Therapeutics

Anterior Shoulder Dislocation: A Review GREGORY

of Reduction

Techniques

D. RIEBEL, MD,* JOHN 8. MCCABE, MDt

Anterior gleno humeral dislocation is the most common dislocation seen in the emergency department.‘.* Many methods have been advocated for reduction of this common dislocation with varying success rates and complications.2-3h Most dislocations can be reduced in the emergency department (ED) using simple methods. Occasionally, dislocations will require the use of more than one method. In 5% to 10% of cases, ED reduction can not be accomplished. Due to the common nature of shoulder dislocations, the ease with which most dislocations are treated, and the large number of reduction techniques that have been advocated, it is important for the emergency physician to have a clear understanding of various techniques to accomplish reduction of this dislocation. This review will discuss the anatomy and diagnosis of anterior shoulder dislocation. Methods used for reduction of the dislocated shoulder will be categorized and described in detail. This article provides the clinician with a rational treatment protocol based on an understanding of available methods, their categorization, and a comparison of techniques to determine the difficulty of reduction, the need for analgesia, the efficacy. and the specific indications for each technique. ANATOMY Both anterior and posterior dislocations of the shoulder can occur, but the anterior type is most common, making up 90% to 96% of all shoulder dislocations.’ Several types of anterior dislocation have been described in relation to the anatomic location of the dislocated humeral head: subclavicular, subglenoid, intrathoracic, and the most common, subcoracoid.’ Reduction maneuvers do not vary according to the type of dislocation. Anatomy of the shoulder predisposes to instability. The joint has a small, shallow glenoid. and a relatively large humeral head with only a small portion of the humeral head articulating with the glenoid at any time. The glenoid has a tibrocartilaginous structure, the glenoid labrum, circumfer-

From the *Department of Orthopedics and the j-Department of Critical Care and Emergency Medicine, State University of New York, Health Science Center, Syracuse, NY. Manuscript received April 14, 1990; accepted August 31, 1990. Address reprint requests to Dr McCabe, Dept of Critical Care and Emergency Medicine, SUNY Health Science Center, 750 E Adams St, Syracuse, NY 13210. Key Words: Shoulder, dislocation, reduction techniques. Copyright 0 1991 by W.B. Saunders Company 0735-6757/91/0902-0021$5.00/O 180

entially along its articular edge that inserts into this edge with the joint capsule. This deepens the glenoid slightly and cups the humeral head. The first significant restraint to dislocation is the joint capsule. This is a thin, inelastic structure covering the humeral head, originating along the edge of the glenoid and inserting into the proximal humeral neck. The anterior-inferior portion of the normal capsule, the inferior glenohumeral ligament, is thickened and is the primary restraint to anterior dislocation.30 This structure must fail for dislocation to occur. Anterior to the joint capsule is the subscapularis muscle, originating along the undersurface of the scapula and inserted into the lesser tuberosity of the humerus. This muscle acts as a secondary restraint and is often atenuated with shoulder dislocation. The long head of the biceps tendon, originating from the superior aspect of the glenoid and running through the bicipital groove of the humerus, also lends additional anterior shoulder support and has been reported to dislocate from its groove in the humerus with anterior shoulder dislocation? Although the subscapularis is the major anterior muscular restraint of the shoulder, the other rotator cuff muscles play a role. The supraspinatus. intraspinatus, and teres minor originate from the posterior aspect of the scapula and insert into the greater tuberosity. These muscles form the major posterior restraint or “check rein” to anterior translation of the proximal humerus. These muscles are necessarily stretched to allow anterior dislocation. In 10% to 15% of cases, these muscles avulse their insertion during dislocation (greater tuberosity fracture), as they contract in an attempt to stabilize the shoulder. Relationships of the above structures are illustrated in Figure 1. DIAGNOSIS Diagnosis in the patient with an injured shoulder should involve history. physical examination, and roentgenographic evaluation. Anterior dislocation is caused most frequently by an indirect mechanism with the arm forced into abduction, extension, and external rotation.‘6 Physical examination shows both direct and indirect signs of dislocation. The patient with anterior shoulder dislocation supports the affected arm at the side of the body in slight external rotation. The shoulder will lose its usual roundness and will be full anteriorly to palpation. Associated injuries include nerve and vascular structures that may be stretched or torn at the time of injury. The axillary nerve is the most commonly injured nervous struc-

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Superior joint

Long head of bmps

\

FIGURE 1. Muscular and ligamentous structures surrounding the shoulder joint. (Reprinted with permission from Hoppenfeld S: Surgical in Orthopedics. Lippincott, 1984.)

