Shoulder and Elbow Reduction

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 ( Fig. 9.1 )

  

• 2.

  Medial physeal clavicle fractures

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 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.

Improvisation

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

Equipment

• 1.

  A sling

• 2.

  A figure-of-8 strap (alternative)

Basic/Detailed Technique

• 1.

  A sling (see Chapter 13 )

• 2.

  A figure-of-8 strap (see Chapter 13 )

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 1–3) ( Fig. 9.2 )

  

• 2.

  Severely displaced AC separations (grades 4–6) ( Fig. 9.3 )

  

Precautions

Do not attempt heroic measures to reduce AC separations.

Pearls

• 1.

  AC separations with severe displacement or soft tissue interposition (grades 4–6) should be surgically reduced 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, then a simple scarf or a towel can be used.

Equipment

A sling

Basic/Detailed Technique

A sling (see Chapter 13 )

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 ( Fig. 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 Fig. 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, this can result in a forearm fracture.

• 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 to not attempt a reduction and instead 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 else this may result in a fracture.

Pearls

• 1.

  Be patient; the stability of the shoulder is largely provided 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 immediately available.

• 6.

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

Improvisation

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

Equipment

• 1.

  Two bedsheets

• 2.

  A stretcher

• 3.

  Medications for conscious sedation

• 4.

  A sling or a gunslinger brace (if available)