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Prospective evaluation of the scapular manipulation technique in reducing anterior shoulder dislocations
ORIGINAL CONTRIBUTION
anterior shoulder, dislocation scapular manipulation technique
Prospective Evaluation of the Scapular Manipulation Technique in Reducing Anterior Shoulder Dislocations From the Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Rashmikant U Kothari, MD Steven C Dronen, MD
Receivedfor publication February 7, 1992. Revision received May 18, 1992. Accepted for publication June 1, 1992.
Study objective: To evaluate the speed, efficacy, and safety of the scapular manipulation technique in reducing acute anterior shoulder dislocations. Design: Prospective study. S e t t i n g : Urban emergency department with an annual census of 65,000 patients.
Participants: Forty-eight adult patients with acute anterior shoulder dislocation. Interventions: Patients had an initial neurovascular and radiographic evaluation performed. They were sedated with IV fentanyl and midazolam. The shoulder was reduced using the scapular manipulation technique. The patient was re-evaluated for any evidence of complication. The total dose of analgesic required and time to reduction were recorded. Results: The scapular manipulation technique was successful in 46 of 48 (96%) cases. The average time to reduction was 6.05 minutes, and no complications were detected. Average doses of 1.83 mg midazolam and 204 pg fentanyl were required for reduction. Conclusion: The scapular manipulation technique is a very fast, effective, safe method of reducing anterior shoulder dislocations in the ED. [Kothari RU, Dronen SO: Prospective evaluation of the scapular manipulation technique in reducing anterior shoulder dislocations. Ann Emerg Mefl November 1992;21:1349-1352.]
NOVEMBER1992 21:11 ANNALS OF EMERGENCY MEDICINE
1349/65
SCAPULAR MANIPULATION Kothari & Dronen
We prospectively evaluated consecutive patients presenting to the University of Cincinnati ED between November 1988 and March 1990 in whom a diagnosis of anterior shoulder dislocation was made. The study was a p p r o v e d by the University of Cincinnati Institutional Review Board. Patients older than 17 years without evidence of associated fracture who were able to give informed consent were eligible for inclusion into the study. Patients were excluded if they had a humeral shaft fracture or other significant associated injuries, if they had a contraindication to the use of fentanyl or midazolam, or if the dislocation occurred more than 24 hours before ED presentation. One of the investigators or
other members of the ED staff who were familiar with the protocol were present in every case to supervise or perform the procedure. After clinical and radiographic determination of an anterior shoulder dislocation, the study was explained to the patient, and informed consent was obtained. An IV line was established, an initial dose of analgesic (fentanyl 1 to 2 ~Lg/kg, midazolam 0.01 to 0.02 mg/kg) was given, and the patient was placed in the prone position with the affected arm hanging vertically over the edge of the stretcher (Figure 1). From 5 to 10 lb of orthopedic weights were hung from the wrist using a p r e f a b r i c a t e d Velcro ® wrist splint (De Puy, Warsaw, Indiana). Immediately thereafter, the reduction was attempted by rotating medially the inferior scapular tip while simultaneously fixing the superior and medial edge with the opposite hand (Figure 2). Patients were given additional fentanyl and midazolam as needed to relieve pain and produce adequate relaxation. After reduction, the patient was placed in a sling and swathe, and the reduction was confirmed radiograplfically. Data collected included patient age and sex, method of dislocation, and history of p r i o r dislocation. An upperextremity neurovascular examination and the presence of radiographic abnormalities (eg, Hill-Sach deformity, B a n k h a r t fracture) were recorded before and after reduction. Reduction time was recorded beginning with the hanging of weights on the arm until there was clinical evidence of reduction, usually a palpable pop. We used the P e a r s o n product-moment correlation with two-tailed probability to determine whether there was a correlation between time to reduction and each of the following: age, time to presentation, and doses of fentanyl and midazolam required. We used the two-tailed Student's t-test to compare mean reduction times with and without a previous history of dislocation. P < .05 was considered significant.