Exposures

ture associated with anterior dislocation, presenting as decreased sensation over the lateral shoulder and loss of deltoid power. Less commonly, a stretch injury to the brachial plexus will occur with variable deficits. The rotator cuff is commonly damaged. Rotator cuff tears are easier to evaluate after reduction. Rarely, the axillary artery may be damaged as well.29 Roentgenographic evaluation usually shows a dislocation on the anterior-posterior (AP) view. An axillary or Yscapular view will differentiate anterior from posterior dislocation of the humeral head. Posterolateral humeral head compression fractures (the Hill-Sach’s Defect) has been reported to occur in 35% to 40% of anterior dislocations,’ as the soft base of the humeral head impacts against the relatively hard anterior glenoid. This defect is visualized on the AP roentgenogram with the arm in internal rotation and may be missed on routine AP views. Special internal rotation views are needed to find the defect in many patients. Anterior glenoid fractures commonly occur by the same mechanism. Greater tuberosity fractures are present in 5% to 15% of patients with anterior dislocation,’ as the rotator cuff avulses its bony attachment rather than failing in its substance. TREATMENT TECHNIQUES Four basic methods of reduction of the anteriorly dislocated shoulder have been described: Traction, leverage, scapular manipulation, and combinations of the above (Table 1). The best treatment method is one which is highly effective, quick, can be done with minimal analgesic or muscle relaxants, requires little assistance, and causes no additional injury to the shoulder. Traction methods comprise the largest group and can be further subdivided according to the position of the arm while the traction technique is applied. Hippocrates is widely

given credit as the first to describe traction methods of shoulder reduction in which he advocated traction to the abducted arm. Overhead, lateral, and forward flexed positions are also commonly used. Traction is a means of overcoming the muscle spasm around the shoulder that holds the humeral head in the dislocated position. As the muscles are gradually stretched out to their usual resting lengths, the humeral head will slide over the anterior scapular border until it is perched on the edge of the glenoid. At this point, the pull of the muscles inserting on the back of the humeral neck allow the head to spring back into appropriate anatomic position. In anterior shoulder dislocation, the humeral head is always pulled medially by spasm and rotator cuff musculature. To pull laterally on the abducted arm would seem a straightforward method of reduction. The strong pectoralis major and latissimus dorsi will give an inferior direction to the resultant traction, counter-traction vector. Abduction maneuvers, as advocated by Hippocrates and championed by many since, involve placing the physician’s foot into the axilla of the unhappy patient and effecting longitudinal traction on the abducted arm as the physician leans backwards. A commonly used alternative to this method inTABLE1. Major Reduction Techniques I Traction Methods a. Adduction (Hippocratic) b. Overhead (Milch, Cooper) c. Lateral (Eskimo) d. Forward Flexed (Stimson) I I Leverage a. Kocher b. External Rotation (Danzl, Leidelmeyer) Ill Scapula Manipulation (Anderson) IV Combinations (DePalma, Manes, Parisien)

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FIGURE 2. In the Hippocratic technique. linear traction on the arm balanced by counteraction with a sheet effects reduction.

