No patient is the ever same and the same goes for shoulder dislocations. If you use the same technique every time there is going to be situations where you are simply using the wrong technique. That’s why I take an algorithmic approach to the patient in front of me. This includes addressing whether this patient needs an X-Ray, what type of injury they might have, whether this patient need sedating, and pre-planning what to do if Plan A fails. There are anatomical reasons why no technique works every time on every patient and it is important to be skilled in several methods so you can use the best method for each presentation. The techniques discussed rely upon the relative movements of the humeral head and the glenoid fossa of the scapula. Used correctly, these techniques require little or no force.
Here’s the generic algorithm, once you have mastered a few techniques you can adapt this to your particular skill set. For example, if your favourite zero position technique is FARES, then that fits into your own personal algorithm – my algorithm appears below the generic one.
I'd also recommend declaring your plan to your patient and your team. 'Preparing to fail' is a great way to make good decisions in evolving situations especially when things aren't going to plan. Saying to your patient "I'm going to try a gentle technique using positioning and massage. Your shoulder may pop back in just with that, if not we are going to stop, get an X-ray, and get a bit more information before we try the next technique." This allows you to maintain the confidence of your patient (and yourself) if Plan A doesn't work, and stop you from spending too long on a technique that doesn't suit the patient or the injury..
And if you happen to be working on a football or ski field, here’s my field algorithm.
Here’s a tip for knowing when your zero position isn’t working and you need to try a different approach. If you can feel the scapula move in rigid tandem with any movements of the humerus once you are in an abducted position, and your patient is relaxed and cooperative, then you have a case where the head is wedged under the glenoid rim. Attempted movements include further abduction, external rotation or anterior/posterior, and you will feel the scapula move as if it is stuck to the head. You are unlikely to be able to coax the head into sliding out and will need to either sedate your patient and see if removal of all muscle spasm is the issue, or try an alternative approach. Moving the humerus into a forward (anterior) elevation position while an assistant keeps the tip of the scapula pushed medially, allows the head to dislodge from the wedged position and either reduce immediately, or move into a freer sub-glenoid position where you can re-attempt a zero position. The other option is formally moving your patient into a prone position and performing scapula manipulation. The take home message is that if you are stuck – stop, reassess why you are stuck, use the additional information you have gained based on your first attempt to be flexible and alter your plan.
Sometimes you have to manage situations in suboptimal environments. I tried my first spartan race this weekend with the team from my local gym @fitnesskickflemington and one of my team mates Jason popped his shoulder out mid race and somehow kept going to the finish. I often talk about how it is not important where you stand as an operator or whether the patient is sitting, lying, prone, or hanging from their feet as long as you know where the scapula is compared to the humeral head. In this case, Jason had a medal round his neck and a victory beer in one hand, so I reduced his shoulder standing in the field, flanked by men in capes.