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Scapular manipulation techniques |
It has been recognised for thousands of years that the shoulder joint is particularly prone to dislocation following trauma. From the time of Hippocrates, physicians have described a variety of different techniques aimed at reducing shoulder dislocations. In this article we review the historical development of these techniques and suggest that, despite being described as new, many of these are simply variations on an already established method.
Keywords: manipulation, shoulder dislocation
J.R.Coll.Surg.Edinb., 45,October 2000, 312-316
The shoulder is a ball and socket joint whose shallow socket, the glenoid, accommodates a relatively large ball, the humeral head. The shoulder joint, thus, enjoys a remarkable range of mobility, but at the expense of stability. It is the commonest of the major joints to dislocate and presents frequently to departments of Accident and Emergency.1 The rate of dislocation is 17 per 100000 population per year, of which the vast majority (97%) are anterior dislocations.2 The only real restraints to dislocation are a thin capsule and surrounding muscles. A degree of indirect trauma (such as falling onto an outstretched hand or a direct blow posteriorly to the shoulder) is usually responsible for overcoming the restraining forces. However, there is a case report of a snooker player dislocating his shoulder for the first time merely by 'playing a shot.'3
Descriptions of shoulder dislocations go back many centuries and are accompanied by a variety of different descriptions of how to reduce them. Some of these reduction techniques have been passed on through generations of doctors and survive today. Many recent descriptions, claimed as new methods, are simply modifications of previously established techniques.
Most descriptions of techniques of reduction of shoulder dislocation involve trying to manipulate the humeral head back into its position in the glenoid. These techniques are of two basic types utilising either traction or leverage of the humerus, although often combinations of the two are employed. The aim of traction is to overcome the muscle spasm that almost inevitably ensues once the shoulder loses its usual anatomical integrity, whilst leverage aims to forcibly manipulate the humeral head back into its anatomical position. Relatively recently, an alternative approach has been suggested, which aims to try to reduce the dislocation by manipulating the scapula, not the humerus. This article reviews the development of reduction techniques for anterior dislocation of the shoulder from a historical perspective.
TRACTION TECHNIQUES
These are categorised according to the position of the arm during traction.
Abduction
The oldest surviving descriptions of how to reduce a shoulder dislocation originate from Hippocrates (460-377 BC), recognised by many as "the father of medicine". Translations of his written works show that he described several techniques, all based upon traction of the injured arm, but using different methods of counter-traction. The descriptions involve the injured arm being placed in slight abduction and downward/adduction forces then being applied to the arm, whilst counter-traction is used. The form of counter-traction, which has survived in a popular fashion to modern times, is that provided by the surgeon's foot placed in the patient's axilla. The patient lies supine whilst the surgeon stands on the patient's affected side simultaneously holding the arm and applying traction. Alternative methods described by Hippocrates involved placing the affected arm over a variety of objects, including a long stick, a ladder rung, or the back of a chair and pulling down using gravity as counter-traction. In cases where none of these objects were readily available, Hippocrates suggested that the surgeon placed his shoulder in the patient's axilla, then lifted the patient up whilst holding the affected arm. He stated that, for success, the surgeon required a certain amount of strength and that he needed to be taller than the patient. Hippocrates methods have been used through the centuries and survive in various forms to this day (Figure 1).
Figure 1: Reduction using the surgeon's knee reproduced from Illustrations of Dislocations & Fractures, 1842
In the sixteenth century Ambroise Paré, a French surgeon, reintroduced the methods of Hippocrates in a published collection of his surgical practice.5 He elaborated on the "ladder method" by mounting the patient on a stool adjacent to the ladder and binding their sound arm and both their legs "lest the patient hinder the operation and spoil all by laying a hand or setting a foot upon the ladder". Once the affected arm was placed through the rung of the ladder the patient should come as close to the ladder as is possible before the stool was taken away "lest the force break his shoulder bone". As an added safety tip he recommended that the patient did not place his head through the rungs of the ladder prior to the stool removal "lest he break his neck" one would presume!
