Shoulder dislocation

[roja]

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So, I have done this with scapular manipulation, traction/countertraction, and Hennipen..... both with concious sedation, propofol and with intra-articular injection of lidocaine/morphine.


What's your favorite way?

 

[southerndoc]

From personal experience, sedated. I didn't have enough sedation or pain medicine when I had my shoulder reduced (rollerblading accident -- see a pattern here? previous post about a lac from rollerblading). Anyhow, it hurt like hell.

 

[beyond all hope]

Actually, traction/countertraction works well with little old ladies. Hell, anything works with someone with no muscle mass. With the big muscular guys, you'll never get it without a LOT of sedation and scapular maneuver or hanging technique.

Had a guy on 100 Demerol and 4 of Versed, we were doing traction/countertraction and he was screaming in pain. No luck. I was just about to increase the sedation when his cellphone rang. While we were yanking on his left shoulder he picked up the phone with his right hand. He probably would have started chatting if I hadn't burned holes in him with my steely glare.

 

[southerndoc]

Actually, traction/countertraction works well with little old ladies. Hell, anything works with someone with no muscle mass. With the big muscular guys, you'll never get it without a LOT of sedation and scapular maneuver or hanging technique.

By the way, what is a Hennepin maneuver? I tried searching online but didn't find it. My EM textbook isn't readily available.

Anyhow, one of the EM attendings I worked with as a medical student taught me an excellent way to reduce shoulders. He learned it during his residency at DGH.

Basically it's "sheet-assisted" traction/counter-traction. Roll two sheets up lengthwise. Place one around the patient's body and tie the ends together around another person. This person uses this sheet to hold traction. Take the two ends of the unused sheet and tie them together. Then place it around your waist. Abduct the patient's arm slightly, flex the forearm at the elbow, and place the sheet around the patient's arm so that it rests on the elbow. Sedate with some propofol and use your weight to reduce the shoulder. Works like a charm. (Step backwards instead of leaning backwards to prevent a catastrophe.)

 

[DocWagner]

The above technique (simply stated as "traction counter traction" is also the Hippocratic Method)

I use traction counter traction and I use Etomidate dosed at .1mg/kg. Never fails. I like it far better than propofol.

The Hennepin Method: Pt. lies supine on table, affected arm at his side. Elbow is flexed to 90 degrees of flexion, one of your arms keeps his upper arm next to his side with your other arm gently externally rotates the affected arm (while his elbow is still flexed at 90)...kerplunk.

 

[southerndoc]

The above technique (simply stated as "traction counter traction" is also the Hippocratic Method)

I use traction counter traction and I use Etomidate dosed at .1mg/kg. Never fails. I like it far better than propofol.

The Hennepin Method: Pt. lies supine on table, affected arm at his side. Elbow is flexed to 90 degrees of flexion, one of your arms keeps his upper arm next to his side with your other arm gently externally rotates the affected arm (while his elbow is still flexed at 90)...kerplunk.

Thanks DW. I had never heard of the Hennepin method.

Still have a lot to learn... the intern year is going to be another great learning year, just like 3rd year. 🙂

 

[roja]

I try to cultivate as many ways to relocate a shoulder. While shoulder manip is very popular here, I have done a number of different ways. Right now, I am a big fan of intraarticular injection with a touch of po valiaum. both times I have used it (a post disl and an anter) it worked really well. Any of the manuevers can be used.

I used it last night because I had a patient who had been assaulted int eh neck with swelling around the epiglottis on soft tissue films, so no concious sedation. We gave him five of valium and the new attending let me inject the lido with morphine into the joint. we did traction/counter and it went right in. No concious sedationa dn he went home shortly after....

 

[deleted6669]

if you are not terribly busy stinson's maneuver requires minimal sedation and is very unlkely to result in a hill-sachs lesion
(stinson's involves pt prone on table with weight hanging straingt down off affected arm several inches above table...muscles fatigue, shoulder reduces)
if in a hurry I use the traction/countertraction or hennepin as described above
doc wagner- I thought the hippocratic method involved placing ones foot in the pts axilla and pulling on the affected arm( a big no-no if I recall)

 

[DocWagner]

EmedPA, yeah that is the described location of the foot...I guess we use variations of the original procedure, Greeks do odd things with their feet anyway.

 

[12R34Y]

the stinson's that EMEDPA described is very popular with the ED docs i used to work with. I've never seen it fail.

what is a hill-sachs lesion?

later

 

[DrQuinn]

the stinson's that EMEDPA described is very popular with the ED docs i used to work with. I've never seen it fail.

what is a hill-sachs lesion?

later

The HS Lesion is a little bump or indendation on the lateral aspect of the humeral head. Its from compression on the lip of the glenoid. This is one reason why you get the post reduction films. Even if you find it, I dont' think you do much different anyways, you just need to document it and refer to ortho. As far as I remember anywho...

Q, DO

 

[spyderdoc]

I use Stinson's very frequently. I usually give 2.5 of Valium IM and 4 of MS IM right after exam (for pain control and muscle relaxation...Not procedural sedation...Therefore no procedural sedation protocol paperwork, etc...Nice!)), the patient goes off to xray, and when they come back they are nice and relaxed. I prone them and hang the weight. Leave for about 15 min. When I come back, it is usually reduced. If not, I do a little scapular manipulation with the weight still present and it almost always goes back in....
It this does not work, flip them supine and then must do conscious sedation with traction/countertraction....My drug of choice is either 10 of Etomidate or Propofol titrated to effect...Works very quicly and produces excellent sedation...Very short duration of action...Patient wakes up in no time and can be discharged very quickly...

 

[roja]

Unfortunately, at our institution we aren't allowed to use propofol unless a pt is intubated or up in the OR. Its one of those institutional things. I did have a ridiculously difficult relocation the other week. We had given this very slight guy enough concious sedation to kill a horse. He would stop breathing before he would relax his shoulder girdle.

We ended up taking him all the way up to anesthesia, they gave a touch of propofol and *ping* it was in.

We also aren't approved for etomidate yet at our hospital, despite the literature that states its safe to use.....