Figure1.
Figure 2.
INTRODUCTION
As many as half of all m a j o r joint dislocations in patients presenting to an emergency d e p a r t m e n t involve the shoulder, and of these, the most common is the anterior dislocation J , 2 Although many reduction techniques have been described, few reports have provided more than anecdotal evidence of the success and safety of the various techniques, and fewer still have evaluated the techniques in a prospective fashion.342 F o r the past several years, we have used the scapular manipulation technique as our p r i m a r y method of reducing anterior dislocation. This technique was described by Bosley and Miles in 1979 and differs from other techniques in that the focus of the reduction is on repositioning the glenoid rather than the humeral head. 13-15 The technique has the theoretical advantages of being relatively atraumatic as well as quick and easy to perform. The purpose of our study was to prospectively evaluate the scapular manipulation technique, considering specifically the success rate, incidence of complications, and time involved. MATERIALS
AND
METHODS
Patient positioning and the use of a Velcro ® volar wrist splint in the scapular manipulation technique
86/1350
Proper hand positioning and direction qf rotation during shoulder relocation using the scapular manipulation technique
ANNALS OF EMERGENCYMEDICINE 21:11 NOVEMBER1992
SCAPULAR M A N I P U L A T I O N Kothari & Dronen
RESULTS
During a 16-nmnth period, 54 dislocation reductions were attempted in our ED. By retrospective chart review, two cases were identified in which no study investigator was notified. Four patients were excluded because the dislocation was more than 24 hours old or they did not wish to be in the study. Forty-one patients were entered into the study. Of the 41 patients, six were treated on two separate occasions and one patient was treated for bilateral dislocations, for a total 0f48 dislocations. The study population ranged in age from 18 to 64 years. Eighty-four percent of the patients were men. Dislocations associated with a fall or other traumatic event were slightly more common than were atraumatic dislocations (56% and 42%, respectively). One patient (2%) could not remember how he had i n j u r e d his shoulder. In 58% of cases, there was a history of dislocations. The scapular manipulation technique was successful in 46 of 48 cases (96%). One of the failed cases was reduced by the traction-countertraction technique, and the other was reduced by the external rotation technique. Both required multiple attempts using several different techniques. Mean time to reduction using the scapular manipulation technique was 6.05 minutes. Twenty-five percent of the cases were reduced within one minute, and 95% were reduced within 1l minutes. Time to reduction was not correlated with the patient's age, sex, or time from dislocation to treatment. There was a positive correlation between increased fentanyl dose and prolonged time to reduction (P < .0001, r = .785). Furthermore, there was a trend toward prolongation of reduction time with midazolam use (P < .063, r = .377) or history of dislocation (P < .092). Parenteral analgesics and sedation were used in all except one case. The average dose of midazolam was 1.83 mg (range, 0 to 5.0 rag). The average dose of fentanyl was 204 ~tg (range, 0 to 600 ~g). Detailed post-reduction neurovascular examinations failed to reveal any complications associated with the technique, and no new radiographic abnormalities were noted. Two patients were noted to have decreased sensation in the distribution of the axillary nerve, but both had this deficit before reduction. Routine use of oxygen and oxygen saturation monitoring was initiated in the last half of the study. No patients had oxygen desaturation.