Since Paré's time other traction methods with the arm held in slight abduction have been advocated. In 1949, Nicola described a technique using a fist in the axilla as a passive fulcrum.5 More recently, Manes (1980) devised a method he felt would be ideal to use on the elderly population due to the lesser forces required. He suggested the surgeon stood behind the seated patient and inserted his flexed forearm into the axilla of the patient's affected shoulder. The surgeon's free hand was then placed on the flexed forearm of the patient and gentle traction applied. The surgeon's forearm pulls in a proximal and lateral direction levering the head of the humerus into the socket.
Many medieval devices have been described in the literature as aids to facilitating shoulder reduction. However, too often they resembled torture devices! Boger et al (1984) devised more modern traction straps to aid surgeons during their joint reduction procedures.6 The padded strapping was connected to the supine patient's flexed elbow and then around the waist of the surgeon. The surgeon then used his body weight as traction during reduction, decreasing operator fatigue. Such devices have been met with limited approval.7
One further variation of Hippocrates' method was described by Noordeen et al (1992) which involves the patient sitting on a chair facing the backrest with his affected arm hanging over it. The wrist is held down and the patient instructed to attempt to stand, thus reducing his own shoulder.11 In a similar fashion, Westin et al (1995) advocated reduction by the application of downward traction applied by a sling to the arm of the seated patient.9
Forward flexion
Stimson, in 1900, whilst Professor of surgery in Cornell University, described the hanging arm technique.10 With this method, the patient was made to lie prone on a canvas cot with his injured arm hanging through a hole cut in the canvas (Figure 2). A sandbag of 10 lbs was applied to the wrist of the dependent arm and "after no greater than 6 minutes, reduction occurred due to muscle relaxation". Pick (1977) and Lipper (1982) both reported a modification of this method in that the patient's elbow was flexed allowing the biceps to relax.11,12
Figure 2: Stimson's Hanging Arm Technique, reproduced from A Treatise on Fractures and Dislocations, 1905
Almost a century after Stimson described his technique Shackleford (1982), a cardiothoracic resident in Pittsburgh, was exasperated with the difficulty in finding weights to enable him to perform this original method. As a result, he took advantage of the hydraulic stretchers found in many Accident and Emergency departments. With the patient prone and his injured arm hanging over the stretcher he described binding the patient’s hand to the bottom of the frame or wheel and then using the hydraulic pedal to elevate the patient, thereby applying traction and resulting in successful reduction.13
In 1988, Rollinson, whilst working in a rural hospital in Natal, proposed a similar method, but suggested that the patient's affected arm should hang over the side of the bed. Also, instead of applying weights he used a supraclavicular brachial nerve block to relieve pain and evoke muscle relaxation.14 Aronen (1986) proposed a method of self-reduction for athletes shortly after their injury. He used a variant of the forward flexion method and suggested that the athlete sit on the ground, lean forward, locking his fingers around the flexed ipsilateral knee. Traction is then applied by the athlete leaning backwards and extending the hip.15
Lateral flexion
Stimson also described the 'pendle-method' in which the patient was placed on the ground lying on his non-dislocated arm. An assistant standing on a stool grasped the dislocated arm, pulled upwards and lifted the shoulders off the floor. The surgeon may be required to press the humeral head towards its socket.16
This method, as with many of the reduction techniques, has been described subsequently and claimed as "new."17 Poulson in 1988, whilst working as a medical officer in Greenland, provided an account of how, after he had several unsuccessful attempts to reduce a hunter's dislocated shoulder, the hunter's friends "finally lost patience" and reduced their friend's shoulder using the method described above, which he named the "Eskimo method".
Upward traction (overhead)
This method involves raising the arm above the head and pulling whilst applying counter traction via the hand or foot upon the top of the shoulder (Figure 3). This method was known to Celsus, practised by Brunus in the thirteenth century and used extensively in England during the nineteenth century.16 Lacour in 1847 proposed the addition of external followed by internal rotation to aid the technique.18 However, this method fell into disuse because of the risk of causing additional injury to nerves and vessels.
