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Use of the Scapular Manipulation Method to Reduce an Anterior Shoulder Dislocation in the Supine Position
CASE REPORT
U s e of the Scapular Manipulation Method to Reduce an Anterior Shoulder Dislocation in the Supine Position From the Department of Emergency Medicine, ProvidenceYakima Medical Center, Yahima, Washington. Receivedfor p~blication July 11, 1995. Acceptedfor publicationJuly 25, 1995. Copyright © by the American College of Emergency Physicians.
William L Doyle, MD Todd Ragar, MD
We report the successful use of the scapular manipulation method to reduce an anterior shoulder dislocation in a multiply traumatized patient in the supine position. We discuss the treatment options for multiply traumatized patients with anterior shoulder dislocations in whom cervical spine injury is a possibility. Although larger patient studies are necessary for confirmation, we show that in this particular case the scapular manipulation technique was safely employed. To our knowledge, this is the first reported case of use of the scapular manipulation method with the patient in the supine position, [Doyle WL, Ragar T: Use of the scapular manipulation method to reduce an anterior shoulder dislocation in the supine position. Ann EmergMealJanuary1996;27:92-94.] INTRODUCTION Anterior shoulder dislocations are commonly seen after blunt trauma and are the most common of all dislocations seen in American emergency departments. 1 Several methods exist for reducing anterior shoulder dislocations. Some methods require that the patient lie supine (the tractioncountertraction technique 2, the Kocher procedure 3, the Hippocratic maneuver 2, external rotation 4, and the MilchCooper methodS); others require the prone or sitting position (scapular manipulation 6, the Stimson technique7). We report the successful reduction of an anterior shoulder dislocation in a multiply traumatized patient using the scapular manipulation method while the patient was in the supine position. We discuss the treatment options available to the emergency physician confronted with such a patient and show that scapular manipulation may be considered for use in the supine position.
CASE REPORT A 30-year-old man was transported to our ED by paramedics after he was struck by a small truck when he ran into the street to rescue his cat. He was thrown into a group of
92
ANNALS OF EMERGENCY MEDICINE
27:1
JANUARY 1996
SCAPULAR MANIPULATION
Doyle & Ragar
bushes at the roadside, where he was found by paramedic personnel. On presentation to the ED, the patient complained of severe pain in his right shoulder and in his left lower abdomen. He denied any loss of consciousness but admitted to confusion at the scene of the accident. He reported a history of recurrent right shoulder dislocation as a youth; dislocation had not recurred after surgery to correct this problem 5 years previously. His initial vital signs were blood pressure, 128/80 mm Hg; pulse, 78; respirations, 22; and temperature, 36.5°C. The patient was on a backboard because of possible cervical spine injury. He was alert and oriented to person, place, and time. Examination of the head revealed several large flap lacerations of the frontal scalp and was otherwise unremarkable. His neck showed no tracheal deviation or palpable abnormalities. His chest and cardiac examinations were unremarkabte. His abdomen showed moderate to severe left lower quadrant tenderness on palpation without rebound. Bowel sounds were mildly diminished. Examination of the extremities showed a well-healed surgical scar over the anterior aspect of the right shoulder along with an obvious palpable defect consistent with an anterior shoulder dislocation. Axillary, median, radial, and ulnar nerve function were intact in the right upper extremity, and there were no appreciable vascular abnormalities. His neurologic examination was normal. The patient continued to complain and at times yell about the pain in his right shoulder. He was given ketorolac, 30 mg intravenously, but showed only mild improvement in his discomfort. Cross-table lateral radiography of the cervical spine was performed and showed normal anatomy down to C5 but was obscured below this level by the patient's shoulder. An anteroposterior view of his right shoulder showed a presumed anterior dislocation at the glenohumeral joint. Radiographs of the chest and pelvis were unremarkable. Because persistent patient discomfort was slowing our evaluation and prohibiting our obtaining adequate cervical radiographs, a decision was made to reduce his shoulder dislocation at this time. We did not want to use any narcotics or benzodiazepines if it could be avoided, so as not to depress the patient's respiratory status or confuse the ongoing monitoring of his mental status and abdominal examinations. Several attempts to reduce the dislocation using the external rotation technique 4 were unsuccessful. The Milch-Cooper technique 5 was precluded by the fact that the patient began to shift uncomfortably when we attempted abduction of the shoulder, possibly placing the
JANUARY 1996 2 7 : 1 ANNALS OF EMERGENCY MEDICINE
cervical spine at risk. Believing that the traction-countertraction 2, Kocher 3, and Hippocratic; methods were inappropriate in this situation, we elected to attempt the scapular manipulation method.6
Figure. The technique for the use of the scapular manipulation method in the supine position involves placing the involved extremity in adduction and 90-degree flexion at both the shoulder and elbow with steady, gentle upward traction while the inferior tip of the scapula is gently manipulated with a force directed mediaIly. An assistant on the opposite side of the patient ensures that the patient does not move.
