Tuesday, November 03, 2009

Use the Force... I'm Serious


Most docs find something in their areas of expertise that they just have a knack for, and for me that thing is reducing dislocated shoulders without sedation. Now this sounds barbaric, especially if you remember Mel Gibson in Lethal Weapon very dramatically dislocating and relocating his own shoulder to either kill the bad guy or screw the hot chick... can't remember, but it ain't like that bro'. The quicker the shoulder is reduced the less pain experienced, period.

Now I am not the only doc who can do this and most ortho guys can do it but most docs see a dislocated shoulder and just order up the meds and figure they will end up giving them anyway so they don't bother with a gentle tug.

Here's where 'the force' comes in... My little trick is to get complete focus from the patient and complete agreement that getting their shoulder in place now is much better for all involved than waiting thirty minutes to get that first Xray and set up for conscious sedation. Most folks will let me try and here's what I do.

I talk the patient through the procedure... I watch their eyes... and slowly, ever so slowly, I extend their dislocated extremity up into a sort of Roman salute... Usually, near the apex, a 'clunk' lets me and the patient know that all is well. Start to finish, about three minutes.

Of course, there are those people, usually those that tell me that they have a 'really high pain threshold', who can not relax their muscles enough for me to perform this maneuver and propofol here we come.

But the trick, the real trick, is getting that patient to trust you and listen. There, I may retire in peace now.


15 comments:

  1. Oh, of all things that I might pass out over. I can do GI bleeds, burns, etc. and the rest. But I cannot even watch sports replay if a limb is going to go "elsewhere" in slow motion under a pile of bodies. Now it can be totally contorted and open on the table and it's no problem. I just cannot watch you reduce it. Ugh.

    -SCNS

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  2. I have had about a 50% success rate with scapular rotation while having the patient hold a 10lb sand bag, just as long as the patient is not obese.

    I have used the technique you wrote about also for stubborn anterior disloactions with great success.

    One other method I have used is having the patient standing with the affected arm at their side, with gentle traction while pronating and supinating the arm it will usually slip right back in.

    Just a few other methods I have had success with.

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  3. Whats with the presbyopic digram??? 6 feet from the monitor and its still as blurry as America's future.
    And I think Riggs dislocated his shoulder to get out of a straight jacket...

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  4. There, I may retire in peace now.

    Sorry, toots, you're too young to retire.

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  5. That is how my shoulder was relocated...on Vail's back bowl no less by my ex ER doc boyfriend.....I think he was more diaphoretic than me....lol....we are still good friends...so that does say something. There was NO way in hell I was going down the rest of that mountain with my shoulder like that......OUCH!

    Seriously....I ALWAYS try to convince my ER docs to do this....with little to no success.....most will not even consider it. They just don't understand...while that shoulder is out..it's sweat and vomit inducing pain...once back in..it's "ahhhh....that is so much better" And NEVER done without an x-ray......it's enough to drive me batty.

    Is there some danger in attempting a reduction if there is also a fracture?

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  6. Jennifer,

    Not really. Pre-reduction films for should dislocations are a great example of CYA(cover your ass) films to prove that any fracture identified didn't occur due to the relocation attempt. Never mind that these types of fractures usually have good clinical outcomes anyways. Still got to watch out for the old NPD.

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  7. Yeah, I usually first try the maneouvre where I get the a patient to reach other his or her head with the affected limb and touch the opposite ear. Works about 25-30% of the time I would guess.

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  8. pussies

    foot in armpit then pull...hard

    done

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  9. Etotheipi ~ That's 'cause the dead ones don't complain if you accidentally pull their arms off.

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  10. For some reason I am the go-to -guy for reducing displaced mandibles. Don't know what I do different, but it always seems to work.

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  11. my answer to the pre-reduction Xray is this... if it's a 90 year old patient i want the film because i don't want to pull on a fracture-dislocation without sedation. if it's a healthy patient with a classic dislocation story then i'll try it.

    eto',
    the foot in the armpit trick may work well on your patients but it comes with too many complications... nerve damage etc... stay near the slab bizzle.

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  12. Been there - on the patient side. With a broken clavicle to boot...

    Ouch. But yeah - sweet relief when it's over...

    DD

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  13. I have been so lucky to have dislocated my shoulder 25+ times. Always from an overhead position with forward momentum. Originally, in High School spiking a volleyball. Fortunately for me, the football 'trainer' taught me Cynic's 3rd method minus the traction: bringing my elbow to my side then slowly wrapping my arm around my stomach, starting with the palm facing up and rotating the so the palm is facing my body. Two pop pops and it is back in. Worked every time except once when I finally conceded to go to the ER and a 'bump' in the road took care of it on the way. The relief of getting it back in makes the need to heave go away instantly. The only downside of getting it in myself...I have had more than one Dr. not believe me. Ah well, not too important except when I needed a new shoulder immobilizer. Thanks for all you do everyone!

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