volves using a folded sheet around the patient’s chest for countertraction. The folded sheet is held by an assistant. The elbow should be flexed 90” to relax the biceps muscle. With gradually increasing traction and gentle external rotation of the arm, reduction will occur and be felt with a clunk. In difficult reductions, anterior force on the undersurface of the humeral head by an assistant’s thumb is helpful to release the humeral head impaction into the glenoid (Figure 2). Anatomically the humeral head is being pulled caudad along the glenoid while the foot is acting minimally as a lever pushing the humeral head laterally. A second method of reduction using traction is the “Eskimo” method of lateral traction.” In this method, the patient must lie with the unaffected side on the floor while the physician and assistant lift the patient from the ground (Figure 3). Paulsen reports that the majority of dislocations will reduce within several minutes. All patients required intravenous analgesics. Seventeen of 22 dislocations were able to be reduced using this method. Boger et al and Clotteau et a15-6describe devices to allow the patient to remain supine while lateral traction is applied. Clotteau et al report the method is painless and requires no anesthesia or assistance. Boger et al studied 97 patients, all who required intravenous sedation. They report that in an average of 21%minutes, 43 of 47 shoulder dislocations were reduced, including one posterior dislocation. A fairly popular method of reduction reported by Stimson and others’S.26,33.34 involves traction in forward flexion. Originally, Stimson described placing the patient prone with the affected arm hanging through a hole cut in the cot. with a 10 lb sandbag attached to the hand. No analgesia was needed, and reduction occurred in a “few minutes”.33 Pick26 and Lippert” report the same modification, namely flexion at the patient’s elbow to 90” while applying traction. Theoretically, this will relax the biceps as well as the neurovascular structures. Pick routinely uses intravenous Valium (diazepam, Roche Laboratories, Nutley, NJ), while Lippert did not report whether medications were used. Waldron34 uses traction in forward flexion with a flexed elbow while the patient is supine. Intravenous analgesics were used in half of his patients. All methods can be done in several minutes without requiring an assistant. There is no indication as to

the efficacy by the mentioned authors. The most common of these methods is shown in Figure 4A. Traction on the forward flexed arm would seem to be contraindicated as the dislocation is usually anterior and inferior. The effectiveness of this method would argue against this theoretical difficulty. In fact, the muscles of the shoulder girdle are in spasm due to the local damage caused by dislocation. This method and others are effective in relaxing and lengthening the contracted muscles, thus allowing the shoulder to reduce spontaneously (Figure 4B). The fourth method of reduction which uses traction maneuvers is that of Milch, modified from Cooper.’ In his orig-

FIGURE 3. The Eskimo method requires at least two persons for traction against gravity.

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FIGURE 4. Patience is necessary with the Stimson hanging traction method as reduction may take 15 to 20 minutes.

inal article in 1938, Milch*’ describes the method as follows. The patient lies in the supine position while the surgeon takes his place on the side of the dislocation. The surgeon places his hand on the patient’s shoulder such that the thumb is braced against the dislocated humeral head. The surgeon’s other arm gently abducts the affected arm to the overhead position. During this maneuver, the head of the humerus is supported so that it can not move downward as the arm moves upward. As the arm is abducted, it is gently externally rotated to release the twisted capsule. Once the arm has been brought into complete abduction, the humeral head can be gently pushed over the rim of the glenoid with the thumb and dislocation reduced. Milch stated that even in “old, nervous” patients, these maneuvers can be performed without intravenous anesthesia. The technique is demonstrated in Figure 5. In his 1963 paper,” Milch states, “This method has proven universally successful without any complications.” In 1949, Milch” reported “The method has been found to be easy in its application and no bone, vascular, or nerve lesions can be attributed to its use.” Milch does not report how many patients were treated, what percentage required anesthesia, or how many failures he encountered. Lacey, I3 in 1952, reported on 18 patients reduced with the Milch technique without anesthesia. He found the technique

easier to perform with the patient prone. He emphasized the importance of taking as much time as needed to effect the reduction, as pain, with resultant muscle spasm, will hamper reduction efforts. Another modification Lacey advanced was to flex the elbow to 90”, which he believes relaxes the biceps allowing easier reduction (Figure 6). Russell, over a 3-year period, encountered 76 anterior shoulder dislocations which were treated using the Milch method.32 Eight-nine percent were reduced on the first attempt, with only 5% requiring general anesthesia, and another 5% reduced under intravenous Demerol (merperidine, Winthrop Pharmaceuticals, New York, NY) and Valium. He also stated that no complications were encountered. In 1983, Janecki reported results with the Milch maneuver.‘* Fifty consecutive cases of anterior dislocation, with and without fracture, were reduced. Sixty percent received intramuscular analgesics, 20% intravenous Valium (some in combination with intramuscular analgesia), and 34% with no medications. In conclusion, the authors were pleased with the ease of reduction and patient acceptance of this maneuver. Analgesia is often not required and, interestingly, there are no reports of failure. Anatomically, the muscles of the shoulder girdle numbering eleven, act on the proximal humerus in various directions

FIGURE 5. Traction, external rotation, and direct pressure on the humeral head are all involved in the Milch maneuver.

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FIGURE 6. Poulsen’s modification volves placing the patient prone.

