Reduction of Anterior Shoulder Dislocation: The External Rotation Method
Vs The Milch Method
There are a variety of glenohumeral shoulder dislocation types and this literature review will specifically concentrate on Anterior Shoulder Dislocation (ASD) treatment. The first documented shoulder dislocation comes from as early as 3000BC, with murals depicting the Kocher technique for reduction. ASD accounts for more than fifty percent of all dislocations that occur with the human body (Sapkota et al., 2015). Most ASD’s can be reduced with success in the Emergency Department (ED) (Ufberg et al., 2004).
Shah et al (2017) identified that the incidence of ASD in the UK between 1995 – 2015, in adult patients aged 16-70 was 16763, according to UK Primary Care data taken from Clinical Practice Research Datalink (CPRD). 12148 (72%) were males and 4615 (28% were female).
The shoulder joint is a shallow ball and socket joint with a vast range of movement that permits the arm to move in all directions. It consists of the glenohumeral joint, acromioclavicular joint and the sternal clavicular joint (Tripathy et al., 2016). It articulates between the humeral head and the glenoid cavity of the scapula, whilst being stabilised and protected by the rotary cuff muscles (Henderson, 2015). Being highly mobile it is more vulnerable to dislocation than any other joint in the human body and consequently is the most frequent joint dislocation treated in ED; roughly fifty percent of all joint dislocations (Sapkota et al., 2015), (Kanji et al., 2014), (Janitzky et al., 2015), (Helfen et al., 2016).
ASD’s are sub divided into the following four types:
Subcoracoid and Subglenoid dislocations are ninety-nine percent of ASD’s presenting in ED. Subclavicular and Intrathoracic are not easily reduced and are normally corrected with surgical intervention (Mallia, 2018).
ASD is a common sports injury with the shoulder capsule being a potential weak spot (Dreu et al., 2015), (Tripathy et al., 2016). The muscle and ligament support anteriorly is less robust that the stronger bony and muscular support offered by the scapula and rotator cuff (Mallia, 2018). The frequent mechanism of injury (MOI) is a fall onto out stretched hand, in abduction with external rotation, normally as a parachute reflex or high energy trauma (Donohue et al., 2016), (Avis, 2018). The consequence of this is the head of the humerus is levered out of the glenoid socket in an anterior direction (Theivendran et al., 2014), (Janitzky et al., 2015). The shoulder ‘pops’ out of its socket and can cause associated muscular tears (National Health Service (NHS), 2017). Due to the traumatic nature of the injury there is a high recurrence rate following the initial insult (Tripathy et al., 2016), (Itoi et al., 2015). Increased ligament laxity can also contribute to ASD.
Posterior Shoulder Dislocations (PSD) are often a result of convulsion or backward displacement (Wirbel et al., 2014). They make up three percent of all glenohumeral dislocations (Theivendran et al., 2014)
The challenge faced by the clinician is to safely rule out a fracture and relocate/reduce the dislocation with minimal analgesia/anaesthesia in an ethical, safe and timely manner (Stafylakis et al., 2016). Eighty percent of diagnosis is made from history taking alone, so a detailed history and mechanism of injury recognition; followed by a thorough physical examination is paramount to aid the diagnosis and subsequent clinical management of ASD (Donohue et al., 2016). Generally, patients will present supporting their arm in an abduction and often refuse to adduct or internally rotate the limb (Naples et al., 2018). Shoulder dislocations not reduced within twelve hours have a higher rate of axillary nerve injury. Those reduced after two hours following injury are less likely to recover within six months than those promptly reduced (Avis, 2018).
A 2013 study suggests that ultrasonography should be a diagnostic tool to gain a clinical impression of the shoulder to detect ASD after a study of 73 patients were 100 hundred percent accurate in diagnosis (Abbasi et al., 2013).
Clinical Standards for Emergency Departments (College of Emergency Medicine (CEM), 2014), (National Health Service (NHS), 2017), recommend the following standards must be withheld with regards to the management of ASD:
1. Pain managed as per CEM standard
2. X-ray within sixty minutes of arrival – 75%
3. 75% – 1st attempt at reduction within two hours and 90% within three hours of arrival
4. The name, dose and time of administration of sedation drug documented
5. Post-reduction X-Ray and result of review documented in the notes
6. Follow up arrangements documented (or the reasons why no follow-up necessary)
(Kanji et al., 2014) report that the failure rate for closed reduction of ASD is low in ED and is often achieved on the first attempt. Further attempts cause patients pain so whilst this is being managed, it adds to department burden and patient caseload. Furthermore, neurovascular complications may occur if the ASD is not reduced in a timely manner, although the neurovascular injury is caused by the dislocation, not the reduction technique.
It is well documented that appropriate neurovascular assessment is to be perform pre-and post procedure, concentration on the regimental badge area of the deltoid assessing sensory change in the axillary nerve. The axillary nerve is derived from the fifth and sixth cervical nerve roots and wraps around the anatomical neck of the humerus. Low grade axillary nerve injuries often make a full recovery without the need for intervention. However, a portion of patients who suffer higher grade nerve injuries have a reduced functional outcome without surgery (Avis, 2018), (Naples et al., 2018).
