Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
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.
Muscle cramps are involuntarily and forcibly contracted muscles that do not relax. Extremely common, any muscles that have voluntary control, including some organs, are subject to cramp. Since there is such variety in the types of muscle cramps that can occur, many causes and preventative medications are known. Stretching is the most common way to stop or prevent most muscle cramps.
A frozen shoulder (adhesive capsulitis) is when the shoulder joint experiences a significant loss in its range of motion due to inflammation, scarring, or injury. Treatment involves anti-inflammatory medication, cortisone injections, and physical therapy.
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