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What Lies Beneath

What Lies Beneath

Consider the Shoulder

Johnston, Michelle MBBS

doi: 10.1097/01.EEM.0000731744.95662.18
    Figure
    Figure:
    shoulder dislocation, relocation
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    Figure

    Eponymous nomenclature is a little on the nose these days. For much of medicine's history, many distinguished men have laid claim and put names to medical terms.

    Nowhere has the ownership of body parts been more colonially masculine than in the flag-plant of gynecological terms. You can hardly turn a corner in the female pelvis without running into a structure named by and for a man. Robert Buttner, MBBS, Jessica Lee, MBBS, and Mike Cadogan, FACEM, took fair and true aim at this anachronistic practice, and have promulgated the worthy cause of anatomical de-eponymization. (EMN. 2020;42[10]:29; https://bit.ly/2Io4nFp.)

    Annexing procedures, however, is still fair game, and there are few states of taxonomy as energetic as the naming ways of enlocating shoulders.

    I recently had an elderly patient as a category one emergency with a shoulder injury. She was 84 and had had an unwitnessed fall. Her shoulder was in a peculiar position, and she had no radial pulse and an ischemic hand. Indeed, on presentation, she had a true Luxatio erecta, with her hand perched above her head and that hand pale and pulseless.

    Inferior shoulder dislocations are uncommon, and even more rare is an associated axillary artery injury (despite the monotony with which we teach our juniors about neurovascular complications). This is particularly so for low-energy incidents, such as a fall. The term Luxatio erecta is refreshingly anonymous, not yet truffled over by man, and literally means dislocation erect, referring to the positioning of the arm above the head when the humeral head subluxes directly inferior to the glenoid.

    There are several proposed techniques for enlocating inferior dislocations, but in my series of three, I have found the most reliable is to apply upward traction with a firm, guiding hand on the humeral head, which converts an inferior dislocation into an anterior one. Expediency was of the essence in this case, and the conversion of the inferior into an anterior dislocation resulted in the rapid and happy restoration of a radial pulse.

    No Superior Technique

    But now to the choice of enlocation techniques for an anterior dislocation. There are more named techniques to choose from than a phone book (and some are equally obsolescent). The only thing that this demonstrates is that there is no one superior technique. All experienced clinicians I know use their own hybrid escalation of techniques, a gumbo of described procedures (which I suspect they subconsciously dub with their own name). Several have a higher rate of collateral injury, however, and should be avoided where possible.

    Most procedures for enlocation are variations on a theme of traction and leverage. The original description was by our man Hippocrates (460-377 BCE). His method was all about traction and countertraction, using any sort of lever in the axilla to assist (a stick, ladder rung, etc.). Into the modern era, the countertraction progressed into the operator's own body, and it was recommended that a stockinged foot be placed into the axilla as the fulcrum.

    Kocher, of course, described the fancier technique using leverage alone. The true, original Kocher technique had no traction, and relied primarily on slow external rotation and lifting in the sagittal plane before gentle internal rotation to complete the maneuver. The later addition of traction simply tended to add complications, such as muscular and bony injuries. Kocher may have felt pride in his description in 1870, but he had been pipped by about 3000 years. A similar depiction of enlocation was discovered on the Egyptian tomb of Ipuy, dating back to 1200 BCE, just going to show that there is little new under the Luxor sun. (Image.)

    What Next?

    The other eponymous techniques are legion. Milch in 1938 modified Sir Ashley Cooper's 1825 leverage technique, where the arm is gently abducted and externally rotated all the way into an overhead position, and the operator can guide the humeral head with his other hand.

    Stimson has the patient prone, with a bound weight on the wrist to provide traction and muscle relaxation. Add to that scapular rotation (has nobody claimed this yet?) pushing the tip of the scapula medially while rotating the superior aspect of the scapula laterally.

    We also have Matsen's traction-countertraction, Spaso's vertical lift with alternating internal and external rotation, and the more gentle Manes with a flexed forearm in the axilla and a slow proximal and lateral pull. We have Eskimos and Snowbird, giving the patient control and autonomy in places as advertised by the names. We have Cunningham and FARES, providing muscle relaxation as part of the procedure. I have no doubt you know of more.

    Opportunity and possible fame await. What technique next?

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    Dr. Johnstonis a board-certified emergency physician, thus the same as you but with a weird accent. She works in a trauma center situated down the unfashionable end of Perth, Western Australia. She is the author of the novel Dustfall, available on her website, http://michellejohnston.com.au/. She also contributes regularly to the blog, Life in the Fast Lane, https://lifeinthefastlane.com. Follow her on Twitter@Eleytherius, and read her past columns at http://bit.ly/EMN-WhatLiesBeneath.

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