Fig. 1
Description of reduction techniques: The pictures were taken at the emergency department of the Diakonessenhuis by the authors from a volunteer. Scapular manipulation. How to perform. Seated scapular manipulation allows the patient to remain seated upright. Facing the patient, a physician or assistant grasps the wrist of the patient’s affected side and slowly raises this to the horizontal plane and let the palm of the hand face upwards (exorotation) (Fig. 1a). Firm, but gentle, forward traction is applied with counterbalancing provided by placing the palm of the extended free arm over the patient’s midclavicular region. The force required in applying this traction is not great. Once gentle traction is applied, a second physician or assistant manipulates the scapula by applying constant pressure on the abducted inferior tip of the scapula to the medial, while holding the upper part of the scapula and putting pressure on this to the lateral. This allows the abducted inferior tip of the scapula to be rotated bringing the scapular neck and glenoid fossa into the correct alignment (Fig. 1b). It sometimes takes some time (minutes) before the muscles relax and the scapula moves. The shoulder is reduced when the scapula moves and the assistant feels the humeral head moving back in anatomical position [15]. Modified Milch. How to perform. Dislocated shoulder of the seated patient is positioned in an analgesic position by externally rotating the extended arm and slightly abducting anterolateral. This will decrease tension on m. infraspinatus, m. terres minor, and m. supraspinatus (Fig. 1c). Gently abduct the exorotated arm until reduction is achieved, often around 140–160° (Fig. 1d). Placing a thumb in the armpit can prevent the humeral head from sliding medially. No traction is used, but the arm is kept on length by the physician. After completing the 180° abduction, the arm is moved back in front of the patient to a neutral position. The procedure is painless, but sometimes gives discomfort when the humeral head is moving back in place. If there is pain while abducting the arm the speed of movement should be slowed down and/or a more anterior or posterior trajectory of the abduction can be followed [9, 16]. Cunningham. How to perform. The patient sits upright against a hard surface (i.e., chair of upright bed), the affected arm adducted to the body and the elbow fully flexed. The operator kneels/sits next to the patient and places his wrist onto the patient’s forearm (no pressure, this adds discomfort to the patient), the patient’s hand resting on the operator’s shoulder (Fig. 1e). It is important to keep the injured arm close to the body of the patient and flex their elbow to relax the bicep muscle. The patient is asked to shrug the shoulders superiorly and posteriorly, which “squares off” the angle of the shoulder (reducing scapular anteversion and the static obstruction of the glenoid rim). Start with the trapezius and deltoid muscles and afterwards move to the bicep muscle (Fig. 1f). Then, the biceps is massaged at a mid-humeral level to specifically relax the muscle (removing dynamic obstruction). The massage by the physician is not to relax the muscles, but to make the patient conscious of their muscle tension. Reduction is often after a couples of minutes and is expected when the shoulder contour has been restored [9]