Anaesthesia for reduction of anterior dislocations of the shoulder.

Abstract

Letters to the Editor 71 Anaesthesia for reduction of anterior dislocations of the shoulder Sir, Further to Mr A. Banerjee's letter to your journal regarding the requirement of anaesthesia for reduction of anterior dislocations of the shoulder, while agreeing with him that anaesthesia is not necessary for the majority of patients, I would like to point out that in the original description by Theodore Kocher published in 1881 there is no mention of traction during the manoeuvre. In fact, Kocher describes flexion at the elbow with the arm parallel to the chest, lateral rotation of the humerus, flexion at the shoulder, adduction and lastly internal rotation. He claimed that anterior sub-coracoid dislocation of the shoulder can be reduced without either assistants or anaesthesia, provided that neither the glenoid rim nor the greater tuberosity were fractured and that capsular damage was not so extensive that the bone surfaces were not held apposed. In our department we have used Kochers method without anaesthesia or analgesia for 42 consecutive anterior subcoracoid dislocations of the shoulder since August 1990 with a success rate of 40 out of 42. The two failures were due to undiagnosed greater tuberosity fracture, and subsequently required general anaesthesia.

Efficacy of the assisted self-reduction technique for acute anterior shoulder dislocation

“…Hence the original Kocher technique, without traction, results in an effective-assisted self-reduction method. Our excellent success rates agree with those already reported by the few investigators who used the original Kocher technique [12][13][14][15][16].…”

“…Most investigators agree that the main problem in treating shoulder dislocations arises by the muscular contraction which accompanies all shoulder dislocations making the reduction difficult and painful [4,5,9,10,[12][13][14][15][16].…”

“…The traction, described in a large number of technique raises several problems: the pain caused by the traction increases the muscle contracture making the reduction trying and poorly tolerated by patients [4,5,9,10,[12][13][14][15][16][17]; it increases the risk of procedural complications such as humeral neck fractures (mainly in osteoporotic bones), brachial plexus and axillary nerve damage [4,5,7,9,10,[12][13][14][15][16][17][18]. Although unusual, the literature describes occasional risks for the operator: Pimpalnerkar et al [19] observed the case of a resident orthopaedic who suffered a total pectoralis major tendon rupture while tractioning a dislocated shoulder.…”

“…The ''original'' traction-free Kocher's method [11] to perform the reduction of a shoulder dislocation has been recently reviewed by many authors with excellent results regarding the success rate and the control of the pain [12][13][14][15][16]. Some authors speculated that it can be self performed by patients under the guide of the physician, in this way, it can be considered an ''assisted self-reduction'' technique and it results both effective and simple to perform [12,13].…”

Closed Reduction Techniques for Acute Anterior Shoulder Dislocation: from Egyptians to Australians

“…7,37 Kocher did not recommend traction which was added later. 7,11,37,38 The usual description is as follows: -I. Gentle, firm, downward, longitudinal traction is applied to the humerus, with the arm slightly away from the patient's side.…”