93
SCAPULAR MANIPULATION
Doyle & Ragar
The right arm was brought into adduction and 90 degrees flexion at the shoulder, with the elbow also at 90 degrees flexion (Figure 1). Gentle upward traction was maintained by an assistant without lifting the patient from his position. Gentle, steady pressure was applied to the inferior tip of the scapula and was directed medially while another assistant made sure that the patient did not shift from his location on the backboard. Successful reduction was accomplished within 2 minutes, and the patient experienced immediate relief. A postreduction film confirmed return to normal anatomic position with no evidence of acute fractures. The remainder of this patient's evaluation continued without complications and ultimately revealed an abdominal wall hematoma, as seen by abdominal computed tomography, as his only other significant injuu. The patient's right arm was placed in a shoulder immobilizer, and his recovery was monitored by an orthopedic physician, who noted no significant complications 8 weeks after this incident. DISCUSSION
Anterior shoulder dislocation is the most commonly seen dislocation in emergency medicine, x Several techniques have been developed to reduce such injuries and have been extensively reported. 2-r The scapular manipulation method has been shown to be both efficacious and relatively painless <8, and it often can be performed without the use of sedation or analgesia, s Our patient had to remain supine because of the possibility of an undetected cervical spine injury. Previous techniques shown to be effective in the supine position include external rotation 4, the MilchCooper method 5, the Kocher procedure 3, traction-countertraction 2, and the Hippocratic method} We have found no previous reports of the use of scapular manipulation in the supine position. We believed that traction-countertraction, the Kocher procedure, and the Hippocratic method were either too dangerous or placed the cervical spine at too great a risk to be used in this situation. External rotation and the MilchCooper method were tried unsuccessfully. We desired to avoid the use of drugs that could alter either the respiratory or mental status of this patient with concurrent injuries involving the head and abdomen. Because scapular manipulation has been previously employed without the use of pharmacologic adjuncts s, we believed that it was a viable option in this situation. The presence of a backboard was probably helpful because it left enough room between the patient's back
94
and the examination bed to allow manipulation of the tip of the scapula. The absence of a backboard may have precluded scapular manipulation as a possibility in this situation. We employed slight upward traction on the involved extremity (Figure), but not enough to move the patient's body. We also employed an assistant on the opposite side of the patient to ensure that the patient was not moved. The reduction occurred rather easily once proper positioning of the extremity and the assistants was obtained. One potential criticism is that an entire radiographic shoulder series was not taken before the diagnosis of anterior shoulder dislocation was made; only an anteroposterior view of the shoulder was obtained. Further views were made difficult to obtain because the patient could not be moved and was unable to move his extremity. However, dislocation was easily diagnosed on the anteroposterior view, making the diagnosis of posterior shoulder dislocation unlikely. This is probably the first reported incident of the use of the scapular manipulation in the supine position. Although we believe that the external rotation and Milch-Cooper methods are still preferable, this case shows that the scapular manipulation method can be used both safely and effectively with the patient in the supine position if necessary. Larger studies are needed to definitively confirm this conclusion. REFERENCES 1. Danzl DF,Vicario SJ, Gleis GL, et al: Closed reduction of anterior subcoracoidshoulder dislocation. OrthopRev1986;15:75~79. 2. RobertsJR, HedgesJR: Clinical proceduresin emergencymedicine, ed 2.Philadelphia,WB Saundars Co, 1991, p 763-770. 3. DePalmaAF, FianneryGF:Acuteanteriordislocationof the shoulder.Am J SportsMsd 1973;1:6-15. 4. Mirick MJ, Clinton JE, Ruiz E, et ah Externalrotation method of shoulderdislocation reduction. JACEP1979;8:528-531. 5. Milch H: Treatmentof dislocation of the shoulder, Surgery1938;3:732. 8. Kothari RU, DrenenSO: Prospectiveevaluation of the scapular manipulation technique in reducing anterior shoulder dislocations.Ann EmergMad 1992;21:1349-1352. 7. Riebel GD, McCabeJB: Anterior shoulder dislocation: A review of reductiontechniques. J EmergMad 1991;9:1808. 8. McNamara RM: Reductionof anterior shoulder dislocations by scapularmanipulation. Ann EmergMad 1993;22:1140-1144.
