm should be adducted (with help by operator) When patient is relaxed, gently external rotate (best to let gravity does its job) A clunk and full abduction signifies reduction
The Stimson technique for reduction of anterior dislocation of the shoulder. With the patient in the prone position, a weight is applied to the dislocated shoulder. The humerus returns to its normal position over a period of time. http://www.youtube.com/watch?v=8xibzOM7Hp0 (from 4:35 to 5:50)
Traction-counter traction Two operator needed Padding of axilla to prevent excessive pressure Patient relaxed by drug Traction will lever shoulder back http://www.youtube.com/watch?v=8xibzOM7Hp0 ( from 3:50 to 4:20 )
Hippocrates Single operator Foot used as counter- traction
Kochers method Traction External rotation => Adduction => Internal rotation http://www.youtube.com/watch?v=8xibzOM7Hp0 ( from 1:37 to 3:05 )
The new FARES method From Greece FARES et al 2009 RCT No sedation / analgesic required Lying supine with elbow fully extended and neutral position of forearm While maintaining axial traction, apply vertical oscillation at a rate of 2-3 hertz with a distance of 5 cm above and below the horizontal plane.
Since passing the 90° abduction, the arm is gently externally rotated with the palm now facing upward,while keeping the vertical oscillation and traction. Reduction usually occurs at 120° abduction http://www.youtube.com/watch?v=8xibzOM7Hp0 ( from 00:00 to 1:35 )