Shoulder reduction

Shoulder reduction is a procedure in which a dislocated shoulder is returned to its anatomical position. Shoulder reduction is indicated for all confirmed shoulder dislocations. It is typically performed as soon as possible by the treating clinician. Certain complicated shoulder dislocations require orthopedics consultation before reduction or may need to be reduced by an orthopedic surgeon using specialized techniques. There are several recommended reduction techniques for anterior shoulder dislocations (e.g., scapular manipulation, Milch technique, and traction-countertraction), none of which are considered superior. Procedural sedation and analgesia may be necessary to facilitate reduction. A neurovascular examination should be performed before and after reduction, and successful reduction should be confirmed with x-ray. Complications include axillary artery and/or axillary nerve injuries.

This article primarily focuses on closed reduction of anterior shoulder dislocations.

• Shoulder reduction is indicated for shoulder dislocations confirmed with x-ray. ^[1]
• The following anterior shoulder dislocations require orthopedic consultation prior to reduction and are typically reduced by an orthopedic surgeon: ^[2]
  • Fracture-dislocations with:
    • Greater tuberosity fracture with > 1 cm displacement
    • Glenoid rim fracture with > 5 mm displacement
    • Proximal humeral fractures
    • Humeral shaft fracture
  • Open shoulder dislocations
  • Late presentation (7–10 days after injury)
  • Shoulder dislocations in children without evidence of neurovascular injury

• There are no absolute contraindications. ^[2]
• Generalists should not perform unsupervised shoulder reductions for injuries that require orthopedic consultation unless any delay would be limb-threatening (e.g., obvious neurovascular compromise). ^[2]

We list the most important contraindications. The selection is not exhaustive.

• Obtain informed consent.
• Perform a neurovascular assessment to evaluate for:
  • Axillary nerve injury
  • Axillary artery injury
  • Brachial plexus injury
  • Other peripheral nerve injuries in the upper extremity (e.g., radial nerve injury, ulnar nerve injury)
• Provide acute pain management.
• Consider providing an intraarticular joint injection of local anesthetic.
• Obtain prereduction x-rays to evaluate the dislocation and check for concurrent injury (e.g., fractures, Hill-Sachs lesion, Bankart lesion). ^[1]
• See “Shoulder dislocation” for details.

General approach

• Select a shoulder reduction technique.
• Set up patient, clinician, and (if needed) assistant positions.
• Provide procedural sedation, if indicated.
• Perform the reduction.
• Immobilize the shoulder (e.g., with a sling or shoulder immobilizer).

Shoulder reduction techniques ^[2][3][4]

• Recommended ^[4][5][6]
  • Scapular manipulation
  • Milch technique
  • Traction-countertraction
  • FARES technique
  • Boss-Holzach-Matter technique
  • External rotation technique
  • Spaso technique
  • Stimson technique
  • Cunningham technique
  • Hennepin technique
• Not routinely recommended ^[2][3][4]
  • Kocher technique ^[4]
  • Hippocratic technique ^[6]

All of the recommended techniques to reduce anterior shoulder dislocations are considered equally effective, with minimal complications. ^[5][6]

The Kocher technique and Hippocratic techniques are no longer routinely recommended. ^[1]

Positioning ^[2][3]

• Patient: prone or upright
  • Prone: affected arm hangs off the stretcher with shoulder flexed to 90°
  • Upright
    • Unaffected shoulder rests against the head of the bed
    • Affected arm is held forward with shoulder flexed to 90°
• Clinician
  • Place one hand at the superior border of the scapula, with the thumb at the superolateral border.
  • Place the other hand at the inferior tip of the scapula.

Reduction ^[2][3]

1. Apply anterior traction to the affected arm (e.g., manually with an assistant or with wrist weights in prone position).
2. Stabilize the superior border of the scapula.
3. Rotate the scapula medially by pushing the inferior tip of the scapula toward the spine.
4. Consider applying inferior pressure to the superior border of the scapula to help rotational movement of the scapula.

Positioning ^[2][3]

• Patient: supine
• Clinician
  • Place one hand on the dislocated humeral head, with the thumb in the axilla.
  • With the other hand, grasp the wrist or elbow of the affected arm.

Reduction ^[2][3]

1. Abduct the affected arm overhead.
2. Apply longitudinal traction while gently externally rotating the arm.
3. Use the other hand to push the humeral head upward into the glenoid fossa.

This technique requires two providers to perform.

Positioning ^[2][3]

• Patient
  • Supine with the bed elevated to the level of the clinician's hip
  • Abduct the affected arm to 45° with the elbow flexed to 90°.
• Assistant
  • Wrap a sheet around the patient's chest by passing it under the axilla of the affected arm.
  • Grasp the two ends of the sheet or tie the sheet around the assistant's waist.
• Clinician
  • Wrap a sheet around the patient's affected forearm with the elbow flexed to 90°.
  • Tie the sheet around the clinician's waist.

Reduction ^[2][3]

1. Grasp the patient's distal forearm and apply steady traction while the assistant applies countertraction.
2. The clinician and/or assistant may lean back slowly against their tied sheet to use their body weight to supply additional tractional force.
3. Apply continuous traction-countertraction for several minutes or until reduction is complete.

• Postprocedural sedation care
• Postreduction neurovascular assessment
• Reduction confirmed with postreduction x-rays and any new injuries documented
• Shoulder immobilized (e.g., with a sling or shoulder immobilizer)
• Patient referred for orthopedic follow-up within 1–2 weeks ^[1]

The following are potential complications of reduction. Many of these overlap with complications of shoulder dislocation.

• Axillary nerve injury
• Brachial plexus injury
• Axillary artery injury
• Repeated dislocation
• Fractures: e.g., Hill-Sachs lesion, Bankart lesion

Neurovascular examination before and after the reduction is essential to differentiate neurovascular injuries caused by the dislocation from those caused by the reduction.

Compare prereduction and postreduction x-rays to determine if associated fractures are iatrogenic.

We list the most important complications. The selection is not exhaustive.