How is the FARES technique performed to reduce an acute anterior shoulder dislocation in a cooperative adult patient without contraindications to sedation?

FARES Method for Shoulder Reduction

The FARES (Fast, Reliable, and Safe) method is a highly effective, minimally painful technique for reducing acute anterior shoulder dislocations that can be performed without sedation in cooperative patients, making it a superior first-line choice compared to traditional methods.

Technique Description

The FARES method involves the following steps:

• Patient positioning: Patient lies supine on the examination table
• Operator position: Stand on the side of the dislocated shoulder
• Traction application: Grasp the patient's wrist/forearm with both hands and apply gentle, continuous longitudinal traction along the axis of the humerus
• Concurrent maneuvers: While maintaining traction, perform slow, gentle oscillating movements (small amplitude back-and-forth motions) of the arm
• Progressive external rotation: Gradually and gently externally rotate the shoulder while continuing traction and oscillating movements
• Completion: Continue until reduction occurs (typically felt/heard as a "clunk")

The key distinguishing features are the continuous gentle traction combined with oscillating movements and gradual external rotation, which allows muscle relaxation without requiring sedation 1.

Clinical Evidence and Performance

A high-quality prospective randomized trial demonstrated the FARES method's superiority 1:

• Success rate: 95% (76/80 patients) on first attempt
• Speed: Significantly faster reduction time compared to other methods
• Pain: Significantly less painful during reduction (lower VAS scores)
• Attempts needed: Fewer attempts required for successful reduction
• Safety: No post-reduction complications in any patients
• Applicability: Effective even with associated greater tuberosity fractures

When Sedation May Be Required

If the FARES method fails on initial attempt, procedural sedation and analgesia should be considered 2. For sedation when needed:

• Preferred agents: Propofol or etomidate are recommended for procedural sedation in the emergency department setting 3
• Etomidate specifics: ~90% success rate for shoulder reduction, minimal respiratory depression, though myoclonus occurs in ~21% of patients 3
• Opioid considerations: If combining benzodiazepines with opioids, administer the opioid first and carefully titrate the benzodiazepine to reduce respiratory depression risk 3

Pre-Reduction Requirements

Before attempting reduction:

• Imaging mandatory: Obtain pre-reduction radiographs (AP views in internal/external rotation plus axillary or scapular Y-view) to confirm dislocation and rule out fractures requiring surgical management 4, 2
• Neurovascular assessment: Document neurovascular status before and after reduction
• Timing: Prompt reduction after diagnostic imaging is essential 2

Post-Reduction Protocol

After successful reduction:

• Confirm reduction: Repeat imaging to verify successful reduction and rule out complications 2
• Immobilization: One week of relative immobilization (sling use) 5, 2
• Early rehabilitation: Initiate physical therapy targeting early restoration of function, coordination, and proprioception after the acute protection phase 5

Critical Advantages Over Traditional Methods

The FARES method addresses common pitfalls of traditional techniques:

• No sedation required: Eliminates sedation-related risks and delays in cooperative patients
• Single operator: Can be performed by one physician without assistance
• Gentle approach: The oscillating movements facilitate muscle relaxation naturally
• Lower pain: Significantly less painful than forceful manipulation techniques
• Faster: Quicker reduction time improves patient comfort and ED throughput

When to Consider Alternative Approaches

Contraindications or situations requiring different management:

• Multiple trauma patients
• Neer's three- or four-part proximal humerus fractures
• Uncooperative or highly anxious patients (consider sedation first)
• Failed initial FARES attempt (proceed to sedation-assisted reduction)
• Presentation >24 hours after injury (may require sedation due to muscle spasm)

The FARES method should be the first-line reduction technique attempted in cooperative adult patients with acute anterior shoulder dislocation, reserving procedural sedation for cases where this gentle approach fails 1, 2.