Blackwell Science, LtdOxford, UKEMMEmergency Medicine Australasia1035-68512005 Blackwell Publishing Asia Pty Ltd 2005175463471Review ArticleAnteroinferior shoulder dislocationNJ

Cunningham

Emergency Medicine Australasia (2005) 17, 463–471

REVIEW ARTICLE

Techniques for reduction of anteroinferior

shoulder dislocation
Neil J Cunningham
Department of Emergency Medicine, St Vincent’s Hospital, Fitzroy, Victoria, Australia

Abstract

Dislocation of the shoulder joint is common. The shoulder is affected in up to 60% of all
major joint dislocations, one study citing an incidence of 1.7% in the general population.
The most common form is anteroinferior dislocation. A variety of techniques to reduce
shoulder dislocation has been described. The key to successful relocation is a thorough
understanding of the anatomy of both the enlocated and the dislocated shoulder joint.
Key words: dislocation, method, reduction, shoulder, technique.

Methodology 2. Limited joint volume and negative intra-articular

pressure.
A comprehensive literature search was performed with 3. Static stabilizers: the fibrous labrum is composed
these methods: MEDLINE search using keywords of fibrocartilage. The loose joint capsule is rein-
(‘shoulder’, ‘dislocation’, ‘reduction’, ‘technique’, forced by rotator cuff tendon insertions. The
‘method’) identifying 47 relevant papers; manual search glenohumeral ligaments are important anterior
of bibliographies; scans of abstracts of recent interna- stabilizers providing resistance to anterior transla-
tional meetings; trawl of standard Emergency Medicine, tion at different stages of abduction. The inferior
Orthopaedic and Anatomy textbooks. glenohumeral ligament (IGHL) is a complex made
up of anterior and posterior bands with an
interposing pouch. Injury to IGHL complex is
Anatomy of the shoulder common in younger patients, leaving the joint
unstable.1,2
The glenohumeral joint is a highly mobile ball and 4. Dynamic stabilizers: several groups of muscles act
socket joint. This comes at a cost to stability. Stability over the shoulder joint contributing to stability.
and resistance to translating forces is provided by: Milch separated these into four groups based on
1. The suction cup effect of the labrum. The socket is length and insertion onto the humerus, radius and
formed by the shallow glenoid fossa reinforced by a ulna.3 Group one is the rotator cuff muscles. These
fibrous labrum that doubles the depth of the fossa muscles are the most important stabilizers, their ten-
and creates a suction cup effect on the humeral dons reinforcing the joint capsule. Group two is
head. larger and more superficial and inserts onto the

Correspondence: Dr Neil J Cunningham, Department of Emergency Medicine, St Vincent’s Hospital, Victoria Parade, Fitzroy, Vic. 3065,
Australia. Email: [email protected]
Neil J Cunningham, MB BS, Registrar.
 NJ Cunningham

proximal humeral shaft. Group three inserts more Dynamic forces

distally onto the humerus. Group four is the longest
and inserts into the bones of the forearm. With the humerus in the anatomical position the result-
ant force of the shoulder girdle muscles acts to pull the
humeral head and neck in a medial direction. The
Anatomy in dislocation dynamic stabilizers normally function to hold the joint
in place. However, when the humeral head is displaced
In dislocation the anatomy and inherent stability these muscles continue to contract reflexly. Muscular
changes. The humeral head sits in either a subcoracoid spasm, and therefore shortening, continues to pull the
or subglenoid position. Return of the humeral head to humeral head (through the tuberosities) and shaft
the glenoid fossa is confronted by two major obstacles, despite the head being malpositioned. The long head of
static and dynamic forces. biceps and subscapularis resist reduction of the dis-
placed humeral head.3
Longitudinally directed muscles positioned across
Static forces
the glenohumeral joint, act to pull the humeral head
The patient classically presents with the humerus in upwards, fixing it in the subcoracoid/glenoid areas. The
abduction. The arm however, can appear adducted, long head of biceps is proximally inserted at the supra-
because the patient slouches to the affected side glenoid tubercle and superior labrum, the tendon then
with the scapula fully rotated and anteverted. This passing anterior to the humeral head. In spasm this
can be felt clinically and seen on X-ray radiograph muscle resists anterior movement of the head. It might
(Fig. 1). Consequently supralateral to the displaced also have the added effect of bowstringing anterolateral
head is a fixed obstacle, the prominent anteriorly to the axis of the head, further restricting the lateral/
placed glenoid rim and labrum. To relocate from supralateral movement of the humeral head required to
this position and move past the glenoid rim the move past the glenoid rim/labrum.
humeral head must move anteriorly and lateral/ Subscapularis inserts into the lesser tuberosity, act-
supralaterally. ing to internally rotate the humerus and hold the head
This obstacle is overcome by external rotation of the medially, resisting lateral movement. Spasm of this
humeral head; a greater articular surface on the humeral muscle also restricts the external rotation required for
head is presented superiorly to the receiving fossa reduction.
allowing it to roll past the rim.4 Alternatively rotation
of the scapula with retroversion presents an easier path
for the returning head. Types of dislocation
There are four types of anteroinferior shoulder disloca-
tion, denoted by the final position of the humeral head.
Subcoracoid dislocations constitute 70% of all disloca-
tions.5,6 Subglenoid dislocations (Fig. 2) are the second
most common, 30%.5 Subclavicular and intrathoracic
dislocations are associated with fractures and violent
forces.7 Luxatio erectae is regarded as a pure inferior
dislocation and is not discussed here.

