Dislocated Shoulder (cont.)

The purpose of the initial treatment of a dislocated shoulder is to reduce the dislocation and return the humeral head to its normal place in the glenoid fossa. There are a variety of methods that may be used to achieve this goal. The decision as to which one to use depends upon the patient, the situation, and the experience of the clinician performing the reduction. Regardless of the technique used, the hope is to be able to efficiently reduce the dislocation with a minimum of anesthesia required. Most often, a closed reduction is attempted and is successful; that is, no incision or cut is made into the joint to assist in returning the bones to their normal position. The term "open reduction" refers to performing surgery to repair the dislocation. Methods for reduction of a shoulder dislocation are described below.

Scapular manipulation

The patient may be sitting up or lying prone. The health-care provider attempts to rotate the shoulder blade, dislodging the humeral head, and allowing spontaneous relocation. An assistant may be needed to help stabilize the arm.

External rotation (Hennepin maneuver)

With the patient lying flat or sitting up, the health-care provider flexes the elbow to 90 degrees and gradually rotates the shoulder outward (external rotation). Muscle spasm may be able to be overcome after five to 10 minutes, allowing the shoulder to spontaneously relocate. The Milch technique adds gentle lifting of the arm above the head to achieve reduction.

Traction-counter traction

With the patient lying flat, a sheet is looped around the armpit. While the health-care provider pulls down on the arm, an assistant, located at the head of the bed, pulls on the sheet to apply counter traction. As the muscles relax, the humeral head is able to return to its normal position.

Open reduction

In rare circumstances, the shoulder cannot be reduced using closed reduction techniques because a tendon, ligament, or piece of broken bone gets caught in the joint, preventing return of the humeral head into the glenoid. When closed reduction fails, an operation or open reduction is considered to treat the shoulder dislocation. This requires that the orthopedic surgeon care for the patient in the operating room.

Procedural medications

Depending upon the amount of pain and spasm present, medication may be needed to sedate and comfort the patient prior to and during the reduction procedure.

Patients receiving intravenous medications need to have their vital signs monitored before, during, and after the shoulder relocation just as if they were in the operating room. In some circumstances, for example a patient with underlying lung or heart illnesses, the presence of an anesthesiologist or nurse anesthetist may be appropriate during the relocation. Intravenous narcotics and muscle relaxants are used in combination to relieve pain, relax muscles, and help promote amnesia of the events. Common pain medications used include morphine, hydromorphone (Dilaudid), and fentanyl. Midazolam (Versed), diazepam (Valium), or lorazepam (Ativan) may be used as a muscle relaxant.

Anesthetics like ketamine or propofol are also commonly used to sedate the patient to allow shoulder reduction. Intra-articular (intra = within + articular = joint) injections of lidocaine into the shoulder joint itself may be used as local anesthesia.

Source: MedicineNet.com
http://www.medicinenet.com/dislocated_shoulder/article.htm