What is the best technique for shoulder reduction?

Best Shoulder Reduction Technique for Acute Anterior Dislocation

For acute anterior shoulder dislocations, scapular manipulation is the optimal first-line technique, achieving 97% success rate with fastest reduction time (1.75 minutes) and lowest pain scores (VAS 1.47), followed by the FARES method as the best alternative with 92% success and 2.24-minute reduction time. 1

Primary Reduction Technique Selection

First-Line: Scapular Manipulation

• Scapular manipulation demonstrates superior outcomes across all metrics with 97% success rate, 1.75-minute mean reduction time, and VAS pain score of 1.47 during reduction 1
• This technique can be performed by a single physician without sedation or anesthesia in most cases 1
• The method involves positioning the patient prone or seated, applying gentle traction to the affected arm, while an assistant (or the physician's other hand) pushes the inferior tip of the scapula medially and superiorly 1

Second-Line: FARES Method

• The FARES (Fast, Reliable, and Safe) method serves as the best alternative when scapular manipulation fails, with 92% success rate, 2.24-minute reduction time, and VAS 1.59 1
• This technique involves gentle traction, abduction, and external rotation without sedation 2
• The traction-abduction-external rotation (TAE) approach achieved 90.63% success without sedation with significantly higher patient satisfaction scores (9.38/10) compared to traditional methods requiring sedation (7.94/10) 2

Third-Line: Traction-Countertraction

• Traction-countertraction achieves 95% success but requires significantly longer time (6.05 minutes) and causes substantially more pain (VAS 4.75) 1
• This method typically requires conscious sedation and an assistant 2

Emerging Techniques Without Sedation

Novel Single-Physician Methods

• The lateral position maneuver (Makihara method) achieved 100% success in 13 patients without sedation, performed by a single physician in lateral decubitus position 3
• Han's technique (Touch overhead technique) demonstrated 95% success rate with mean reduction time of 138 seconds and pain score of only 1.83 points, requiring no anesthesia or sedation 4
• A novel traction-abduction-external rotation variant achieved 95.08% first-attempt success in 58 of 61 shoulders without any sedation, with mean reduction time of 130.5 seconds 5

Sedation Protocol When Required

Medication Selection

• Etomidate is recommended as first-line sedation with median procedural time of 10 minutes, though myoclonus occurs in 21% of patients 6
• Propofol provides faster recovery (14.9 minutes) compared to midazolam-based regimens (76 minutes), with initial dosing of 1 mg/kg followed by 0.5 mg/kg supplements 6
• Ketamine/midazolam combination shows superior efficacy over fentanyl/midazolam for orthopedic procedures with fewer respiratory complications 6

Critical Safety Considerations

• When combining benzodiazepines and opioids, administer the opioid first, then titrate benzodiazepine dose to minimize respiratory depression risk 6
• Respiratory depression increases significantly with combined benzodiazepine/opioid use, with hypoxemia occurring in 25% of patients receiving fentanyl/midazolam 6
• Reversal agents (naloxone for opioids, flumazenil for benzodiazepines) must be immediately available 6

Clinical Algorithm

1. Attempt scapular manipulation first without sedation for all acute anterior dislocations without contraindications 1
2. If scapular manipulation fails, proceed to FARES method without sedation 1
3. If both fail or patient cannot tolerate sedation-free techniques, administer etomidate or propofol and reattempt scapular manipulation or use traction-countertraction 6, 1
4. Consider emerging single-physician techniques (lateral position maneuver, Han's technique) as alternatives when traditional methods fail 3, 4

Critical Pitfalls to Avoid

• Never use overhead pulley exercises for post-reduction rehabilitation, as they encourage uncontrolled abduction and worsen shoulder pathology 7
• Do not delay reduction attempts in patients with vascular compromise; emergent closed reduction should be performed immediately 8
• Avoid routine sedation for initial reduction attempts, as sedation-free techniques achieve comparable or superior success rates with higher patient satisfaction 2, 1
• Do not assume all dislocations require sedation; 90-97% can be reduced without anesthesia using appropriate techniques 5, 2, 1, 4

Post-Reduction Management

• Initiate range of motion exercises focusing specifically on external rotation and abduction to prevent frozen shoulder 7
• Implement gentle mobilization and stretching techniques emphasizing external rotation movements 7
• Apply shoulder strapping to prevent trauma and provide support 7
• Consider functional electrical stimulation to improve shoulder lateral rotation 7