procedure. Both studies demonstrated a high success rate that compares favorably with rates reported for other commonly performed techniques. Although the Kocher and traction-countertraction techniques have been reported to have similar success rates, both have been associated with brachial plexus, vascular, and bony injuries. 16-2l In contrast, there have been no complications reported in association with the scapular manipulation technique. The absence of complications probably is due to the atraumatic nature of the reduction and its focus on glenoid rather than humeral head repositioning. It does not require the brute strength for which some techniques are noted and, in fact, can be accomplished with a minimum of exertion, even in muscular patients. This study also documents the rapidity with which reduction may be accomplished using the scapular manipulation technique. The Stimson technique is noted for its ease and safety, b u t it often requires 20 to 30 minutes to perform. 12 This clearly is a disadvantage when dealing with a sedated patient in a busy ED. Although authors have claimed that the H e n n e p i n technique (external rotation) is f a s t , 22 n o study has examined the average time to reduction. Mirick et al stated that rotation in the external rotation technique occurs during a five- to ten-minute period. 9 Similarly, the Milch technique (external rotation and abduction) has been reported to induce reduction within ten minutes. However, in the only study that recorded reduction times, it took an average of 20 minutes using a variation of the Milch technique. 23 Thus, the scapular m a n i p u l a t i o n technique appears to be at least as fast as the H e n n e p i n technique and p r o b a b l y is faster than the Milch technique. F u r t h e r m o r e , it has the additional advantage of having a higher reported success rate than either of these techniques. One major limitation of this study is that we did not directly compare the scapular manipulation technique with other techniques. It is difficult to compare techniques from different studies when the exact methods and types and doses of analgesics are not known. In the majority of previous studies, the type of analgesics was not controlled for. In addition, if only one analgesic or sedative was being used, the dose often was not recorded. Direct comparison could be accomplished in the future with a prospective, randomized trial comparing different techniques.
DISCUSSION
CONCLUSION
Results of this study confirm previous results reported by Anderson et a] showing that the scapular manipulation technique is a rapid, safe, and effective method for reducing anterior shoulder dislocations. 15 This study differs from that of Anderson et al in that the procedure was performed exclusively by emergency physicians rather than by orthopedic surgeons. We also were more lik6ly to provide patients with parenteral analgesics before performance of this painful
Many techniques have been described for reduction of anterior shoulder dislocations, but there is little documentation of the speed, efficacy, o r safety of these techniques. In this study, we found the scapular manipulation technique to be effective in 96% of cases, with an average reduction time of six minutes and no complications. We therefore conclude that this technique is a safe, fast, and effective method of reduction, and we strongly recommend its use in the ED.
NOVEMBER 1992 21:11 ANNALS OF EMERGENCYMEDEINE
1351/67
SCAPULAR MANIPULATION Kothari & Dronen
REFERENCES 1. Kazar B, Relovszky E: Prognosis of primary dislocation of the shoulder. Acta Orthop Scand 1969;40:216-224. 2. Koenijsknect ST: The shoulder and upper arm, in Simon RR (ed): Emergency Medicine. New York, Appleton-Century Crofts, 1982. 3. Manes HR: A new method of shoulder reduction in the elderly. Clin Orthep Rel Res 1980;147:200-202.
Address for reprints: Rashmikant U Kethari, MD Department of Emergency Medicine University Hospital 234 Goodman Street Cincinnati, Ohio 45267-0769