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while the arm is at the side. Milch showed that when the arm is placed in the overhead position, the vectors of the muscle pull are all nearly parallel with the humeral shaft (Figure 7). Traction in direction with the muscle pull offers the simplest

FIGURE 7. Muscular vectors around the shoulder joint. A displays the shoulder with the arm at the side. B demonstrating how the vectors align with overhead placement of the arm. (Reproduced with permission from Milch H: Pulsion and traction in the reduction of dislocations or reduction dislocations of the humerus, Bull Hosp Joint Dis 1963;24:147-152.)

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and safest method of reduction according to Milch.‘“.” External rotation of the arm presents the thinnest profile of the humeral head to the glenoid and tilts the greater tuberosity backwards. thus allowing the head to slide more easily back into appropriate anatomical position. The second major type of reduction technique involves leverage. This has been popularized by Kocher and with slight modification by other authors.8.‘4.‘3 It has been pictured as far back as 1200 BC on the tomb of Rameses II.” Watson-Jones describes the technique of reduction we1L3’ Gentle, firm traction is applied to the humerus while it is gently and smoothly externally rotated by moving the forearm out to about 60” (full external rotation). While the forearm is held in external rotation, the arm is brought forward across the chest. This should effect the reduction, and the arm is internally rotated placing the affected hand on the patient’s opposite shoulder. He stressed the importance of performing the technique gently and smoothly and cautioned that it is easy to tear the subscapularis muscle or to produce a spiral fracture of the humeral neck. The technique of the Kocher maneuver is illustrated in Figure 8. This technique, with minor modification. has been advanced by several authors since Kocher. Royle” studied 39 patients who were given various intravenous analgesic and muscle relaxant agents. All but two cases (9.5%) were reduced without complications. a comprehensive review of In 1934. Nash” presented Kocher’s method. Kocher and his pupils were the strongest

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FIGURE 8. The steps included in the Kocher Technique. (A) Traction with the arm slightly away from the patient’s side. (B) Slow, gentle external rotation. (C) The elbow is brought back over the patient’s chest levering the humeral head laterally. (D) Internal rotation of the arm.

advocates of this method and found the fewest complications. Reasons for avoiding this method include the dangers of fracture, pain associated with its use, difficulty in application of the procedure, and damage to surrounding soft tissues. The reported success of the authors was 75% to 90%. In addition to the above complications, was that of axillary vein tear and associated death.29 Nash summarized his paper with a statement that “Kocher’s method for reducing dislocation of the shoulder may well be omitted from the textbooks and more physiologic methods substituted”.24 A comparison of the Milch and Kocher techniques by Beattie et al4 in 111 patients reported Milch’s technique as being less traumatic and more successful in those patients over 40 years of age with dislocations more than 4 hours old. In other patients, he suggested use of Kocher’s technique. His study was a prospective randomized trial and showed primary success rate to be 72% with Kocher’s and 70% for Milch’s technique. The patients over 40 years of age were somewhat more difficult to reduce with either method. When comparing duration of dislocation, those of less than 4 hours duration had equal chances of first reduction, although there was a decrease of success as time from dislocation to treatment increased. In those whose dislocations were more than 4 hours old, the Kocher technique was slightly more successful. In those with heavy build, reduction was much more

difficult (54% compared with 86% of slightly built people). He reports 65% success rate with Kocher in the heavy patient versus 92% with Milch. One complication was encountered, that of humeral neck fracture, after reduction by Kocher’s maneuver. Leidelmeyer14 advanced a method of leverage reduction reported as being less traumatic than the traditional Kocher method. Traction is placed on the humerus with external rotation of the forearm with the arm abducted to the patient’s side, thus performing only the first steps of the Kocher maneuver. The patients were given intravenous Valium prior to reduction, and he stated that he had been successful in 50 patients without any failures. Mirick23 applied this method to 85 consecutive patients. His use of premedication was variable. Eighty-one percent of the dislocations were reduced after the first attempt. No complications were related to the method of reduction. Fractures were evenly distributed between primary and recurrent dislocations. DanzIg evaluated 100 consecutive patients and found reduction successful in an average of 5 minutes in 78% of patients using this technique. Most were given intravenous morphine and Valium. Only one complication, that of a glenoid rim fracture noted on postreduction films, was noted. Greater tuberosity fracture or Hills-Sachs lesions were not treated differently. No breakdown of failed attempts was presented.

