What is the initial approach for shoulder relocation manoeuvres?

Initial Approach for Shoulder Relocation Maneuvers

The initial approach for shoulder relocation should prioritize gentle, nontraumatic techniques that minimize pain and avoid complications, with radiographic confirmation of dislocation before attempting reduction. 1, 2

Pre-reduction Assessment

• Obtain standard shoulder radiographs including anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view to confirm dislocation and identify any associated fractures 3
• Axillary or scapula-Y views are vital as acromioclavicular and glenohumeral dislocations can be misclassified on AP views alone 3
• Radiography should be performed upright because malalignment of the shoulder can be underrepresented on supine radiography 3

Fracture-Dislocation Considerations

• For anterior dislocations with greater tuberosity fracture (Type I injury), reduction under sedation can be attempted with a 94% success rate 4
• For dislocations involving the surgical neck of the humerus with or without greater tuberosity fracture (Type II injury), reduction under general anesthesia is recommended to avoid fracture propagation 4
• Posterior dislocations with associated fractures should not be reduced under sedation and require general anesthesia 4

Recommended Reduction Techniques

Scapulohumeral Distraction Technique

• Combines traction with scapular manipulation
• Demonstrates high success rate (95.3%) with significantly less procedure time and pain compared to traditional methods 5
• Patients report greater satisfaction levels with this technique 5

Davos Technique (Boss-Holzach-Matter)

• Nontraumatic and well-tolerated approach with success rates of 86%
• Can be performed with minimal or no analgesia in some cases
• Positioning: Patient sits with 90° flexion of the elbow joint and hand positioned in supination on the patient's thigh 6, 7

Single-Person Reduction Technique

• Physician stands behind seated patient at the affected side
• One fist is positioned in the anterior axillary fossa (avoiding direct pressure)
• The other hand applies gentle traction by grasping the patient's forearm
• Maintains gentle traction until muscle relaxation occurs, often resulting in spontaneous reduction
• If needed, slow external rotation of the fist placed in the axilla can facilitate reduction
• Success rate of 90.7% with only 16.3% of patients requiring premedication 1

Post-reduction Management

• Obtain post-reduction radiographs to confirm successful reduction and rule out iatrogenic fractures 3
• Radiographs should include the same views as pre-reduction imaging to ensure proper alignment 3

Common Pitfalls and Caveats

• Avoid forceful reduction maneuvers that can lead to iatrogenic injuries, fracture displacement, or neurological complications 7
• Delays from presentation to first reduction attempt and failed initial reduction are associated with lower rates of overall reduction success 2
• Be familiar with multiple reduction techniques in case the initial attempt fails or patient-specific characteristics limit the ability to perform certain techniques 2
• For posterior dislocations, which are less common but more challenging, consider early consultation for general anesthesia rather than multiple failed reduction attempts 4