Reprint no, 47/1/69557 Address for reprints: William L Doyle,MD ProvidenceYakimaMedicalCenter 110 SouthNinthAvenue Yakima,Washington98902 509-575-5060
ANNALS OF EMERGENCY MEDICINE
27:1 ,JANUARY 1996
U s e of the Scapular Manipulation Method to Reduce an Anterior Shoulder Dislocation in the Supine Position From the Department of Emergency Medicine, ProvidenceYakima Medical Center, Yahima, Washington. Receivedfor p~blication July 11, 1995. Acceptedfor publicationJuly 25, 1995. Copyright © by the American College of Emergency Physicians.
William L Doyle, MD Todd Ragar, MD
We report the successful use of the scapular manipulation method to reduce an anterior shoulder dislocation in a multiply traumatized patient in the supine position. We discuss the treatment options for multiply traumatized patients with anterior shoulder dislocations in whom cervical spine injury is a possibility. Although larger patient studies are necessary for confirmation, we show that in this particular case the scapular manipulation technique was safely employed. To our knowledge, this is the first reported case of use of the scapular manipulation method with the patient in the supine position, [Doyle WL, Ragar T: Use of the scapular manipulation method to reduce an anterior shoulder dislocation in the supine position. Ann EmergMealJanuary1996;27:92-94.] INTRODUCTION Anterior shoulder dislocations are commonly seen after blunt trauma and are the most common of all dislocations seen in American emergency departments. 1 Several methods exist for reducing anterior shoulder dislocations. Some methods require that the patient lie supine (the tractioncountertraction technique 2, the Kocher procedure 3, the Hippocratic maneuver 2, external rotation 4, and the MilchCooper methodS); others require the prone or sitting position (scapular manipulation 6, the Stimson technique7). We report the successful reduction of an anterior shoulder dislocation in a multiply traumatized patient using the scapular manipulation method while the patient was in the supine position. We discuss the treatment options available to the emergency physician confronted with such a patient and show that scapular manipulation may be considered for use in the supine position.
CASE REPORT A 30-year-old man was transported to our ED by paramedics after he was struck by a small truck when he ran into the street to rescue his cat. He was thrown into a group of
92
ANNALS OF EMERGENCY MEDICINE
27:1
JANUARY 1996
SCAPULAR MANIPULATION
Doyle & Ragar
bushes at the roadside, where he was found by paramedic personnel. On presentation to the ED, the patient complained of severe pain in his right shoulder and in his left lower abdomen. He denied any loss of consciousness but admitted to confusion at the scene of the accident. He reported a history of recurrent right shoulder dislocation as a youth; dislocation had not recurred after surgery to correct this problem 5 years previously. His initial vital signs were blood pressure, 128/80 mm Hg; pulse, 78; respirations, 22; and temperature, 36.5°C. The patient was on a backboard because of possible cervical spine injury. He was alert and oriented to person, place, and time. Examination of the head revealed several large flap lacerations of the frontal scalp and was otherwise unremarkable. His neck showed no tracheal deviation or palpable abnormalities. His chest and cardiac examinations were unremarkabte. His abdomen showed moderate to severe left lower quadrant tenderness on palpation without rebound. Bowel sounds were mildly diminished. Examination of the extremities showed a well-healed surgical scar over the anterior aspect of the right shoulder along with an obvious palpable defect consistent with an anterior shoulder dislocation. Axillary, median, radial, and ulnar nerve function were intact in the right upper extremity, and there were no appreciable vascular abnormalities. His neurologic examination was normal. The patient continued to complain and at times yell about the pain in his right shoulder. He was given ketorolac, 30 mg intravenously, but showed only mild improvement in his discomfort. Cross-table lateral radiography of the cervical spine was performed and showed normal anatomy down to C5 but was obscured below this level by the patient's shoulder. An anteroposterior view of his right shoulder showed a presumed anterior dislocation at the glenohumeral joint. Radiographs of the chest and pelvis were unremarkable. Because persistent patient discomfort was slowing our evaluation and prohibiting our obtaining adequate cervical radiographs, a decision was made to reduce his shoulder dislocation at this time. We did not want to use any narcotics or benzodiazepines if it could be avoided, so as not to depress the patient's respiratory status or confuse the ongoing monitoring of his mental status and abdominal examinations. Several attempts to reduce the dislocation using the external rotation technique 4 were unsuccessful. The Milch-Cooper technique 5 was precluded by the fact that the patient began to shift uncomfortably when we attempted abduction of the shoulder, possibly placing the
JANUARY 1996 2 7 : 1 ANNALS OF EMERGENCY MEDICINE
cervical spine at risk. Believing that the traction-countertraction 2, Kocher 3, and Hippocratic; methods were inappropriate in this situation, we elected to attempt the scapular manipulation method.6
Figure. The technique for the use of the scapular manipulation method in the supine position involves placing the involved extremity in adduction and 90-degree flexion at both the shoulder and elbow with steady, gentle upward traction while the inferior tip of the scapula is gently manipulated with a force directed mediaIly. An assistant on the opposite side of the patient ensures that the patient does not move.
