How to Reduce a Dislocated Shoulder in the Backcountry by dianegaydos | Apr 22, 2014 | Beginner Moves, Intermediate Moves, JK University, Whitewater | 3 comments How to Reduce a Dislocated Shoulder in the Backcountry This article was written for the new KayakEducation.com website that will be released this spring, 2014. Check it out! Whether or not this is a topic you have personally had to deal with on the river, you have probably thought about it. How do you put the shoulder back in place? Should you put the shoulder back in place? While this is in no way an extensive guide, hopefully it will help clear up a few things. Disclaimer: This article is meant to be an introductory guide and does not replace wilderness first aid training. If you do not feel comfortable with the technique or the patient experiences increased pain at any point, STOP, and reassess. 1. Decision to Treat Is it an anterior (forward) dislocation? This guide only applies to anterior dislocations. With that said, around 95-97% of shoulder dislocations are anterior and only 2-4% are posterior (backward). While less common, posterior dislocations can occur while kayaking, especially if the shoulder pops out by forcefully hitting a rock. If you suspect a posterior dislocation, DO NOT attempt to reduce. Evacuate the patient to the nearest emergency department. Should you try to pop it back in? Wilderness Medicine studies agree that reduction of simple dislocations in the wilderness setting by non-medical personnel may be safe, effective, and significantly decrease the time to reduction. The longer a shoulder is dislocated, the more difficult it is to reduce and the more likely long-term complications will occur. Plus, reduction will immediately decrease the patient’s pain, making evacuation easier. When not to? If it is a posterior (backwards) dislocation. If the patient’s arm or clavicle is broken in addition to the shoulder dislocation. If the patient has life threatening injuries or conditions. If you do not feel comfortable reducing the shoulder. 2. Assess First, make sure the shoulder is dislocated. There are plenty of other shoulder injuries that can occur while kayaking and we don’t have room to get into all of them. If the shoulder is dislocated, it will appear deformed compared to the other side and the shoulder loses its rounded shape (see picture below). The patient will also resist movement and will hold their arm away from their body. If you suspect an injury other than, or in addition to, a shoulder dislocation, DO NOT attempt to reduce it. It is possible to also fracture the clavicle (collar bone) or the humerus (upper arm bone) and it is important NOT to reduce the shoulder in these cases. Before you attempt the reduction steps below, gently push on the patient’s clavicle to make sure it’s not broken. Check CSM (circulation, sensation, motor). Touch the outside of the patient’s injured shoulder to ensure that they can feel you touching them. The most commonly injured nerve is to this area. Next, check the patient’s pulse at their wrist, grip strength by having them squeeze your hand, and motion of their arm. Compare all of these to the uninjured side. Remember to also check CSM after the shoulder reduction to compare to how it was prior to the reduction. 3. Position and Technique There are tons of different ways to reduce a shoulder. I’m going to describe the two that I think are the easiest to use in the backcountry. For both techniques, make sure the patient first gives you consent to treat. Then, go slow and gentle. Method 1 Find a large rock or picnic table where the patient can lie on his stomach with the injured arm dangling towards the ground but not touching it. The injured shoulder should be just off the edge of the rock so it is dangling free. Slowly pull gentle, constant traction on the arm. A good way to do this is to have the patient hold a helmet in the dangling hand and place several rocks in it so it weighs about 10 pounds. Be patient, this technique could take 5-10 minutes. Continue the steady traction until you hear or feel a “clunk” which means the shoulder has gone back in the joint. If at any point, the patient experiences increased pain, STOP. Method 2 Have the patient lie on his back. Bring his elbow in by his side and bend the elbow to 90 degrees so his hand is pointing towards the sky. Keeping the elbow bent, slowly rotate the arm away from the body. Stop every few degrees to allow the muscles to relax before continuing. Continue until you hear or feel a “clunk” which means the shoulder has gone back in the joint. If at any point, the patient experiences increased pain, STOP. 4. After Reduction After the shoulder has successfully gone back in the joint, now you need to stabilize it. Slowly and carefully, bring the injured arm across the patient’s body to sling and swathe. Immobilization is important so that dislocation does not reoccur during evacuation. Re-check the CSM: patient’s pulse at their wrist and their grip strength by having them squeeze your hand. Both should be strong and present. If not, evacuate the patient immediately. Make your plans to hike out and take the patient to the nearest emergency department for evaluation. Have fun and be safe out there! ~Diane Gaydos The writer of this article is a medical student, however information contained herein has been collected from sources believed to be reliable, and every precaution has been taken to