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Anatomically, the humeral head is resting on the anterior scapular neck. Slow external rotation will allow the head to “roll” laterally on the neck to perch on the edge of the glenoid or, perhaps, with further external rotation, to reduce it into the glenoid cavity. The Kocher method adds humeral adduction to attempt to force the humeral head laterally in addition to the external rotation advanced by Leidelmeyer and others.8,‘4,23 Figures 8C and 8D show these anatomic relationships. Scapular manipulation has been advanced by Anderson et al3 after being originally presented in a paper read before the American Association of Orthopedic Surgeons (AAOS) in 1979 by Bosley. The patient is placed in a prone position

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Milch + Failure

Obese or frail individual

A

\Muscular,

4 Stimson (zscapula manipulation)

young individual

+ Failure 1 Hippocratic

+ Hippocratic

Method

t If failure

+ If failure

+ Kocher

c Kocher

c If failure

+ If failure \ General

Anesthesia

Method

/

FIGURE 10. Reduction algorithm.

with the affected arm forward flexed to 90”. hanging off the table, with 5 to 10 lbs of traction. After 5 to 10 minutes of traction, the scapula is manipulated in the following manner. The physician pushes the tip of the scapula medially while simultaneously rotating the superior aspect of the scapula laterally. He treated 51 patients, 31 with intravenous sedation, and achieved reduction in 92%. Only 20 of his patients did not have prior dislocations. No complications are reported. The method is shown in Figure 9. Anderson believes that scapular manipulation reverses the mechanics of the original dislocation. Traction on the externally rotated humerus elevates the humeral head from the glenoid rim allowing the scapula to be manipulated back into anatomic position, effecting reduction of the humeral head. The final set of reduction techniques are those that combine various aspects of the previously mentioned maneuvers. Parisian” is a proponent of a method combining elements of leverage and direct pressure. The patient is seated in a highbacked chair with much of their weight resting on the chair through the proximal portion of the arm which is dislocated. He then slowly externally rotates the humerus with and without traction. He reports sedation is unnecessary. No failures or complications were encountered. DePalma and Flannery’ uses a variation of Kocher’s maneuver, while constant traction is applied along the humeral shaft with the arm in slight abduction. They gave sedation to all of his patients, stressing the importance of gentle reduction. DISCUSSION

FIGURE 9. Scapular manipulation involves pushing the inferior border of the scapula medially while the patient’s arm is hanging.

Many methods of reduction have been described. The physician seeing such an injury must be comfortable with one or two methods, the choice of which is related to several points. The technique one chooses should be effective, involve minimal pain to the patient, not add to the damage already done, and be relatively simple to perform. Other considerations that may be encountered include the need for

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necessary. The traction methods are the least technically demanding, whereas the Kocher and scapular manipulations involve more steps. The Hippocratic and Eskimo methods also require additional personnel. In our review of the present reduction techniques, we have developed an algorithm as illustrated in Figure 10. This is based on review of the characteristics of each technique as outlined in Table 2. The Milch method seems quite effective and minimally traumatic. For these reasons, it is our maneuver of choice. If this method fails, with adequate anesthesia, a second method would be chosen, In the obese or frail, as well as the extremely apprehensive patient, the Stimpson method of traction is effective. It has a low rate of complication and is atraumatic. The major drawbacks are positioning the patient, and the time necessary for reduction to occur. Scapular manipulation may be added at this time while the patient is prone in traction. If, on the other hand, the patient is young and muscular, the Hippocratic method with an assistant providing counter-traction with a folded sheet across the chest and into the axilla may be effective. Only after failure of these methods would we advise careful Hippocratic traction in the elderly or the Kocher maneuver in the young. In those few patients in which all attempts have failed, general anesthesia and closed reduction or, if necessary, open reduction of dislocation should be performed. There are two major indications for operative intervention; inability to reduce the dislocation or bony instability. Several structures can prevent reduction by their interposition in the joint. These include the long head of the biceps tendon, shoulder joint capsule, and greater tuberosity fracture fragment. Large fragments fractured from the anterior glenoid lip should be treated operatively to prevent late joint instability or degenerative arthritis due to articular cartilage incongruity. Displacement of a greater tuberosity fragment more than 1 cm has been reported as a reason for operative intervention, as shortening of rotater cuff musculature will result in loss of shoulder strength.