4. Russell JA, Holmes EM, Keller DJ, et al: Reduction of acute anterior shoulder dislocations using the Milch technique: A study of ski injuries. J Trauma 1981;21:802604. 5. Leidelmeyer R: Reduced! A shoulder, subtly and painlessly. Emerg Med 1977;9:233234. 6. Shackelford HL; Hydraulic stretcher reduction technique for anterior dislocation of the shoulder. W Va Meal J1982;78:9. 7. Lippert FG: A modification of the gravity method of reducing anterior shoulder dislocations. Clin Orthop Rel Res 1982;165:259-260. 8. Rollinson PD: Reduction of shoulder dislocations by the hanging method. South Afr Med J 1988;73:106-108. 9. Mirick M J, Clinton JE, Ruiz E: External rotation method of shoulder dislocation reduction. JACEP 1979;8:528-531. 10. Poulsen SR: Reduction of acute shoulder dislocations using the Eskimo technique: A study of 23 consecutive cases. J Trauma 1988;28:1382-1383. 11. Lacey T, Crawford HB: Reduction of anterior dislocations of the shoulder by means of the Milch abduction technique. J Bone Joint Surg 1952;34A:108-109. 12. Stimson LA: An easy method of reducing dislocations of the shoulder and hip. Med Record 1900;57:356. 13. Bosley R, Miles J: Scapular manipulation for reduction of anterior inferior dislocations. A new procedure. Presented at the American Association of Orthopedic Surgeons, June 1979. 14. Kothari RU, Dronen SC: The scapular manipulation technique for the reduction of acute anterior shoulder dislocations. J Emerg Med 1990;8:625-628. 15. Anderson D, Zvirbulis R, Ciullo J: Scapular manipulation for reduction of anterior shoulder dislocations. Clin Orthop Rel Res 1982;164:181-183. 16. Beattie TF, Steedman BJ, McGowan A, et al: A comparison of the Milch and Kocher techniques for acute anterior dislocation of the shoulder. Injury1986;17:349-352. 17. Curley SA, 0sler T, Demarest GB: Traumatic disruption of the subclavian artery and brachial plexus in a patient with Ehlers-Danlos syndrome. Ann EmergMed;988;17:850-852. 18. Plummet D, Clinton J: The external rotation method for reduction of acute anterior shoulder dislocation. Emerg Med Clin North Am 1989;7:165-175. 19. De Palma A: Surgery of the Shoulder, ed 2. Philadelphia, JB Lippincett, 1973, p 361-377. 20. Conwell HE, Reynolds FC: Key and Conwefl's Management of Fractures, Dislocation, and Sprains. St Louis, CV Mosby, 1961, p 404. 21. Nash J: The status of Kocher's method of reducing recent anterior dislocation of the shoulder. J Bone Joint Surg 1934;16:535-544. 22. Danzl DF, Vicario SJ, 6lois GL, et al: Closed reduction of anterior subcoracoid shoulder dislocation: Evaluation of an external rotation method. Ortho Rev1986;5:311-315. 23. McNair TJ: A elinicaltrial of "hanging arm" reduction of dislocation of the shoulder. J R Coil Surg Edinburgh 1957;3:47-53.
68/1352
ANNALS 0F EMERGENCY MEDICINE
21:11
NOVEMBER1992
anterior shoulder, dislocation scapular manipulation technique
Prospective Evaluation of the Scapular Manipulation Technique in Reducing Anterior Shoulder Dislocations From the Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Rashmikant U Kothari, MD Steven C Dronen, MD
Receivedfor publication February 7, 1992. Revision received May 18, 1992. Accepted for publication June 1, 1992.
Study objective: To evaluate the speed, efficacy, and safety of the scapular manipulation technique in reducing acute anterior shoulder dislocations. Design: Prospective study. S e t t i n g : Urban emergency department with an annual census of 65,000 patients.
Participants: Forty-eight adult patients with acute anterior shoulder dislocation. Interventions: Patients had an initial neurovascular and radiographic evaluation performed. They were sedated with IV fentanyl and midazolam. The shoulder was reduced using the scapular manipulation technique. The patient was re-evaluated for any evidence of complication. The total dose of analgesic required and time to reduction were recorded. Results: The scapular manipulation technique was successful in 46 of 48 (96%) cases. The average time to reduction was 6.05 minutes, and no complications were detected. Average doses of 1.83 mg midazolam and 204 pg fentanyl were required for reduction. Conclusion: The scapular manipulation technique is a very fast, effective, safe method of reducing anterior shoulder dislocations in the ED. [Kothari RU, Dronen SO: Prospective evaluation of the scapular manipulation technique in reducing anterior shoulder dislocations. Ann Emerg Mefl November 1992;21:1349-1352.]
