Shoulder Dislocations in Austere Environments – A Novel Approach

This month’s meeting of our Wilderness Medicine group discussed acute shoulder dislocations in the austere environment. Before we begin, let’s consider the following questions: Can the diagnosis of anterior shoulder dislocation be made clinically? Do all patients with anterior shoulder dislocations need a pre-reduction x-ray? If you answered ‘yes’ to the first question and ‘no’ to the second question, then one must ask, do all patients need to come to the Emergency Department (ED) following an anterior shoulder dislocation? Or can it be diagnosed and reduced in the field with outpatient follow-up, sparing an ED visit?

In 2011, Orloski, et al demonstrated that in individuals in their 2^nd and 3^rd decade of life, the incidence of fractures in an acute shoulder dislocation was found to be less than 1%. Bokor-Billmann, et al took this idea a bit further by designing an observational study at two locations, mountains in Eastern France and Southwestern Germany, to evaluate on-site reductions of anterior shoulder dislocations. There were a total of 39 participants. The exclusion criteria for participation in the study were: 1) prior sedation or analgesia, 2) dislocation with obviously associated fractures, 3) altered mental status, 4) dislocation for > 12 hours, 5) dislocation associated with other traumatic injuries, and 6) refusal to give consent.

The field reductions were performed by one of three physicians who participated in a 3-hour instructional course prior to start of the study. The reductions were performed using a novel technique (see below) adapted from a method taught at a mountain medicine course in Paris, France. Their reduction success rate was 100%, mean time of injury to reduction was 3.9 hours (+/- 2.1 hours), and mean time of shoulder reduction was 6.1 minutes (+/- 1.4 minutes). The participants’ pain-rating on a visual analog scale (VAS) of zero to 10 was a mean of 1.7 (+/- 1.4) – a very impressive feat considering no one received pain medication at any point prior to reduction. Participants were not taken to a hospital afterwards; however, they were asked to have a shoulder x-ray within 2 weeks of injury. The participants were contacted at a 6-month follow-up to determine if there were any long-term post-reduction complications.

The field shoulder reduction technique used by Bokor-Billmann, et al is as follows:

1. Hold the patient’s wrist with your left hand (in the case of a left shoulder dislocation) and the elbow with your right hand
2. Flex the patient’s elbow to 90 degrees, followed by shoulder flexion to 90 degrees
3. While both the shoulder and elbow are flexed to 90 degrees, adduct at the shoulder until the patient’s elbow reaches their midline, an important landmark in this method.
4. Maintaining the elbow positioned at the midline, internally rotate at the shoulder. At 25-30 degrees of internal rotation, mild resistance may be encountered.
5. Apply constant internal rotation pressure to overcome any resistance. Reduction will usually occur at 30 degrees.

The participants in the study were mostly men (79.5%) with mean age 42.3 +/- 16.3 years. Most common mechanism of injury was alpine climbing (30.8%), kayaking (23.1%), skiing (12.8%), and other (33.3%). At 6-month follow-up there were no short-term or long-term complications reported, and none required surgery.

Limitations of this study include the small number of patients and no radiographic confirmation of shoulder dislocation; therefore, we can only assume the clinical impression was correct. All participants were people engaged in outdoor sporting activities (i.e. alpine climbing), which likely represent a more active and possibly overall healthier subset of people and perhaps even a higher pain threshold on average when compared to the general population.

Upon review of the different shoulder reduction maneuvers, most of the procedures have in common traction, leverage, rotation, and scapular manipulation. Different studies find a modest difference in success rate with each maneuver, and some maneuvers tend to be less painful than others. Again, the mean reduction time in this study was approximately 6 minutes. This study demonstrates that with patience and slow movements to overcome muscle spasm, we can reduce shoulder dislocations with less associated pain for our patients. This reduces the amount of analgesia required and just about eliminates the need for procedural sedation in isolated shoulder dislocations that were sustained within 12 hours prior to arrival.

Participants in this study sat on the ground with their back against a firm surface to minimize movements of the upper body. The method used in this study is an ideal one being that no equipment is needed (no stretcher, chair, bed sheets, etc.), it can be done with one provider (in theory one can possibly perform it on themselves, although it may be hard to overcome the resistance with internal rotation), and is associated with a low degree of pain (although this is more likely due to patience and slow movements).

Is anyone ready to adopt this maneuver into their practice? Why or why not? I, for one, cannot wait to give it a try.

References

Orloski J, Eskin B, Allegra PC, Allegra JR. Do all patients with shoulder dislocations need prereduction x-rays. Am J Emerg Med. 2011;29:609-612.

Bokor-Billmann, T, et al. Reduction of Remote Shoulder Dislocations in a Remote Environment: A Prospective Multicenter Observational Study. Wilderness Environ Med. 2015;26:395-400.

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