medication, the number of personnel required, and the speed of reduction. There are a few studies comparing the efficacy of one technique over another. Review of the literature discloses a 70% to 90% success rate for first reduction regardless of technique used. Those patients with avulsion fractures have a similar rate of successful reduction. The heavily muscularized individual may be more successfully reduced using the Kocher maneuver, but would be more difficult to reduce than the slightly built patient regardless of procedure. In those with an old dislocation (greater than 2 weeks), reduction may not be possible, and the risk of fracture in attempting reduction is much higher.” Waldron34 found these patients more difficult to reduce using the Kocher maneuver. Throughout the literature and in our experience, the method of Milch has been shown to be minimally painful and quite successful. In Beattie et al’s comparison,4 they state Milch’s technique was impressive because of its atraumatic nature and the ease of application. The hanging traction of Stimson is fairly atraumatic but takes the longest time to perform, which results in lying for a long period of time in an uncomfortable position. Complications have been frequently reported, both with the Hippocratic and Kocher methods. Brachial plexus palsy, or damage to frail vessels which is 50% fatalI complicates the procedure of placing the stockinged foot in the patient’s axilla. One must be careful to engage both axillary folds with the foot to avoid this. Humeral shaft and neck fractures are cited as major complicating factors to Kocher’s method. Recurrence is a long-term complication that frequently occurs after shoulder dislocation. In those under 20 years of age, 80% to 90% of patients will suffer redislocation9.16.‘7 but the frequency falls in older patients, as well as those with associated avulsion fractures.’ Other factors found to be associated with increased redislocation rate are compression fracture of the posterior humeral head and that of the anterior glenoid rim.” McLaughlin and Cavallaro” found that treatment of the primary episode of dislocation was of little importance, but the nature of the injury is what determined whether or not recurrence would take place. Postreduction, 70% of the dislocations will recur if the patient is not appropriately immobilized.29 This figure drops with longer period of immobilization until a 3-week point,” the recommended time for sling and swath treatment. Simplicity of a method is determined by the technical difficulty in its performance, as well as the number of assistants TABLE 2. Comparison

of

Major Reduction

CONCLUSION Shoulder dislocations are extremely common in the acute care setting and many techniques for reduction have been advanced. Efficacy of techniques is similar at 70% to 90% reduction on first attempt. Reduction will be more difficult in older dislocations and in muscular patients. The Kocher method is difficult in obese individuals. The Milch method is probably least painful overall, with the Hippocratic method

Techniques Hippocratic

Milch

Stimson

Kocher

Effective

70%-90%

70%-90%

70%-90%

Rapid Minimally painful Atraumatic

Intermediate Painful May cause nerve or vascular damage in elderly Somewhat more physical than others 2

Intermediate Less pain Atraumatic

Slow Less pain Atraumatic

Complex

Simple

70%-90% (may be less effective in obese, but more effective in muscular individuals Rapid Painful Spiral humeral fracture in frail patients Complex

l-2

1

1

Easily performed/learned Performed with minimal number of personnel

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most painful. The Hippocratic and Kocher methods have the worst track records in terms of complications. Recurrence rates are determined more by the original trauma than by the reduction technique used. The Stimson method is probably the simplest to learn, with the Kocher being the most technically demanding. These conclusions lead us to recommend the Milch method as a primary reduction maneuver, and to keep one or two others available for appropriate selection in the event of failure of the Milch technique. The authors would like to thank Dr. John Mosher for his careful and helpful review of the manuscript, and Barbara Delaney for her assistance in manuscript preparation.