NOVEMBER1992 21:11 ANNALS OF EMERGENCY MEDICINE
1349/65
SCAPULAR MANIPULATION Kothari & Dronen
We prospectively evaluated consecutive patients presenting to the University of Cincinnati ED between November 1988 and March 1990 in whom a diagnosis of anterior shoulder dislocation was made. The study was a p p r o v e d by the University of Cincinnati Institutional Review Board. Patients older than 17 years without evidence of associated fracture who were able to give informed consent were eligible for inclusion into the study. Patients were excluded if they had a humeral shaft fracture or other significant associated injuries, if they had a contraindication to the use of fentanyl or midazolam, or if the dislocation occurred more than 24 hours before ED presentation. One of the investigators or
other members of the ED staff who were familiar with the protocol were present in every case to supervise or perform the procedure. After clinical and radiographic determination of an anterior shoulder dislocation, the study was explained to the patient, and informed consent was obtained. An IV line was established, an initial dose of analgesic (fentanyl 1 to 2 ~Lg/kg, midazolam 0.01 to 0.02 mg/kg) was given, and the patient was placed in the prone position with the affected arm hanging vertically over the edge of the stretcher (Figure 1). From 5 to 10 lb of orthopedic weights were hung from the wrist using a p r e f a b r i c a t e d Velcro ® wrist splint (De Puy, Warsaw, Indiana). Immediately thereafter, the reduction was attempted by rotating medially the inferior scapular tip while simultaneously fixing the superior and medial edge with the opposite hand (Figure 2). Patients were given additional fentanyl and midazolam as needed to relieve pain and produce adequate relaxation. After reduction, the patient was placed in a sling and swathe, and the reduction was confirmed radiograplfically. Data collected included patient age and sex, method of dislocation, and history of p r i o r dislocation. An upperextremity neurovascular examination and the presence of radiographic abnormalities (eg, Hill-Sach deformity, B a n k h a r t fracture) were recorded before and after reduction. Reduction time was recorded beginning with the hanging of weights on the arm until there was clinical evidence of reduction, usually a palpable pop. We used the P e a r s o n product-moment correlation with two-tailed probability to determine whether there was a correlation between time to reduction and each of the following: age, time to presentation, and doses of fentanyl and midazolam required. We used the two-tailed Student's t-test to compare mean reduction times with and without a previous history of dislocation. P < .05 was considered significant.
Figure1.
Figure 2.
INTRODUCTION
As many as half of all m a j o r joint dislocations in patients presenting to an emergency d e p a r t m e n t involve the shoulder, and of these, the most common is the anterior dislocation J , 2 Although many reduction techniques have been described, few reports have provided more than anecdotal evidence of the success and safety of the various techniques, and fewer still have evaluated the techniques in a prospective fashion.342 F o r the past several years, we have used the scapular manipulation technique as our p r i m a r y method of reducing anterior dislocation. This technique was described by Bosley and Miles in 1979 and differs from other techniques in that the focus of the reduction is on repositioning the glenoid rather than the humeral head. 13-15 The technique has the theoretical advantages of being relatively atraumatic as well as quick and easy to perform. The purpose of our study was to prospectively evaluate the scapular manipulation technique, considering specifically the success rate, incidence of complications, and time involved. MATERIALS
AND
METHODS
Patient positioning and the use of a Velcro ® volar wrist splint in the scapular manipulation technique
86/1350
Proper hand positioning and direction qf rotation during shoulder relocation using the scapular manipulation technique
ANNALS OF EMERGENCYMEDICINE 21:11 NOVEMBER1992
SCAPULAR M A N I P U L A T I O N Kothari & Dronen
RESULTS
During a 16-nmnth period, 54 dislocation reductions were attempted in our ED. By retrospective chart review, two cases were identified in which no study investigator was notified. Four patients were excluded because the dislocation was more than 24 hours old or they did not wish to be in the study. Forty-one patients were entered into the study. Of the 41 patients, six were treated on two separate occasions and one patient was treated for bilateral dislocations, for a total 0f48 dislocations. The study population ranged in age from 18 to 64 years. Eighty-four percent of the patients were men. Dislocations associated with a fall or other traumatic event were slightly more common than were atraumatic dislocations (56% and 42%, respectively). One patient (2%) could not remember how he