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Shoulder Relocation ManeuversAka: Shoulder Dislocation Management

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  1. See also
    1. Shoulder Dislocation
  2. Management: Premedications
    1. Conscious Sedation
      1. Sedation: Versed 0.5 to 2 mg IV
      2. Analgesia
        1. Morphine Sulfate 1 to 6 mg IV or
        2. Fentanyl 100 mg IV over 1 minute
          1. May repeat q5 min to total maximum of 3 mg/kg
      3. Precautions during Conscious Sedation
        1. Supplemental Oxygen
        2. Oxygen Saturation monitoring
        3. Naloxone at bedside
    2. General anesthesia
      1. Indicated for failed reduction under Sedation
  3. Management: Post-Reduction
    1. Immobilize shoulder with sling
      1. Age under 40 years old
        1. Sling for 1 to 2 weeks
      2. Age over 40 years old
        1. Sling for only 2 to 3 days
        2. Risk of Frozen Shoulder
    2. Consider orthopedic referral
      1. Indicated for young or athletic patients
      2. Stabilization surgery prevents recurrent injury
        1. Bottoni (2002) Am J Sports Med 30:576
    3. Shoulder Range of Motion Exercises as symptoms allow
      1. Pendulum Exercises and Circumduction at 5-10 days
        1. Start with arm in sling
          1. Bend at waist
          2. Allow arm to fall toward floor
          3. Rotate arm in circle
        2. Advance Exercise
          1. Arm out of sling
          2. Circles of greater diameter
      2. Advanced range of motion at 2-3 weeks
        1. Abduction via wall walking with fingers
        2. Internal rotation
          1. Start by touching hip
          2. Progress to touching mid-back
        3. Flex and extend elbow out of sling as tolerated
      3. Additional Exercises
        1. See Shoulder Strengthening Exercises
        2. Consider physical therapy
  4. Precautions
    1. Reduction becomes more difficult as muscles tighten
      1. Do not delay reduction
      2. Reduce on sideline in field if possible
    2. Check neurovascular exam before and after reduction
    3. Obtain AP and Axillary XRay prior to reduction
  5. Procedure: Reduction by Stimson's Method (Anterior dislocation)
    1. Preferred method for anterior Shoulder Dislocation
    2. Patient position
      1. Patient lies prone on table
      2. Affected arm hangs over side of table
    3. Downward traction applied
      1. Assistant applies downward traction on arm or
      2. Attach 5 to 10 kg weight (10 to 15 pounds) to wrist
        1. Weight should hang freely and not touch floor
    4. Reduction
      1. Spontaneous reduction as shoulder muscles relax
      2. Pushing humeral head in caudal direction may assist
  6. Procedure: Reduction by Traction (Anterior and Posterior Dislocation)
    1. Patient sitting or prone
    2. Traction at wrist by one provider
      1. Gentle, slight straight (parallel to body) traction
      2. Apply from patient's wrist
    3. Countertraction by second provider
      1. Apply with 4-5 inch sling (e.g. sheet) under axilla
      2. Pull transverse across patient's chest
      3. Consider pulling upward at 30 degrees
  7. Procedure: Reduction by Hippocratic Method (Anterior Dislocation)
    1. Patient lies supine
    2. Single provider reduction method
      1. Counter-traction
        1. Place one foot on patient's chest wall
      2. Traction
        1. Grasp patient's wrist
        2. Apply traction at 45 degree angle
  8. Procedure: Reduction by Modified Traction (Anterior dislocation)
    1. Patient prone, arm at side with elbow flexed 90 degrees
    2. Technique
      1. Traction toward patient's feet (parallel to body)
      2. Externally rotate shoulder by moving wrist laterally
  9. Procedure: Reduction by Strap Method (Anterior dislocation)
    1. Patient in sitting position
    2. Countertraction
      1. Second strap placed under axilla and across chest
      2. Assistant pulls strap across chest
    3. Traction
      1. Patient's elbow flexed at 90 degrees
      2. Strap placed around patient's forearm
      3. Other end of strap placed under examiner's foot
      4. Downward traction applied to forearm via strap
      5. Examiner externally rotates arm 20 degrees
      6. Spontaneous reduction often occurs
  10. Procedure: Reduction by Self-Reduction Method (Anterior Dislocation)
    1. Position
      1. Sit on floor with knees flexed
      2. Wrap both arms around ipsilateral knee
        1. Interlace fingers of each hand with one another
    2. Traction
      1. Lean backward, extend arm at elbow
      2. Applies traction at shoulder for reduction
  11. References
    1. Wirth in Greene (2001) Musculoskeletal Care, p.151-2
    2. Burra (2002) Orthop Clin North Am 33:479

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