REFERENCES 1.Kazar B, Rolowski E: Prognosis of primary dislocation of the shoulder. Acta Orthop Stand 1969;40:216 2. Rowe CR: Anterior dislocation of the shoulder. Surg Clin North Am 1963;43:1609 3. Anderson D, Zvirbulis R, Ciullo J: Scapular manipulation for reduction of anterior shoulder dislocations. Clin Orthop 1982;164:181-183 4. Beattie TF, Steedman DJ, McGowan A, et al: A comparison of the Milch and Kocher techniques for acute anterior dislocation of the shoulder. Injury 1986;17:349-352 5. Boger D, Sipsey J, Anderson G, et al: New traction devices to aid reduction of shoulder dislocations. Ann Emerg Med 1984;13:423-425 6. Clotteau JE, Premont M, Mercier V: Un procede simple de reduction sans anesthesie des luxations de I’paule. Nouv Presse Med 1982;11:127-128 7. Cooper, A: Treatise on Dislocations, and on Fractures of the Joints. Boston, MA, Welk and Libly, 1825 8. Danzl DF: Closed reduction of anterior subcoracoid shoulder dislocation, evaluation of an external rotation method. Orthoped Rev 1986;15:75-79 9. DePalma AF, Flannery GF: Acute anterior dislocation of the shoulder. Am J Sports Med 1973;1:6-15 10. Ferkel RD, Hedley AK, Eckardt JJ: Anterior fracturedislocations of the shoulder: Pitfalls in treatment. J Trauma 1984;24:363-367 11. Hussein MK: Kocher’s method is 3,000 years old. J Bone Joint Surg 1968;508:669-671 12. Janecki CJ, Shahcheragh GH: The forward elevation maneuver for reduction of anterior dislocations of the shoulder. Clin Orthop 1982;164:177-180 13. Lacey T, Crawford HB: Reduction of anterior dislocations on the shoulder by means of the Milch Abduction Technique. J Bone Joint Surg 1952;34A:l08-109 14. Leidelmeyer R: Reduced! A shoulder, subtly and painlessly. J Emerg Med 1977;223-234 15. Lippert FG: A modification of the gravity method of reduc-

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ing anterior shoulder dislocations. Clin Orthop 1982;165:259260 16. Manes HR: A new method of shoulder reduction in the elderly. Clin Orthop 1980;147:200-202 17. McLaughlin HC, Cavallaro WN: Primary anterior dislocation of the shoulder. Am J Surg 1950;80:615-621 18. McLaughlin HL, MacLellan DI: Recurrent anterior dislocation of the shoulder II. A comparative study. J Trauma 1967;7:191-201 19. McNair TJ: A clinical trial of the “Hanging arm” reduction of dislocation of the shoulder. J R Coll Surg Edinb 1957;3:47-53 20. Milch H: Treatment of dislocation of the shoulder. Surgery 1938;3:732-740 21. Milch H: The treatment of recent dislocations and fracture dislocations of the shoulder. J. Bone Joint Surg 1949;3lA:l73180 22. Milch H: Pulsion and traction in the reduction of dislocations or fracture dislocations of the humerus. Bull Hosp Joint Dis 1963;24:147-152 23. Mirick MJ, Clinton JE, Ruiz E: External rotation method of shoulder dislocation reduction. J Am Coll Emerg Phys 1979;8: 528-531 24. Nash J: The status of Kocher’s method of reducing recent anterior dislocation of the shoulder. J Bone Joint Surg 1934;16A:535-544 25. Parisien VM: Shoulder dislocation: An easier method of reduction. J Maine Med Asso 1979;70:102 26. Pick RY: Treatment of the dislocated shoulder. Clin Orthop 1977;123:76-77 27. Plummer D, Clinton J: The external rotation method for reduction of acute anterior shoulder dislocation. Emerg Med Clin North Am 1989;7:165-175 28. Poulsen SR: Reduction of acute shoulder dislocation using the Eskimo technique: a study of 23 consecutive cases. J Trauma 1988;28:1382-1383 29. Kirker JR: Dislocation of the shoulder complicated by rupture of the axillary vessels. Repeat of a case. J Bone Joint Surg 1952;348:72-73 30. Rowe CR: The Shoulder. New York, NY, Churchill Livingstone, 1988 31. Royle G: Treatment of acute anterior dislocation of the shoulder. Br J Clin Pratt 1973;27:403-404 32. Russell JA, Holmes EM, Keller DJ, et al: Reduction of acute anterior shoulder dislocation using the Milch technique: A study of ski injuries. J Trauma 1981;21:802-804 33. Stimson LA: An easy method of reducing dislocations of the shoulder and hip. Med Ret 1900;57:356-357 34. Waldron VD: Dislocated shoulder reduction: A simple method that is done without assistants. Orthopaed Rev 1982; 11:105-106 35. Wilson JN (ed): Fracture and Joint Injuries (vol 2). Edinburgh, London, Churchill Livingstone, 1976, pp 559-565 36. White D: Dislocated shoulder: A simple method of reduction. Med J Aust 1976;2:726-727