had i n j u r e d his shoulder. In 58% of cases, there was a history of dislocations. The scapular manipulation technique was successful in 46 of 48 cases (96%). One of the failed cases was reduced by the traction-countertraction technique, and the other was reduced by the external rotation technique. Both required multiple attempts using several different techniques. Mean time to reduction using the scapular manipulation technique was 6.05 minutes. Twenty-five percent of the cases were reduced within one minute, and 95% were reduced within 1l minutes. Time to reduction was not correlated with the patient's age, sex, or time from dislocation to treatment. There was a positive correlation between increased fentanyl dose and prolonged time to reduction (P < .0001, r = .785). Furthermore, there was a trend toward prolongation of reduction time with midazolam use (P < .063, r = .377) or history of dislocation (P < .092). Parenteral analgesics and sedation were used in all except one case. The average dose of midazolam was 1.83 mg (range, 0 to 5.0 rag). The average dose of fentanyl was 204 ~tg (range, 0 to 600 ~g). Detailed post-reduction neurovascular examinations failed to reveal any complications associated with the technique, and no new radiographic abnormalities were noted. Two patients were noted to have decreased sensation in the distribution of the axillary nerve, but both had this deficit before reduction. Routine use of oxygen and oxygen saturation monitoring was initiated in the last half of the study. No patients had oxygen desaturation.
procedure. Both studies demonstrated a high success rate that compares favorably with rates reported for other commonly performed techniques. Although the Kocher and traction-countertraction techniques have been reported to have similar success rates, both have been associated with brachial plexus, vascular, and bony injuries. 16-2l In contrast, there have been no complications reported in association with the scapular manipulation technique. The absence of complications probably is due to the atraumatic nature of the reduction and its focus on glenoid rather than humeral head repositioning. It does not require the brute strength for which some techniques are noted and, in fact, can be accomplished with a minimum of exertion, even in muscular patients. This study also documents the rapidity with which reduction may be accomplished using the scapular manipulation technique. The Stimson technique is noted for its ease and safety, b u t it often requires 20 to 30 minutes to perform. 12 This clearly is a disadvantage when dealing with a sedated patient in a busy ED. Although authors have claimed that the H e n n e p i n technique (external rotation) is f a s t , 22 n o study has examined the average time to reduction. Mirick et al stated that rotation in the external rotation technique occurs during a five- to ten-minute period. 9 Similarly, the Milch technique (external rotation and abduction) has been reported to induce reduction within ten minutes. However, in the only study that recorded reduction times, it took an average of 20 minutes using a variation of the Milch technique. 23 Thus, the scapular m a n i p u l a t i o n technique appears to be at least as fast as the H e n n e p i n technique and p r o b a b l y is faster than the Milch technique. F u r t h e r m o r e , it has the additional advantage of having a higher reported success rate than either of these techniques. One major limitation of this study is that we did not directly compare the scapular manipulation technique with other techniques. It is difficult to compare techniques from different studies when the exact methods and types and doses of analgesics are not known. In the majority of previous studies, the type of analgesics was not controlled for. In addition, if only one analgesic or sedative was being used, the dose often was not recorded. Direct comparison could be accomplished in the future with a prospective, randomized trial comparing different techniques.
DISCUSSION
CONCLUSION
Results of this study confirm previous results reported by Anderson et a] showing that the scapular manipulation technique is a rapid, safe, and effective method for reducing anterior shoulder dislocations. 15 This study differs from that of Anderson et al in that the procedure was performed exclusively by emergency physicians rather than by orthopedic surgeons. We also were more lik6ly to provide patients with parenteral analgesics before performance of this painful
Many techniques have been described for reduction of anterior shoulder dislocations, but there is little documentation of the speed, efficacy, o r safety of these techniques. In this study, we found the scapular manipulation technique to be effective in 96% of cases, with an average reduction time of six minutes and no complications. We therefore conclude that this technique is a safe, fast, and effective method of reduction, and we strongly recommend its use in the ED.