ensure its accuracy. The information provided here is for general informational purposes only, and should not be used as a substitute for professional medical care. 3 Comments James Sorrentino on April 26, 2014 at 5:10 am I was a paramedic for 30 years. I would advise you not try to reduce a dislocation in the field, generally speaking. Why? Legal liability. I can’t tell you how many dislocated shoulders I took to the hospital during my career. Maybe 25. The first thing a trained ER physician does is take an xray. He/she would never reduce a dislocation before taking an xray. He is protecting himself as well as his patient by doing this. I do not believe the “Good Samaritan Act” would protect you in this case. This is not considered simple rendering of first aid. You can exacerbate the patient’s situation by attempting this. Tear an artery, vein, nerve. Make a small fracture worse. Cause a victim to go into shock. The only time I might do this is if it was my good friend or family member or if the person states they have dislocated their shoulder a few times before. Never do this to a minor without parental consent and a witness to that. It’s a bit of a shame we have to concern ourselves with legalities at such a time – especially when the person is in extreme pain. But, we do. Or, at least, we should be concerned. Reply Ross on May 5, 2014 at 6:53 pm I’ve reduced my own (anterior) shoulder dislocations over ten times, mostly in developing countries a/o the backcountry (I’ve since had it surgically corrected). Usually I’ve done it while still sitting in my kayak. I’m not a doctor so take this with a grain of salt (and no liability!), but what has worked for me every time is: 1) bring your knees to your chest 2) interlock fingers of both hands around the knee/shin on the opposite side of the dislocation 3) slowly lean back and press with your shin until it pops back in The setup seems to put you in a natural position for reduction, allows you to stop immediately if the pain is too great, and is very quick. Sometimes in the backcountry you’ve got to do whatever works. Reply Rob Pealing on May 6, 2014 at 1:30 pm I am a physician with 30yrs of hiking, mountaineering and kayaking behind me. I think James makes some good points. I would only attempt this if I was very very confident that there is nothing other than a dislocated shoulder and if evacuation was not possible. You would not be able to paddle home or continue climbing after a reduction, so the victim is still reliant on friends. Although it sounds easy my experience has been it is not always so, and I have had to anaethetise some people while the orthopaedic surgeons reduce them and sometimes they struggle. Reply Submit a Comment Cancel replyYour email address will not be published. Required fields are marked *Comment * Name * Email * Website Save my name, email, and website in this browser for the next time I comment. Δ
James Sorrentino on April 26, 2014 at 5:10 am I was a paramedic for 30 years. I would advise you not try to reduce a dislocation in the field, generally speaking. Why? Legal liability. I can’t tell you how many dislocated shoulders I took to the hospital during my career. Maybe 25. The first thing a trained ER physician does is take an xray. He/she would never reduce a dislocation before taking an xray. He is protecting himself as well as his patient by doing this. I do not believe the “Good Samaritan Act” would protect you in this case. This is not considered simple rendering of first aid. You can exacerbate the patient’s situation by attempting this. Tear an artery, vein, nerve. Make a small fracture worse. Cause a victim to go into shock. The only time I might do this is if it was my good friend or family member or if the person states they have dislocated their shoulder a few times before. Never do this to a minor without parental consent and a witness to that. It’s a bit of a shame we have to concern ourselves with legalities at such a time – especially when the person is in extreme pain. But, we do. Or, at least, we should be concerned. Reply
Ross on May 5, 2014 at 6:53 pm I’ve reduced my own (anterior) shoulder dislocations over ten times, mostly in developing countries a/o the backcountry (I’ve since had it surgically corrected). Usually I’ve done it while still sitting in my kayak. I’m not a doctor so take this with a grain of salt (and no liability!), but what has worked for me every time is: 1) bring your knees to your chest 2) interlock fingers of both hands around the knee/shin on the opposite side of the dislocation 3) slowly lean back and press with your shin until it pops back in The setup seems to put you in a natural position for reduction, allows you to stop immediately if the pain is too great, and is very quick. Sometimes in the backcountry you’ve got to do whatever works. Reply
Rob Pealing on May 6, 2014 at 1:30 pm I am a physician with 30yrs of hiking, mountaineering and kayaking behind me. I think James makes some good points. I would only attempt this if I was very very confident that there is nothing other than a dislocated shoulder and if evacuation was not possible. You would not be able to paddle home or continue climbing after a reduction, so the victim is still reliant on friends. Although it sounds easy my experience has been it is not always so, and I have had to anaethetise some people while the orthopaedic surgeons reduce them and sometimes they struggle. Reply
