Wilderness and Rescue Medicine 8th Edition

Wilderness and Rescue Medicine 104

While you stabilize the patient’s elbow against the body, slowly externally rotate the arm while massaging the muscles around the shoulder and encouraging the patient to remain relaxed. Slight downward traction at the elbow will allow the humerus to slide rather than snap back into place. Usually, the shoulder will reduce before the limit of normal external rotation is reached. If not, hold the external rotation and continue to massage the shoulder muscles for several minutes. If reduction still does not occur, consider adding scapular manipulation or laying your patient back and trying the baseball position (both described in this chapter). The Baseball Position To reduce a shoulder dislocation using the base- ball position, first support the patient’s armwhile you help them into a supine position. Apply gentle traction on the upper arm to help relieve pain during movement. Laying the patient down may take some time. Once the patient is supine, slowly externally rotate the arm while abducting into a position about 90° from the body, with the elbow bent. It is exactly the position in which the patient would have their arm if they were about to pitch a baseball. Once the arm is in position, make yourself comfortable and begin to apply steady traction. Reduction may take up to 15 minutes.

on ice or snow. Gently and repeatedly encour- age the patient to relax their shoulder muscles. Usually, within a fewminutes, the muscles fatigue, allowing the joint to slip back into place. If the joint has not slipped back into place after about 5–10 minutes, try a move called throwing the baseball. This movement involves exactly what it sounds like. Watch the patient’s shoulder and pick a moment when you see the muscles really relax. Gently rotate the arm and hand forward as if the patient were throwing a ball. This is almost always successful in encouraging the shoulder to pop back into its socket. Scapular Manipulation Another safe reduction technique for field use is scapular manipulation. Instead of rotating the humeral head into place in the socket, slide the socket (glenoid) into place behind the humeral head. Have an assistant apply traction or exter- nally rotate the humerus while you push the lower portion of the scapula medially. This rotates the scapula to drop the socket into place behind the humerus. If you do not have an assistant, the patient may be positioned face down on anything that allows the dislocated humerus to hang off the edge. This could be lying on a picnic table, downed tree, large rock, or the deck of a boat. As with any reduction technique, slow and gen- tle manipulation with a relaxed patient will have the best chance for success. Scapular manipulation can also be used simultaneously with most other reduction techniques, including simple external rotation and the baseball position. Whatever tech- nique you use, the goal is to find the right position in which the humeral head will drop back into its socket. You will recognize a successful reduction by the dramatic relief of pain and return of mobility. You can sometimes feel and see a sudden shift of the upper arm as it relocates in the socket. A success- ful reduction can be confirmed by the patient’s ability to reach across and touch the opposite shoulder. If CSM impairment was present before reduction, it will rapidly improve afterward.

Peter Goth demonstrating the baseball position for shoulder reduction. Traction should be firm, but there should be no need for counter-traction unless you are working