Olcay Guler, Safak Ekinci, Faruk Akyildiz, Uzeyir Tirmik, Selami Cakmak, Akin Ugras, Ahmet Piskin, and Mahir Mahirogullari. JOSPT. 2015; 10:80 Article summary by Cassandra Braddy SPT from Missouri State University, Springfield, Missouri
This case report involved 153 patients, 18 years or older who had acute traumatic anterior shoulder dislocation. The study involved four reduction maneuvers, with different forms of traction and external rotation. Anterior shoulder dislocation was diagnosed by physical examination and radiography. Pre and post-reduction anteroposterior and trans-scapular view for radiographs were completed. The reduction methods were all performed by one of four physicians in the third year of residency in orthopedic surgery. The reduction techniques included the Kocher, Spaso, Chair, and Matsen’s traction-counter-traction methods.
The Kocher method involves the patient lying supine on the table with the physician standing at the patient’s side. The affected arm is bent to 90° at the elbow and adducted against the body. The physician grasps the patient’s wrist and elbow, slowly rotating externally between 70° and 85° until resistance is met. The physician then lifts the rotated upper arm in the sagittal plane as forward as possible, and subsequently internally rotates the arm to bring the patient’s hand towards their opposite shoulder. By doing so, the humeral head should slip back up into glenoid fossa.
The Spaso method involves the patient supine with the physician standing beside the patient, grasping the affected arm. The physician gently lifts the arm upward applying traction vertically. With the traction applied, the physician then slightly rotates the shoulder externally. This technique is complete when a clunk is felt or heard.
The Chair method involves the patient sitting sideways in a stable chair. The patient sits so that the backrest is the fulcrum in the axilla. To minimize the risk of axillary nerve impingement or injury, a small pillow or bed sheet should be placed over the backrest if it is not well padded. The affected arm hangs over the backrest of the chair, while the physician squats down behind the chair. The physician holds the patient’s arm at the elbow in slight flexion. The physicians other hand holds the hand of the patient’s affected arm. After encouraging the patient to relax, the physician applies traction slowly to the involved arm, completing the reduction. Depending on the location of humeral head, a slight external rotation may need to be applied by the hand of the physician.
The Matsen’s traction-counter-traction method involves an assistant and the patient lying supine with a sheet around the chest and around the assistant’s waist for counter-traction. The physician stands on the affected side near the patient’s waist with the patient’s elbow flexed to 90°. A second sheet is tied around the physician’s waist and hung over patient’s forearm. Traction is provided when the physician leans back against the sheet while grasping the forearm. Traction is applied to the arm with the shoulder in abduction, and the assistant applies firm counter-traction to the body using a folded sheet.
Patients who did not have success with the first reduction maneuver, found success with one of the other methods. Following the reduction, the patients were immobilized in internal rotation with a sling; rehabilitation began after three weeks.
Of the 153 patients, 39 patients were treated by the Spaso method, 47 patients by the Chair method, 40 patients by the Kocher’s method, and 27 patients by Matsen’s traction-counter-traction method.
The results indicated that all four reduction techniques provided high success rates with no statistically significance amount them. This study calculated the success rates of the four methods, the results were 97.8%, 97.5%, 94.8%, and 92.5% for Chair, Matsen, Spaso, and Kocher techniques respectively. The physicians involved with this study agreed that the Kocher and Matsen methods required more force to reduce than other methods. The chair method, according to all the physicians, was the easiest because it allowed for complete relaxation of the muscles. Of the four different reduction techniques, this study proved the Chair method had shorter reduction duration, causes less pain, which allows for the fastest reduction. The main disadvantage was a chair and that the patient needed to be conscious and alert.
In conclusion, physicians should be familiar with many techniques for reducing anterior dislocations of the shoulder because no single method has a 100% success rate. The authors in the article suggest that the Chair method is an “effective and fast reduction maneuver that may be an alternative for the treatment of anterior shoulder dislocations.”
Personal Comment:
There are several ways physicians and physical therapists (particularly ‘on the field’) reduce anterior shoulder dislocations. This article describes four different methods and was very informative for determining the best test used to reduce the dislocation the fastest, and with the greatest reduction rate. The article took the basic principles of the biomechanics of the humeral head in the glenoid fossa to reduce the dislocation. By putting the arm into some degree of external rotation and traction, the humeral head slips back into place. It is important to know the quickest and best way to reduce a dislocation because it reduces the amount of time the patient is in pain, decreases the need for anesthesia or pain medication, and decreases the amount of time spent in an emergency room.
While there was no real statistically significant difference between the four methods. The main determinant for choosing the best method mostly depends on the patient’s status (whether they are conscious, the amount of pain they are in, and the ability to relax) and on the resources available. It behooves physicians and physical therapists to be familiar with several different methods of reduction to provide the best care for all patients.
IAOM Comment:
It is always helpful for a physical therapist to have an understanding of methods used for glenohumeral reduction and the potential for harmful sequelae. The IAOM-US shoulder course discusses prognosis and common complications after shoulder dislocation, which varies according to age of the patient.