Mechanism of injury
Anteroinferior dislocations classically occur with a com-
bination of abduction, external rotation and extension.
A fall onto the outstretched arm transmitting the force
to the glenohumeral joint is a typical mechanism.7 A fall
onto the point of the shoulder is an alternative mecha-
Figure 1. Subcoracoid dislocation. nism of injury, forcing the humeral head anteriorly.

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Figure 2. Subglenoid dislocation with greater tuberosity Figure 3. Hill Sach’s Lesion.
fracture.

5. Humeral shaft fracture is rare, associated with sig-

Subcoracoid dislocation occurs when the arm is in the nificant forces.
low to mid range of abduction and externally rotated.8
Subglenoid dislocations usually result from rapid Damage to the glenohumeral ligaments
hyperabduction. Subclavicular and intrathoracic dislo-
cations involve large lateral to medial forces on the These important static stabilizers are damaged in about
abducted humeral shaft.7 55% of cases, more commonly in the young.2,16

Rotator cuff injury

Complications
The rotator cuff is more commonly damaged in the
Fractures elderly (35–86%).17

Fractures occur in about 30% of cases.9,10 The most Neurological injury

common are:
1. Hill Sach’s lesion (Fig. 3), seen in 54–76% of cases, Some form of neurological damage occurs in 21–50%
is a compression fracture that results in the formation of cases of anteroinferior dislocation.2,10 The axillary
of a groove in the posterolateral aspect of the humeral nerve is the most commonly damaged (3%),15 brachial
head.2,9–11 Also known as a hatchet deformity it is plexus and other isolated nerve injuries can occur.
best viewed with internal rotation of the arm.9
2. Fractures of the anterior rim of the glenoid fossa Vascular injury
(Fig. 4) or Bankart’s lesion12,13 (a separation of capsule
and/or labrum from the anteroinferior rim, the term Axillary artery rupture presents with pain, axillary hae-
is often used to refer to bony disruption).2,10 It is the matoma and a cool limb with absent pulses (distal
result of impaction of the humeral head against the pulses might be present, resulting from collateral flow).
anteroinferior glenoid labrum, and is associated with Of axillary artery complications 86% occur in patients
rupture of joint capsule and IGHL damage. It is more aged more than 50 years.18 This is very rare but should
common in younger patients and has a strong asso- be considered if a brachial plexus injury is identified.2
ciation with recurrent dislocations (85–87%).2,13,14
3. Avulsion fracture of the greater tuberosity (Fig. 5) is Recurrence
seen in 10–16% of cases.5,9,10,15,16
4. Uncommonly, the coracoid process can be damaged Age is a major factor in likelihood of recurrence. In the
by the humeral head resulting in painful non-union. <20 years age group, 80–94% of patients develop

