Scapular Manipulation

---

The beauty of this technique is that, where most other techniques use some form of manipulation of the humeral shaft to move the head around the glenoid rim, this one moves the glenoid rim around a fixed humeral head. This technique was first unveiled by Bosley and Miles in 1979 with the patient prone with weights giving traction (Stimson technique plus scapular manipulation), but this may be impossible with elderly, obese or distressed patients. Two operators and a seated patient, or with the patient supine are alternatives. 

It can be useful if you have a fragmented greater tuberosity, with a fragment that causes pain or an anatomical obstruction to the returning humeral head when in a zero position. The scapular manipulation position of reduction can keep those fragments lateral, and out of the way of your reduction. Again, the position of the scapula in relation to the humeral head is the key. 

There is a big difference between steady maintained traction and repetitive yanking which will just cause pain, spasm and failure of your relocation attempt.

For a close look at the anatomy during scapular manipulation click on the video link below.

This technique fixes the humeral head in position and then rotates the scapula around the head into position.

How does it overcome the static and dynamic forces?

Constant traction is applied to the externally rotated humerus, this takes humeral head pressure off the glenoid rim (which is sitting above and lateral to the dislocated head). The inferior tip of the scapula is then rotated bringing the whole scapula in a posterior direction (backwards), this brings the scapular neck and glenoid fossa back into position behind the head. 

The starting point for this is with the arm in 90°of forward flexion and externally rotated to neutral (providing the largest surface area of humeral head articular cartilage to the glenoid rim). (‘scapula manipulation front view close up’ and ‘scapula manipulation starting position front view’ pic) 

Steady traction (5 -15 lbs) on the forearm is maintained until your patient relaxes.

Rest on the clavicle to steady the arm, and yourself.

After the patient begins to relax, rotate the scapula.

Push the inferior tip medially.

Push the superior scapula laterally.