93
SCAPULAR MANIPULATION
Doyle & Ragar
The right arm was brought into adduction and 90 degrees flexion at the shoulder, with the elbow also at 90 degrees flexion (Figure 1). Gentle upward traction was maintained by an assistant without lifting the patient from his position. Gentle, steady pressure was applied to the inferior tip of the scapula and was directed medially while another assistant made sure that the patient did not shift from his location on the backboard. Successful reduction was accomplished within 2 minutes, and the patient experienced immediate relief. A postreduction film confirmed return to normal anatomic position with no evidence of acute fractures. The remainder of this patient's evaluation continued without complications and ultimately revealed an abdominal wall hematoma, as seen by abdominal computed tomography, as his only other significant injuu. The patient's right arm was placed in a shoulder immobilizer, and his recovery was monitored by an orthopedic physician, who noted no significant complications 8 weeks after this incident. DISCUSSION
Anterior shoulder dislocation is the most commonly seen dislocation in emergency medicine, x Several techniques have been developed to reduce such injuries and have been extensively reported. 2-r The scapular manipulation method has been shown to be both efficacious and relatively painless <8, and it often can be performed without the use of sedation or analgesia, s Our patient had to remain supine because of the possibility of an undetected cervical spine injury. Previous techniques shown to be effective in the supine position include external rotation 4, the MilchCooper method 5, the Kocher procedure 3, traction-countertraction 2, and the Hippocratic method} We have found no previous reports of the use of scapular manipulation in the supine position. We believed that traction-countertraction, the Kocher procedure, and the Hippocratic method were either too dangerous or placed the cervical spine at too great a risk to be used in this situation. External rotation and the MilchCooper method were tried unsuccessfully. We desired to avoid the use of drugs that could alter either the respiratory or mental status of this patient with concurrent injuries involving the head and abdomen. Because scapular manipulation has been previously employed without the use of pharmacologic adjuncts s, we believed that it was a viable option in this situation. The presence of a backboard was probably helpful because it left enough room between the patient's back
94
and the examination bed to allow manipulation of the tip of the scapula. The absence of a backboard may have precluded scapular manipulation as a possibility in this situation. We employed slight upward traction on the involved extremity (Figure), but not enough to move the patient's body. We also employed an assistant on the opposite side of the patient to ensure that the patient was not moved. The reduction occurred rather easily once proper positioning of the extremity and the assistants was obtained. One potential criticism is that an entire radiographic shoulder series was not taken before the diagnosis of anterior shoulder dislocation was made; only an anteroposterior view of the shoulder was obtained. Further views were made difficult to obtain because the patient could not be moved and was unable to move his extremity. However, dislocation was easily diagnosed on the anteroposterior view, making the diagnosis of posterior shoulder dislocation unlikely. This is probably the first reported incident of the use of the scapular manipulation in the supine position. Although we believe that the external rotation and Milch-Cooper methods are still preferable, this case shows that the scapular manipulation method can be used both safely and effectively with the patient in the supine position if necessary. Larger studies are needed to definitively confirm this conclusion. REFERENCES 1. Danzl DF,Vicario SJ, Gleis GL, et al: Closed reduction of anterior subcoracoidshoulder dislocation. OrthopRev1986;15:75~79. 2. RobertsJR, HedgesJR: Clinical proceduresin emergencymedicine, ed 2.Philadelphia,WB Saundars Co, 1991, p 763-770. 3. DePalmaAF, FianneryGF:Acuteanteriordislocationof the shoulder.Am J SportsMsd 1973;1:6-15. 4. Mirick MJ, Clinton JE, Ruiz E, et ah Externalrotation method of shoulderdislocation reduction. JACEP1979;8:528-531. 5. Milch H: Treatmentof dislocation of the shoulder, Surgery1938;3:732. 8. Kothari RU, DrenenSO: Prospectiveevaluation of the scapular manipulation technique in reducing anterior shoulder dislocations.Ann EmergMad 1992;21:1349-1352. 7. Riebel GD, McCabeJB: Anterior shoulder dislocation: A review of reductiontechniques. J EmergMad 1991;9:1808. 8. McNamara RM: Reductionof anterior shoulder dislocations by scapularmanipulation. Ann EmergMad 1993;22:1140-1144.
Reprint no, 47/1/69557 Address for reprints: William L Doyle,MD ProvidenceYakimaMedicalCenter 110 SouthNinthAvenue Yakima,Washington98902 509-575-5060
ANNALS OF EMERGENCY MEDICINE
27:1 ,JANUARY 1996