Fig 3 Reduction using the overhead method reproduced from Illustrations of Dislocations & Fractures, 1842
LEVERAGE TECHNIQUES
Theodor Kocher, a famous nineteenth century surgeon whose main interest was thyroid surgery, described possibly the best known leverage technique.26 Interestingly, although he described his method of manipulation in 1870, a wall painting in the Egyptian tomb of Ipuy, dating back to 1200BC, looks deceptively similar, resulting in speculation that "Kocher's method" is actually 3000 years old!27 With this technique, the affected arm is flexed at the elbow and pressed (adducted) against the side of the body. The forearm is rotated outwards until resistance is felt. The externally rotated upper arm is then lifted in a sagittal plane as far as possible forwards and finally, internal rotation is performed (Figure 4). No traction was involved in the original description.28
Figure 4: Reduction using Kocher's method
Variations on Kocher's method abound. Lendelmeyer in 1977, described the external rotation method, which is essentially the first part of Kocher's manoeuvre. Adduction and internal rotation were omitted due to concerns about the unnecessary torque involved - other authors have endorsed this view.
Another leverage technique worthy of mention was that described by Sir Ashley Cooper19 in 1825 and, subsequently reintroduced and popularised, by Milch in 1938.19,20 Milch stressed the importance of muscular forces in preventing reduction. He re-emphasised the teachings of Sir Ashley Cooper who noted that when the arm was overhead the muscles acting on and around the shoulder joint are at their most relaxed. The implication of less muscle spasm is that lesser forces (either in traction or leverage) are required for relocation from what Saha (1983) later defined as the "zero position."21 For this reason many advocate it as the most logical reduction method.
The patient lies supine and the surgeon lays a hand on the injured shoulder, fixing the head of the humerus by bracing the thumb against it. His other hand slowly abducts the injured arm to the overhead position whilst gently externally rotating it. At complete abduction, all cross-stresses exerted by the muscles around the shoulder joint have (in theory) been eliminated and the head can be gently and easily pushed over the rim of the glenoid and the dislocation reduced. As in Kocher's original description, Milch did not employ any traction, yet later authors, who applauded its use, have made slight modifications to the original technique and these often involved traction.22-24 Janecki and Hossain Shahcheragh (1982) appear to have successfully used a combination of the overhead (Milch) and forward flexion (Stimson) manoeuvres.25
SCAPULAR MANIPULATION TECHNIQUE
The scapular manipulation technique is a method more frequently practised in the USA than in Europe and is unique in that it attempts to manipulate the glenoid back to its normal anatomical position, rather than manipulating the humeral head. Bosely and Miles first described it in 1979 and others have since advocated its use.29 The patient is placed prone with a weight attached to the dependent affected arm much like the 'hanging arm' technique of Stimson. However, after a few minutes to allow muscle relaxation, the surgeon pushes the inferior tip of the scapula medially and inferiorly whilst simultaneously fixing the superior and medial edge. This allows the scapula to pivot around an axis and aid reduction. One of the practical problems with this technique is the difficulty and discomfort experienced by the patient in getting into the prone position. As a result, the technique has since been described with the patient seated as well as in the supine position.30,31 The latter is of more importance in the multiply injured in whom torso movement is limited.
There are numerous descriptions of techniques for reduction of anterior dislocation of the shoulder. Many of these descriptions are little more than variations on a previously employed method and some descriptions do not appear to be different at all! Most doctors appear to use the technique with which they are the most familiar. There is continuing controversy as to which technique represents the ideal reduction method and there is little evidence to answer this question, as there are few properly conducted clinical trials comparing different methods. The evidence that does exist indicates that certain reduction techniques are not without risks. It is well recognised, for example, that Kocher's technique when used in an elderly individual may result in fracture of the humeral neck or shaft.22,32
Although the initial concern of the Accident and Emergency or Orthopaedic team will be to employ a method with the highest likelihood of success and lowest risk of early complications, it is possible that the choice of technique may influence long-term complications, most particularly the rate of recurrent dislocation. Similarly, it has been suggested that it may be appropriate to employ different methods of reduction for different subgroups of dislocation.32,33 However, until there have been well conducted clinical studies comparing the various techniques, controversy will continue as to which of the methods is best. No doubt there will continue to be reports of "new" techniques, some of which will probably sound rather familiar!
ACKNOWLEDGEMENT
The authors are grateful to Professor Angus Wallace, Professor of Orthopaedic Surgery, University of Nottingham, for access to original publications, reproduced in the article. These publications may be found in the Library of The Royal College of Surgeons of Edinburgh.
Copyright date: 4th September 2000
Correspondence: Mr Anthony Mattick, Department of Accident and Emergency, The Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh EH3 9YW, U.K.
©2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.