What is the single person technique to reduce a shoulder dislocation?

Single-Person Shoulder Dislocation Reduction Techniques

The most practical single-person techniques for shoulder reduction are the Cunningham technique, the modified self-reduction Milch technique, and the scapulohumeral distraction (SHD) method, all of which can be performed without an assistant and have success rates of 93-95%. 1, 2, 3

Pre-Reduction Requirements

Before attempting any reduction technique, you must obtain radiographs to confirm the dislocation direction and identify associated fractures 4:

• Mandatory views: Anteroposterior (AP) in internal and external rotation PLUS an axillary or scapula-Y view 5, 4
• Critical pitfall: AP views alone miss posterior dislocations in over 60% of cases—never rely on a single view 4
• Never attempt reduction without imaging confirmation, as this could worsen fracture-dislocations 4

Recommended Single-Person Techniques

Cunningham Technique

This method has been successfully used with ultrasound guidance in urgent care settings 2:

• Patient sits upright with the affected arm at their side
• Provider sits facing the patient
• Gently massage and manipulate the shoulder muscles (biceps, deltoid, trapezius) to achieve muscle relaxation
• As muscles relax, the humeral head often spontaneously reduces
• Advantage: Minimal force required, relies on muscle relaxation rather than traction 2

Modified Self-Reduction Milch Technique

This technique demonstrated 100% success in 32 dislocations with a mean reduction time of 10 minutes 1:

• Patient lies supine
• Patient slowly and actively abducts and externally rotates the dislocated shoulder until the arm is overhead
• Once overhead position is achieved, the arm is gently lowered back to the side
• Simultaneously, the patient applies pressure to the front of the shoulder with their opposite hand to maintain position until reduction is complete 1
• Advantage: Can be taught to patients with recurrent dislocations for self-reduction when medical assistance is unavailable 1

Scapulohumeral Distraction (SHD) Technique

This newer method showed 95.3% success rate with significantly less pain and shorter procedure time compared to traditional traction methods 3:

• Combines gentle traction with scapular manipulation
• Requires less procedure time than the Hippocratic technique (statistically significant, p=0.001) 3
• Patients report significantly less pain (p=0.012) and greater satisfaction (p=0.003) 3
• Advantage: Anatomically based, simple, and associated with higher patient satisfaction 3

Pain Management Options

Provide adequate analgesia before attempting reduction 4:

• Procedural sedation with propofol or etomidate plus opioid analgesia is effective 4
• Ultrasound-guided intra-articular lidocaine injection provides excellent analgesia and can be performed at bedside 2
• If no contraindications exist, acetaminophen or ibuprofen can supplement pain control 6

Post-Reduction Protocol

Immediate Confirmation

• Obtain post-reduction radiographs to confirm successful reduction and evaluate for fractures that may have been obscured by the dislocation 4
• Perform neurovascular assessment, particularly evaluating axillary nerve function and vascular integrity 4
• Point-of-care ultrasound can provide bedside confirmation of reduction if available 2

Immobilization and Follow-up

• Immobilize the shoulder with a sling or shoulder strapping 6
• Avoid overhead pulleys during initial recovery as they encourage uncontrolled abduction which may worsen injury 6
• Begin early physical therapy after immobilization period, focusing on gentle stretching and progressive strengthening of rotator cuff muscles 6

Critical Considerations by Patient Age

Elderly Patients (>60 years)

• Significantly higher likelihood of rotator cuff tears with weakness in external rotation, abduction, or internal rotation 4
• Consider MRI if there are concerns about soft tissue injuries after reduction 6

Younger Patients (<35 years)

• Higher risk of recurrent instability requiring evaluation for capsular injuries and bone loss 4
• Consider MR arthrography (gold standard, appropriateness rating 9/9) to evaluate labral tears and capsular injuries 4

Time-Sensitive Factors

Prompt reduction is essential as delays increase the risk of neurovascular complications 4:

• Studies show that delays from presentation to first reduction attempt are associated with lower overall success rates 7
• Most patients in prehospital studies reached the hospital within 10-20 minutes, making field reduction debatable unless transport times are prolonged 8
• Mean reduction time with the modified Milch technique was 10 minutes 1

Common Pitfalls to Avoid

• Never rely on AP radiographs alone—failure to obtain axillary or scapula-Y views leads to missed posterior dislocations 4
• Do not overlook associated rotator cuff tears, especially in patients over 40 years or with high-energy trauma 4
• Do not delay reduction, as this increases neurovascular complications 4
• Monitor for complex regional pain syndrome (shoulder-hand syndrome) during recovery, which may require early intervention with oral corticosteroids 6