465
 NJ Cunningham

recurrence.2,13,14 Bankart’s lesion and its association with manoeuvres with the humerus in different positions,
IGHL damage is the major pathology. In the <40 years leaving the mechanism of relocation unclear.29,30
group 26–48% develop recurrence.2,11 The major pathol- The position of the humerus can be used as the dis-
ogy is disruption of the labral attachment of the gleno- cerning feature in classification. With the scapula fixed
humeral ligaments. In the >40 years group only 0–10% in the anatomical position the operator has a clear
recur.2,13 The major pathology is rotator cuff tear.2 impression of the position of the humeral head in
Greater tuberosity fractures are associated with relation to the glenoid fossa and the various stresses
lower rates of recurrence (4.5%).2 Bankart’s and Hill and forces acting on the humeral head, shaft, glenoid
Sach’s lesions are strongly associated with recurrence.16 labrum and muscle and ligament insertions. Good ana-
Minor trauma producing dislocation is associated with tomical knowledge provides a clear awareness of the
high recurrence rates (86%).13 forces being applied by the operator in a dynamic
situation.
The position of the humeral head in relation to the
Techniques of reduction glenoid fossa at the point of reduction is the critical
feature. Scapular rotation on the chest wall must be
There are a large number of techniques for reduction of taken into account with some techniques, and the posi-
anteroinferior shoulder dislocation. Many, however, are tion of the scapula at clinical presentation should be
variations on classic techniques as first described by sought. Many of the techniques discussed below can be
Kocher,19,20 Milch,3 Stimson13,21 and Bosley.22,23 Tech- employed with the patient supine, seated or prone. If
niques are usually classified as traction, leverage, scap- unsuccessful with one technique, the skilled operator
ular manipulation and combinations thereof.7,24 can then employ a second choice method without hav-
There are problems with current classification guide- ing to move the patient.
lines. There is often confusion about the use of traction
and leverage, some texts describing Milch’s technique Techniques with the arm in the anatomical position
incorrectly as a traction technique,25,26 others adding
traction steps to Kocher’s leverage method.25,27 In clini- The starting point for these techniques is with the
cal practice inappropriate traction and poor technique humerus in the anatomical position, adducted against
can result in complications with otherwise safe meth- the torso. Adduction can be difficult or unobtainable in
ods. Kocher’s method fell into disrepute because of its obese patients.
association with complications occurring with the appli-
cation of large forces,28–30 but has been shown to be a Kocher’s method
safe technique when applied correctly.31 Combination Originally described in 1870 Kocher’s method did not
techniques are simply two or more separate involve traction.19,20,32 Many texts have incorporated

Figure 4. Fracture of anterior rim of glenoid fossa. Figure 5. Greater tuberosity fracture.

466
 Anteroinferior shoulder dislocation

traction,25,27 which has been associated with complica- Techniques with the arm in the zero position
tions,28–30 yet in various case series the original tech-
nique has been used safely.31 Significant traction Saha originally described the zero position as that
forces in combination with forced internal or external ‘where the humero-scapular aligned axes coincide with
rotation place undue stress on the humeral shaft and the common axis of the cone muscle groups . . . the
neck. humerus is 165° overhead and 45° in front of the coronal
The original technique is: ‘Bend arm at the elbow, plane . . . (the scapula) being at the limit of vertical
press it against the body, rotate outwards until resis- rotation and forward migration on the chest wall. In
tance is felt. Lift the externally rotated upper arm in the this position the glenohumeral joint loses all active
sagittal plane as far as possible forwards and finally rotation’.36
turn inwards slowly’.19 Milch separated the muscles around the shoulder into
Variations include: cone groups.3 He noted that with the arm in elevation
• Leidelmeyer’s external rotation technique, which (full glenohumeral abduction and full scapular rotation/
describes the first manoeuvre of Kocher (elbow anteversion) the cone groups arrange in a similar direc-
flexed, adduction of humerus, external rotation) and tion along the humerus and lose their rotatory/trans-
then adds traction24 verse component.
• Mount Beauty method, which describes downward Milch’s technique used this overhead position as the
traction followed by external rotation.33 An assistant critical point at which relocation could most easily
stabilizes the scapula occur. This was chosen as ‘the only position in which a
single force, exerted along the axis of the humerus, is
Snowbird technique accurately directed to overcome each and all of the
This technique is essentially downward traction with muscle actions at the same time’. This statement was
the humerus in the anatomical position.34 used to explain the choice of position as a point of
The patient is sitting up straight with humerus in theory and not as an endorsement in the use of force
anatomical position, elbow flexed, and forearm sup- during the manoeuvre. Indeed, in the supporting case
ported by the unaffected limb or operator. The operator studies he talks about elevating the arm ‘with the great-
places a foot into a stockinette loop wrapped around the est gentleness’. Traction has been recommended as part
forearm. Downward traction from the foot is applied, of the Milch technique,6,7,37 but the original description
with additional rotation or pressure from the operator’s does not use traction.
hands if needed. Importantly, with the humerus in complete overhead
abduction the scapular has rotated fully on the chest.
The Cunningham technique This puts the humerus (in relation to the rotated scap-
This technique addresses static obstruction by posteri- ula) in the zero position.
orly directed shrugging of the shoulders.35 This uses
the rhomboids to retrovert the scapula reducing the The Milch technique
obstruction of the glenoid rim and labrum to the return- ‘The patient lies in the supine position, while the sur-
ing humeral head. The dynamic obstruction of the spas- geon takes his position on the side of the dislocation.
ming biceps is actively reduced by massaging the First manoeuvre – in a right sided dislocation the sur-
muscle at the mid-humeral level. geon places his right hand upon the patient’s right
The patient sits without slouching in a hard backed shoulder, so that the fingers find firm support on the
chair, the affected arm adducted to the body and the top of the shoulder, while the thumb is braced against
elbow fully flexed. The operator kneels next to the the dislocated humeral head. Second manoeuvre – the
patient and places his wrist onto the patient’s forearm, right hand fixes the head as the left hand gently abducts
the patient’s hand resting on the operator’s shoulder. the arm into the overhead position. During this manoeu-
The patient is asked to shrug the shoulders superiorly vre the head of the humerus is supported so that it
and posteriorly, which ‘squares off’ the angle of the cannot move form its dislocated position. As a conse-
shoulder (reducing scapular anteversion and the static quence, instead of moving downward as the arm moves
obstruction of the glenoid rim). The biceps is massaged upward, the head rotates in place. Third manoeuvre –
at mid-humeral level to specifically relax the muscle once the arm has been brought into complete abduction
(removing dynamic obstruction). The head reduces in this overhead position, all cross stresses exerted by
quickly, painlessly and without traction. all the muscles have been eliminated; the head can be