NOVEMBER 1992 21:11 ANNALS OF EMERGENCYMEDEINE
1351/67
SCAPULAR MANIPULATION Kothari & Dronen
REFERENCES 1. Kazar B, Relovszky E: Prognosis of primary dislocation of the shoulder. Acta Orthop Scand 1969;40:216-224. 2. Koenijsknect ST: The shoulder and upper arm, in Simon RR (ed): Emergency Medicine. New York, Appleton-Century Crofts, 1982. 3. Manes HR: A new method of shoulder reduction in the elderly. Clin Orthep Rel Res 1980;147:200-202.
Address for reprints: Rashmikant U Kethari, MD Department of Emergency Medicine University Hospital 234 Goodman Street Cincinnati, Ohio 45267-0769
4. Russell JA, Holmes EM, Keller DJ, et al: Reduction of acute anterior shoulder dislocations using the Milch technique: A study of ski injuries. J Trauma 1981;21:802604. 5. Leidelmeyer R: Reduced! A shoulder, subtly and painlessly. Emerg Med 1977;9:233234. 6. Shackelford HL; Hydraulic stretcher reduction technique for anterior dislocation of the shoulder. W Va Meal J1982;78:9. 7. Lippert FG: A modification of the gravity method of reducing anterior shoulder dislocations. Clin Orthop Rel Res 1982;165:259-260. 8. Rollinson PD: Reduction of shoulder dislocations by the hanging method. South Afr Med J 1988;73:106-108. 9. Mirick M J, Clinton JE, Ruiz E: External rotation method of shoulder dislocation reduction. JACEP 1979;8:528-531. 10. Poulsen SR: Reduction of acute shoulder dislocations using the Eskimo technique: A study of 23 consecutive cases. J Trauma 1988;28:1382-1383. 11. Lacey T, Crawford HB: Reduction of anterior dislocations of the shoulder by means of the Milch abduction technique. J Bone Joint Surg 1952;34A:108-109. 12. Stimson LA: An easy method of reducing dislocations of the shoulder and hip. Med Record 1900;57:356. 13. Bosley R, Miles J: Scapular manipulation for reduction of anterior inferior dislocations. A new procedure. Presented at the American Association of Orthopedic Surgeons, June 1979. 14. Kothari RU, Dronen SC: The scapular manipulation technique for the reduction of acute anterior shoulder dislocations. J Emerg Med 1990;8:625-628. 15. Anderson D, Zvirbulis R, Ciullo J: Scapular manipulation for reduction of anterior shoulder dislocations. Clin Orthop Rel Res 1982;164:181-183. 16. Beattie TF, Steedman BJ, McGowan A, et al: A comparison of the Milch and Kocher techniques for acute anterior dislocation of the shoulder. Injury1986;17:349-352. 17. Curley SA, 0sler T, Demarest GB: Traumatic disruption of the subclavian artery and brachial plexus in a patient with Ehlers-Danlos syndrome. Ann EmergMed;988;17:850-852. 18. Plummet D, Clinton J: The external rotation method for reduction of acute anterior shoulder dislocation. Emerg Med Clin North Am 1989;7:165-175. 19. De Palma A: Surgery of the Shoulder, ed 2. Philadelphia, JB Lippincett, 1973, p 361-377. 20. Conwell HE, Reynolds FC: Key and Conwefl's Management of Fractures, Dislocation, and Sprains. St Louis, CV Mosby, 1961, p 404. 21. Nash J: The status of Kocher's method of reducing recent anterior dislocation of the shoulder. J Bone Joint Surg 1934;16:535-544. 22. Danzl DF, Vicario SJ, 6lois GL, et al: Closed reduction of anterior subcoracoid shoulder dislocation: Evaluation of an external rotation method. Ortho Rev1986;5:311-315. 23. McNair TJ: A elinicaltrial of "hanging arm" reduction of dislocation of the shoulder. J R Coil Surg Edinburgh 1957;3:47-53.
68/1352
ANNALS 0F EMERGENCY MEDICINE
21:11
NOVEMBER1992