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traction and slowly (in about 10-15 minutes) return the shoulder to its normal configuration.
3) “Dirty Sock” or “Water Ski” Technique: Instruct the patient to lie flat on the ground. Sit down beside
the patient on the affected side with your hip touching the patient’s hip. Place your sock covered
foot in the patient’s axilla, grasp the patient’s wrist with both hands, and slowly lean back as if
rowing or water skiing. Maintain slow, steady traction along an axis directly parallel to the patient’s
leg. (Do not pull laterally. Remember that the anterior shoulder dislocation is anterior and inferior).
The firm, steady traction with your foot in the axilla providing counter traction will gradually
overcome the shoulder muscle spasm and the arm will often “clunk” into the socket after several
minutes.
4) Successful reductions will be recognized by marked pain relief, an audible “clunk”, restoration of
normal anatomic appearance of the shoulder, and return of more normal range of motion. Verify
reduction by having the patient touch the opposite shoulder with his hand.
- Post Treatment: Post reduction x-rays
- Patient education:
General: Avoid the motion that contributed to the injury. Consider use of sling +/- swath to restrict
abduction and external rotation. Refer to ortho if possible. Prevention: The recurrence rates for anterior
shoulder dislocations vary markedly with age: < 20 yo = > 80 % recurrence rate; > 40 yo = < 25 % rate;
higher if very active. If young (<35) and active in sports, etc. consider orthopedic consultation ASAP
for acute arthroscopic stabilization to alter the natural history. Instruct in self-reduction technique
described above.
Activity: Restore motion and strength/endurance with physical therapy
Diet: No limitations
Medications: Control pain and inflammation with NSAIDs on regular basis (ibuprofen 800 mg tid x
7 days or diclofenac sodium 150 mg AM and hs x 7 days) - Follow-up actions
Consultation criteria: Failure to reduce the shoulder is a requirement for reduction under anesthesia and
possible surgical stabilization.
Elbow Dislocation:
- Assessment: Examine the affected and confirm the distal sensory, motor, and circulatory status. Repeat
these evaluations post reduction. - Differential Diagnosis: Elbow fractures; combined fracture/dislocation; muscular contusion; ulnar nerve
injury. - Diagnostic Tests: AP and Lateral X-rays if available to confirm dislocation and rule out fracture.
- Procedure:
a. Reduction of a dislocated elbow is straightforward. A local injection of 10 cc of 1% lidocaine w/o epi
in the posterior prominence from the lateral side can be helpful if the reduction has been delayed.
Premedication with an opiate or benzodiazepine may be desirable.
b. Apply longitudinal traction with the patient in the prone position.
c. Position the patient so that an assistant can grasp the upper arm or torso and apply countertraction.
Grasp the forearm at the wrist and apply anterior traction along the axis of the forearm with the
elbow slightly flexed and the forearm at the original degree of pronation or supination and attempt to
move the forearm anteriorly, relative to the humerus, to its proper position. In the case of an anterior
dislocation, move the humerus anterior relative to the forearm.
d. If the reduction is not complete after three vigorous attempts, or if there is evidence of nerve or
vascular injury, splint the arm for comfort and evacuate ASAP.
e. Successful reductions may be recognized by marked pain relief, an audible “clunk”, restoration of
normal anatomic appearance and some mobility in the joint - Post Treatment:
a. Insure integrity of sensory, motor, and circulatory structures. Damage to the median, ulnar, and radial
nerves has been reported, and entrapment of the median nerve following the reduction of a dislocated
elbow has also been reported. Most injuries occur to the ulnar nerve, which sustains a valgus stretch
during dislocation.
b. Apply a posterior splint with the elbow in 90º of flexion and the forearm in the neutral position.