467
 NJ Cunningham

gently pushed over the rim of the glenoid and the dis- For a larger patient an assistant might be employed
location reduced’.3 to fix the scapula, the operator in front of the patient
Variations include: using the left hand, leaving the right free to push the
1. Patient prone with elbow flexed.38 humeral head if needed.
2. Janecki’s ‘forward elevation’ combination
manoeuvre29 begins with forward flexion to 90° (step Techniques with the arm in lateral flexion
one), then traction is applied and abduction
increased (step two). The final position is the over- Eskimo technique40
head position and the humeral head is pushed by The patient is placed on the ground lying on the non-
direct pressure if reduction has not occurred (step dislocated shoulder. Two persons now lift the patient
three). by the dislocated arm, keeping the opposite shoulder
3. ‘Reduction in the position of maximum muscular suspended a couple of centimetres from the ground. If
relaxation’.6 Gentle traction is applied while the no reduction occurs direct pressure on the humeral head
shoulder is abducted to 45° (step one). Traction is is applied.
then increased with further abduction 120° and Stimson also described this technique as the ‘pendle
anteversion 30° (step two). External rotation is then method’.41
applied (step three). Finally, direct pressure is
applied on the humeral head in the axilla (step Hippocratic method
four). The patient lies supine while the surgeon holds the arm
4. Russell placed the patient supine with back at applying traction. A ‘well stockinged foot’ in the axilla
30°.39 The patient moves his arm slowly to the applies countertraction and is also used to lever the
overhead position and places his hand behind his humeral head supralaterally. This technique is still rec-
head. Gentle traction is then applied to the flexed ommended in some texts.25,26,37
elbow while the humeral head is guided over the
glenoid rim. Traction countertraction7,32,37,42
The author uses a new modification of the technique Traction is applied to the arm with the shoulder in
that fixes the scapula. This limits the rotation (around abduction; an assistant applies firm countertraction to
a vertical axis) and anteversion (tilting forward) of the the body using a folded sheet.
scapula that ordinarily occurs with glenohumeral move-
ment during abduction past 30°. This allows the ‘zero Techniques with the arm in forward flexion
position’ (used here to describe the critical angle
between glenoid fossa and humeral head at point of Stimson’s hanging arm technique13,43,44
relocation rather than Saha’s classically described posi- The patient lies prone on a table with the affected arm
tion with the scapula in full rotation and anteversion) hanging downward. A weight of 10 lb is applied to the
to be reached more easily, at about 100° abduction (no wrist. Reduction occurs secondary to fatigue of the
more than 120° abduction is possible at the gleno- spasming muscles.
humeral articulation4). This technique is usually per- Variations include:
formed with the patient seated but has been used in the • Step two of Janecki’s ‘forward elevation’ combination
supine position and, as in the original, no traction is manoeuvre29
used. • Lippert’s ‘modification of the gravity method’43 has
the patient prone with the affected arm hanging ver-
Modified Milch technique (for a right-sided dislocation) tically and the elbow flexed. Downward traction to
The patient is seated in a hard backed chair, the oper- the humerus is then applied through the forearm by
ator standing behind the affected limb. The left hand is the operator
placed over the trapezius and spine of scapula. This • Rollinson used the hanging method in combination
fixes the scapula and detects any scapular movement. with a supraclavicular nerve block44
The right arm is held by the wrist and gently abducted
to 100°. External rotation is applied gradually as the Spaso technique30
arm is lifted. The humeral head can be gently pushed With the patient supine the arm is gently lifted verti-
in a supralateral direction if relocation has not cally. While applying traction rotate the shoulder exter-
occurred. nally. Push the head of the humerus in the axilla.

