what's your preferred method for shoulder reduction

[Painter1]

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i keep to traction-counter traction under conscious sedation however past two times i had a tough time.

i've tried scapular manipulation twice with the patient prone after giving pain meds and it worked in one case. the case where it worked was a kid who had a hx of dislocations.

you guys using intra-articular lidocaine versus consicous sedation?

 

[leorl]

I've had intra-articular lidocaine work and not work. I think there's more consistency with conscious sedation.

some people don't like it, but I am most comfortable and have found highest success with the kocher method. If it doesn't work, then I move to traction counter-traction, but I don't like it because the sheets are always too short and the patient's arm ends up in your crotch.

there's a new technique recently described in ortho literature that's similar to the external rotation method which uses vertical oscillation of the arm to reduce muscular contraction. I recently tried it...I couldn't get it to work, probably wasn't doing it exactly properly.

 

[n2b8me]

😉

 

[roja]

I swear we just had this thread.

*shrug*

I use intra-articular lidocaine mixed with 2mg of morphine (there are mu receptors in the shoulder joint)
toradol
benzos.
I rarely use concious sedation

 

[EMMudphud]

Anyone ever use FARES method? I tried it on my last reduction and it worked like magic. The oscillations worry me as I feel like I could be grinding or damaging something but it was pretty amazing the one time I used it. I gave 5 of oxycodone, acetaminophen and ibuprofen, then it went right back in with almost no effort and no pain. However, this is likely the exception rather than the rule. I'm dying to try it again.

 

[kungfufishing]

Anyone ever use FARES method? I tried it on my last reduction and it worked like magic. The oscillations worry me as I feel like I could be grinding or damaging something but it was pretty amazing the one time I used it. I gave 5 of oxycodone, acetaminophen and ibuprofen, then it went right back in with almost no effort and no pain. However, this is likely the exception rather than the rule. I'm dying to try it again.

I've had one great reduction (first time I tried it) and one comical failure - I think I need to review exactly how it is done as the first one was right after watching the video but the second one a couple weeks later felt like I was just standing there shaking the dude's arm

 

[leorl]

Yeah I tried it and it didn't work. But the guy I tried it with has some serious laxity because as soon as we relocated it using other methods, it would just pop right back out. So I don't know if it was because of an unsuccessful FARES or if this dude just had too much instability of the joint. However, we didn't conscious sedate him so I guess in that respect it worked.

 

[Painter1]

for those that brought up FARES, thanks! looked into it. i think i might give it a shot next time.

in regard to stimson method, where do u get weights or "sandbags" in the ed? how do u attach them to the arm? sorry, i feel i should know this but never performed it or saw it down during my residency. i'm now at a community hosp.

 

[tkim]

for those that brought up FARES, thanks! looked into it. i think i might give it a shot next time.

in regard to stimson method, where do u get weights or "sandbags" in the ed? how do u attach them to the arm? sorry, i feel i should know this but never performed it or saw it down during my residency. i'm now at a community hosp.

There's usually some ortho cart or drawer with weights. Maybe near the splinting material and ace wrap? If you only have weights but not the thin metal stick to hang them with, just drop them into some tube roll with one end tied up, then tie the other end to the patient's wrist.

 

[Old_Mil]

i keep to traction-counter traction under conscious sedation however past two times i had a tough time.

i've tried scapular manipulation twice with the patient prone after giving pain meds and it worked in one case. the case where it worked was a kid who had a hx of dislocations.

you guys using intra-articular lidocaine versus consicous sedation?

The only thing I've ever seen work on a consistent basis is traction-counter traction.

(an aside: I've never actually seen the French Jedi-Mind Trick method attempted...)

I'll continue to use conscious sedation until the day it leads to a ****storm intubation, at which point I'll undoubtedly switch to the intraarticular method.

 

[Tiger26]

I swear we just had this thread.

*shrug*

I use intra-articular lidocaine mixed with 2mg of morphine (there are mu receptors in the shoulder joint)
toradol
benzos.
I rarely use concious sedation

So how much lido do you typically put in the joint?

 

[docB]

Yeah I tried it and it didn't work. But the guy I tried it with has some serious laxity because as soon as we relocated it using other methods, it would just pop right back out. So I don't know if it was because of an unsuccessful FARES or if this dude just had too much instability of the joint. However, we didn't conscious sedate him so I guess in that respect it worked.

We've got a few guys where I am who are chronic dislocators. They show up, get a lot of pain meds because if you don't know them they seem real, and then after you get it back in they want up, pop them back out and ask for more dope. I know most of them but it's really annoying.

for those that brought up FARES, thanks! looked into it. i think i might give it a shot next time.

in regard to stimson method, where do u get weights or "sandbags" in the ed? how do u attach them to the arm? sorry, i feel i should know this but never performed it or saw it down during my residency. i'm now at a community hosp.

I've had little success with it because patients almost always complain that it's too painful and they can lie like that. But I've used water bottles all taped together and those big bags that we use to do CBI. 5L =~10 lbs.

 

[stgeorge]

i keep to traction-counter traction under conscious sedation however past two times i had a tough time.

i've tried scapular manipulation twice with the patient prone after giving pain meds and it worked in one case. the case where it worked was a kid who had a hx of dislocations.

you guys using intra-articular lidocaine versus consicous sedation?

Shoulder Dislocation

This post reviews the glenohumeral (shoulder) dislocation in detail with a focus on multiple reduction techniques.

coreem.net

Scapular manipulation is my go to.

 

[Apollyon]

Wow - 11 year bump. Respeck.

 

[southerndoc]

Wow - 11 year bump. Respeck.

Necrobump FTW.

 

[EMhawkeye]

Propofol/ fentanyl.
Traction / counter traction method.

For hips always use allis technique.

 

[Make Or Break]

Have done the FARES a few times and it works like magic.

 

[Angry Birds]

I've had intra-articular lidocaine work and not work. I think there's more consistency with conscious sedation.

some people don't like it, but I am most comfortable and have found highest success with the kocher method. If it doesn't work, then I move to traction counter-traction, but I don't like it because the sheets are always too short and the patient's arm ends up in your crotch.

there's a new technique recently described in ortho literature that's similar to the external rotation method which uses vertical oscillation of the arm to reduce muscular contraction. I recently tried it...I couldn't get it to work, probably wasn't doing it exactly properly.

New technique? It's been around for more than a decade.

EDIT: NECROBUMP, haha.

Yeah, I've never gotten this to work.

 

[suckstobeme]

So my go to these days is FARES, but I wanted to send some love to Kocher. I work in a place where I often see a drunk dislocated shoulder that I feel is too high an aspiration risk for sedation. I also don't love prone techniques for these patients. So if FARES fails, I go to Kocher, and it always works. I know there's a concern that it's a traumatic technique, but I'm not sure I've really ever heard of any actual complications. To be honest, most of my Kocher reductions go so smoothly there's no pop. I think even Dr. Cunningham recommended it as one of his go to methods (though he may have changed his mind). I did see one lecture about it that claimed it was never intended to be used with traction and the trauma occurs when traction is applied inappropriately during the technique. I don't know enough about it to say for sure, but I think the caution against Kocher may be overblown. If someone out there has a really good reason not to use Kocher, if love to hear it bc it may be practice changing for me. Otherwise, I think we are under utilizing this great technique.