Chapter 9 Shoulder and Elbow Reduction

Clavicle fracture

Overview

1. Most clavicle fractures require no reduction.

2. Closed reductions cannot be maintained and should not be attempted.

Indications for Use

1. Minimally displaced clavicle shaft fractures (Figure 9-1)

2. Medial physeal clavicle fractures

Figure 9-1

Precautions

Do not attempt heroic measures to reduce clavicle fractures.

Pearls

1. Clavicle fractures with more than 1.5 cm of overlap result in long-term disability and should be treated with an open reduction and internal fixation.

2. Fractures that tent the skin can erode through the skin and are unlikely to heal without open reduction and internal fixation.

3. There is no difference in outcome between a figure-of-8 splint and a sling for closed management of clavicle fractures.

4. The sling or figure-of-8 strap should be relatively tight to support the weight of the arm.

Improvization

If no sling is available, a simple scarf or towel can be used.

Equipment

1. Sling

2. Figure-of-8 strap (alternative)

Basic/Detailed Technique

1. Sling (see Chapter 13)

2. Figure-of-8 strap (see Chapter 13)

Acromioclavicular separation

Overview

1. Most acromioclavicular (AC) separations require no reduction.

2. Closed reductions cannot be maintained and should not be attempted.

Indications for Use

1. Minimally displaced AC separations (grades 1 to 3) (Figure 9-2)

2. Severely displaced AC separations (grades 4 to 6) (Figure 9-3)

Figure 9-2

Figure 9-3

Precautions

Do not attempt heroic measures to reduce AC separations.

Pearls

1. AC separations with severe displacement or soft tissue interposition (grades 4 to 6) should be reduced surgically on an elective basis.

2. AC separations that tent the skin are unlikely to heal without fixation.

3. The sling should be relatively tight to support the weight of the arm.

Improvisation

If no sling is available, a simple scarf or towel can be used.

Equipment

Sling

Basic/Detailed Technique

Sling (see Chapter 13)

Glenohumeral dislocation

Overview

1. Most glenohumeral dislocations can be reduced in a closed manner.

2. The reduction technique varies according to the direction of dislocation.

3. An axillary or modified axillary view is an essential part of the radiographic series (Figure 9-4)!

Figure 9-4

Indications for Use

1. Anterior glenohumeral dislocation

2. Posterior glenohumeral dislocation

3. Inferior glenohumeral dislocation (luxatio erecta)

Precautions

1. Confirm that no fracture is present on diagnostic films before attempting a reduction. Standard reduction maneuvers can result in a displaced four-part fracture that requires surgical fixation/prosthetic replacement.

2. Confirm that the humeral head is not impacted onto the glenoid (known as a Hill-Sachs lesion) before attempting a reduction (see Figure 9-4). Standard reduction maneuvers can result in a head-splitting fracture.

3. When applying traction, make sure that the force is applied over a broad area; otherwise, a forearm fracture can result.

4. Be aware that some persons may voluntarily initiate a glenohumeral dislocation in an effort to gain access to drugs.

5. Reducing dislocations in persons who present more than a few days after the injury may not be possible, and attempting to do so could result in a fracture; it is preferable not to attempt a reduction and to take the patient to the operating room if simple traction does not succeed in reducing the dislocation.

6. When reducing posterior dislocations, do not externally rotate the humerus until the head is disimpacted from the glenoid or a fracture may result.

Pearls

1. Be patient; the stability of the shoulder is provided largely by a set of small but powerful muscles that must be overcome with gentle sustained traction before a reduction is possible.

2. Gentle internal and external rotation of the shoulder can coax the humerus back in place.

3. For posterior dislocations, stretching the rotator cuff muscles by maximal internal rotation of the shoulder may be necessary.

4. General anesthesia may be required if muscle spasms are not overcome with sedation.

5. External rotation is a better position for immobilization of both anterior and posterior dislocations after reduction, although a gunslinger brace may not be available immediately.

6. The sling or gunslinger brace can be applied loosely for comfort.

Improvization

When all else fails, try traction at different angles of abduction and extension.

Anterior glenohumeral dislocation

Equipment

1. Two bed sheets

2. Stretcher

3. Medications for conscious sedation

4. Sling or gunslinger brace (if available)

Basic Technique

1. Patient positioning:

a. The patient is supine on the stretcher.

b. The patient’s elbow is bent 90 degrees and the forearm is vertical.

c. The patient’s shoulder is abducted 30 to 60 degrees.

d. A bed sheet is tied around the patient’s trunk and to the opposite side of the stretcher.

e. A bed sheet is tied around your waist and to the patient’s forearm.

2. Landmarks:

a. Acromion

b. Humeral head

c. Coracoid

3. Steps:

a. Position the patient.

b. Induce sedation.

c. Tie the bed sheet to the stretcher.

d. Tie the bed sheet to yourself.

e. Lean back to apply traction.

f. Gently externally rotate the shoulder.

g. Await a clunk as the shoulder reduces.

h. Place the shoulder in a sling or gunslinger brace.

i. Obtain postreduction films.

Detailed Technique

1. Position the patient supine on the stretcher.

2. Induce conscious sedation.

3. Prepare traction setup:

a. Make sure that guard rails are down on the ipsilateral side and up on the contralateral side.

b. Slide a rolled bed sheet around the patient’s trunk under the ipsilateral shoulder and tie it over the contralateral upper corner of the stretcher for countertraction (Figures 9-5 and 9-6).

c. Tie another rolled bed sheet around your waist, leaving about a foot of slack.

d. Place the patient’s forearm inside the sheet around your waist so that the entire proximal half of the forearm is covered by the sheet (Figure 9-7).

4. Apply traction:

a. Position yourself along the ipsilateral side of the stretcher so that the shoulder is slightly abducted.

b. Lean back slowly and gently to apply traction while providing countertraction on the distal half of the forearm with both palms.

(1) Apply traction over the broadest surface area possible to prevent a forearm fracture.

(2) Be patient; slow, steady traction is necessary to achieve reduction (5 to 30 minutes of traction may be required depending on the level of sedation).

5. Gently externally rotate the shoulder (Figure 9-8).

a. If reduction not achieved, alternate internal rotation (Figure 9-9) and external rotation.

b. Vary the degree of abduction if necessary (Figure 9-10).

6. Await a clunk or sudden palpable shift.

7. Gently release traction.

8. Place the arm in a sling (see Chapter 13) in internal rotation or in a gunslinger brace in external rotation.

9. Obtain postreduction radiographs, including an axillary view, before terminating sedation.

Figure 9-5

Figure 9-6

Figure 9-7

Figure 9-8

Figure 9-9

Figure 9-10

Posterior glenohumeral dislocation

Equipment

1. Two bed sheets

2. Stretcher

3. Medications for conscious sedation

4. Sling or gunslinger brace (if available)

Basic Technique

1. Patient positioning:

a. The patient is supine on a stretcher.

b. The patient’s elbow is bent 90 degrees and the shoulder is internally rotated.

c. The patient’s shoulder is abducted 30 to 60 degrees.

d. A bed sheet is tied around the patient’s trunk and to the opposite side of the stretcher.

e. A bed sheet is tied around your waist and to the patient’s forearm.

2. Landmarks:

a. Acromion

b. Humeral head

c. Coracoid

3. Steps:

a. Position the patient.

b. Induce sedation.

c. Tie the bed sheet to the stretcher.

d. Tie the bed sheet to yourself.

e. Lean back to apply traction.

f. Gently rock the shoulder in slight internal and external rotation.

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