468
 Anteroinferior shoulder dislocation

Techniques with the arm in forward flexion plus Hippocrates.25,41 The choice of fulcrum and direction of
scapular manipulation traction varies:
• Nordeen uses the back of a chair in the axilla com-
Scapular manipulation bined with downward traction48
This technique was described by Bosley in 1979:22 • Manes uses downward traction with the operator’s
The patient is placed prone on the examining table with forearm as an external fulcrum49
the shoulder in a position of 90 degrees of forward • Slump reduction technique.50 An assistant sup-
flexion and external rotation. The forearm is suspended ports the axilla from behind while the physician
from the table with the wrist secured and the elbow applies longitudinal traction. If unsuccessful exter-
flexed. Traction on the forearm is maintained with 5 to nal rotation and then scapular manipulation are
15 lbs for a variable period, usually less than five min- added
utes. After the patient begins to relax, the surgeon • White uses the back of a chair as an external fulcrum
pushes on the tip of the scapula medially (lifting it on and abduction with downward traction51
occasion), while simultaneously rotating the superior
aspect of the scapular laterally.
The technique works by applying constant traction Use of analgesics/sedation/anaesthetic
to the externally rotated humerus to reduce pressure of
the humeral head on the glenoid rim (sitting supralat- Benzodiazepines and opiates have been the drugs of
eral to the dislocated head). This allows the abducted choice when manipulating shoulder dislocations. Both
inferior tip of the scapula to be rotated bringing the carry the risk of cardiovascular and respiratory depres-
scapular neck and glenoid fossa into correct alignment. sion, especially in the elderly. Some techniques require
Originally described with the patient prone this caused positioning that would preclude the use of these drugs
problems positioning uncooperative patients or women in high risk groups. Some operators feel that chemical
with large breasts.23 sedation/analgesia should usually or always be
Variations include: given.6,32,45,49 Many studies using a variety of techniques
• Arm hanging vertically with weights hung from have however, shown the standard use of drugs to be
wrist45 unnecessary.8,20,28,34,38,50 Intra-articular and suprascapu-
• Seated patient46 with one physician performing gen- lar nerve blocks have been used. These techniques have
tle traction in the forward flexion position with coun- a theoretical risk of joint infection.
terbalancing in the patient’s midclavicular region. A
second physician manipulates the scapula
• Supine patient47 Success rates
Boss Holzach matter Success rates range between 60 and 100%. Some tech-
This technique relies on movement of the scapula with niques have difficulty with older patients,8 some with
the humerus fixed by axial traction.8 particular subtypes of dislocation.5,6,28 This highlights
The scapula is rotated by the patient by actively the importance of being skilled in more than one
shrugging the shoulders (anteriorly). The patient sits on method.
an examination table, the wrists bound together and
placed around the flexed (homolateral) knee. The head
of the table is lowered and patient asked to lean back Discussion
and hyperextend neck exerting anterior axial traction
on the humeral head. The patient then shrugs the shoul- There has traditionally been a belief that traction is
ders anteriorly increasing anteversion of the glenoid necessary to overcome the forces of muscular spasm
cavity. when reducing shoulder dislocation;6,29 however, a num-
ber of effective techniques not using traction have
Techniques with the arm in abduction/forward similar success rates.3,20,35,52 These techniques are phys-
flexion with external fulcrum iologically sound in that their mechanisms rely upon
careful manipulation of the humeral head around the
Use of an external fulcrum in the axilla as leverage and/ obstructions, blocking its path back to the glenoid fossa.
or countertraction has been recommended since When used correctly, these techniques require no force,

469
 NJ Cunningham

reducing the risk of secondary injury to the joint and Competing interests
surrounding structures.
It is arguable that techniques relying solely on trac- None declared.
tion to ‘overcome’ muscle spasm (Hippocratic, traction/
countertraction) should not be used. Some techniques Accepted 16 March 2005
combining traction and rotation (scapular manipula-
tion) or relying on muscle fatigue (Stimson) are less
traumatic for both joint and patient. References
The following algorithm suggests a hierarchy of
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