Research suggests a variety of reduction methodologies and techniques with different analgesic, sedative and relaxing drug therapies. Some are a painful and unpleasant experience for the patient whilst others may expose the patient to prolonged time in ED and adverse risks of the sedatives, further increasing the clinician’s caseload and adding to the department’s capacity (Hendey, 2014), (Sapkota et al., 2015).
Mallia (2018) recognises that the commonly used techniques include:
- Stimson maneuver
- Scapular manipulation
- External Rotation (ER)
- Milch technique
- Spaso technique
- Traction – counter traction
Subclavicular and intrathoracic ASD as well as associated humeral neck fractures are all contraindications to reduction. Imaging pre-reduction is there for mandated (CEM, 2014). Recognised views include the anteroposterior (AP), lateral (Y) and axillary views. If doubt exists in the x-ray request, then bedside ultrasonography can be used to view the glenohumeral joint (Abbasi et al., 2013), (Mallia, 2018).
This review will compare the External Rotation (ER) Method and the Milch Method for ASD reduction. Both techniques offer an audible or palpable clunk, pain relief, increased range of limb motion as well as a return of rounded shoulder contour.
Smooth technique with appropriate muscle relaxation and pain management are paramount in providing a successful reduction. Slow movements reduce muscle spasm and associated pain. Those patients suffering more than three recurrent anterior shoulder dislocations are recommended a surgical fix as there is no conservative management (Tripathy et al., 2016).
The External Rotation (ER) Method
External Rotation can be performed with or without sedation and analgesia. It is a newer technique that is proven to be reliable (Janitzky et al., 2015). Patients are required to lie as relaxed as possible in the supine position. The affected arm is slowly adducted with a 90-degree flex at the elbow. Slow external rotation (between 70 and 110 degrees) is then applied, holding the patients’ wrist and used as a lever; until in the coronal position. It is to be stopped each time pain is felt and then continued once the patient has relaxed. The procedure can be performed without assistance and is generally well tolerated by patients without the need for sedation. The procedure can take 5-10 minutes and has a success rate of 80-90% (Sapkota et al., 2015). Once the shoulder is reduced, the arm is supported and slowly rotated, bringing the arm to lie across the chest. This allows for appropriate sling/support to be applied, to further support the limb and provide analgesic affect.
Evidence suggests that this method has a lower first-time success rate to other techniques when performed without sedation (Mallia, 2018).
The Milch Method
This procedure named in 1938, levers the humerus head back into the shallow glenoid cavity and can be performed without sedation. The patient is lay supine with the head of the bed elevated. The affected arm is positioned overhead by the patient or with assistance from the clinician. Gentle longitudinal traction and external rotation is applied. If resistance is felt, the procedure is paused until the patient is relaxed. Using a free hand, gentle traction and lateral superior pressure to the humeral head is to be applied if not reduced. The manoeuvre allows the rotator cuff muscles to relax and the humeral head to relocate inside the glenoid fossa. The procedure has a success rate of 75-95% on first attempt (Sapkota et al., 2015), (Naples et al., 2018).
The traction involved in the Milch method is reported to cause more pain due to muscle spasm. However, the technique is safe, effective, well tolerated and shortened the patients stay in hospital (Sing et al., 2012).
Sapkota et al (2015) reports in comparison there is nothing of statistical significance in the success rate of each method to say which is the better technique. However, during the study no pre/during/post procedure pain score was recorded.
Equally, Janitzky et al (2015) also report that neither reduction method used for ASD are superior and the clinician is to familiarise themselves with multiple methods.
External Rotation vs Milch Technique
|External Rotation||Reduction is well tolerated
Can be performed by a single clinician
Premedication is not necessary
Quick and easy reduction
No traction or force is needed
No equipment is needed
|Lower success rate in none sedated patients|
|Milch Technique||Well tolerated by patients
Can be performed by a single clinician
Sedation is not necessary
Minimal traction or force is needed
No equipment is needed
Success rate ranging 70-90%
|No significant disadvantage has been reported|
Shoulder dislocations are a traumatic event and often painful. UK data demonstrates that most ASD occurred in male patients aged 16–20 years, predominantly partaking contact sports (Shah et al., 2017). Techniques for reduction have many variables, including time, equipment and force required. In addition, clinicians chosen technique may be swayed by training, experience and exposure. Muscle relaxation and adequate pain control, including sedation may be required.
ER and Milch Technique are both popular methods of reduction and are very equal in advantages and disadvantages. Both can be performed without anaesthesia or sedation.
Both reduction strategies discussed prove to offer the patient a semi painless and atraumatic experience that can be performed with minimal anaesthesia. This reduces the patients stay in ED as well as minimising their risk to adverse drug affects as well as reducing hospital costs (Sing et al., 2012), (Sapkota et al., 2015).
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|10||EMBASE||(8 AND 9)||331|
|11||EMBASE||(8 AND 9) [DT 2013-2018] [Publication types Article] [English language]||63|