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M2E Too! Mellick's Multimedia EduBlog

The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Monday, June 27, 2016

Davos Technique Gains Traction for Shoulder Dislocations

Multiple methods are touted for reducing anterior shoulder dislocations, and every emergency physician seems to have gravitated to one or two methods that he uses routinely. Why someone prefers one technique over another is not clear, but the factors for technique selection seem to be training, ease of application, and prior successful experiences.

Every reduction procedure will have some degree of applied rotation, torque, and traction, and pain is a common and unavoidable theme. Unfortunately, not all shoulder reductions are created equally. Variations in human anatomy, time duration of dislocation, and the actual location of the humeral head relative to the glenoid fossa will contribute to the reduction technique selection process. Consider the worst-case scenario of the intoxicated weight lifter who presents after dislocating his shoulder many hours earlier.

Our attempts to overcome the serious muscle spasm holding the humeral head in its newly found location involve rotational torque, traction force, leverage maneuvers, relaxation techniques, and medications. Unfortunately, some reductions will still require a visit to the operating room and general anesthesia. And some shoulder dislocations can be successfully reduced without pain and muscle-relaxing medications, but those are less frequent and are usually performed immediately after the dislocation event.

Some procedures are definitely more expedient than others and how busy the emergency department is at the time of presentation may determine the method. Those are the procedures that simply lets the patient reduce himself while you are seeing other patients. On the other hand, a procedure like the traction-countertraction technique requires procedural sedation, more than one operator, and prolonged force, and it ends up being an endurance contest between the patient and the clinicians. The Stimson technique comes to mind when I think of expedient shoulder reduction procedures. The patient lies prone with the affected extremity hanging off the edge of the bed with 10 to 15 pounds of weight attached while the emergency physician continues managing the emergency department.

But now the Davos Technique for anterior shoulder dislocation reductions enters the scene. The technique was described recently in The Journal of Emergency Medicine. (2016;50[4]:656.) It is known as the Davos technique because the physicians who first described it worked at Davos hospital in Switzerland. In reality, this technique has been around for a while, and was first described in 1993. (Z Unfallchir Versicherungsmed 1993;Suppl 1:215; Helv Chir Acta 1993;60[1-2]:263.) Nevertheless, it has never gained traction until now, if you'll pardon the pun. The Davos technique has been described as a nontraumatic, patient-controlled, and auto-reduction technique that does not require the use of anesthesia. (J Orthop Trauma1997;11[6]:399.) It is used only for anterior dislocations, and has a reported success rate of 60 to 90 percent. (J Emerg Med 2016;50[4]:656; J Orthop Trauma1997;11[6]:399.)

The reduction procedures steps are described as:

  • Standard pain and muscle relaxation medications can be used for these patients.
  • The patient sitting on the gurney holding the injured extremity with the other hand is asked to flex the ipsilateral knee as much as possible.
  • The physician assists the patient to place both hands in front of the flexed knee.
  • The hands are then tied together using an elastic band at the wrist joint, not the fingers. (This allows the patient to avoid crossing the fingers, possibly increasing muscle tension.)
  • The elbows should be kept close to the thigh to assist muscle relaxation.
  • The physician or nurse sits on the patient's foot and may help stabilize the wrists against the anterior tibia.
  • The patient is instructed to lean his head back and to let his shoulders roll forward (shrug), extending and relaxing all the muscles. The neck extension exerts a constant traction on the injured shoulder, and the dislocation is reduced without any additional maneuvers.
  • Once reduction occurs, the usual and standard post-reduction interventions, such as radiographs and sling application, are performed.
  • ‚ÄčI could not independently confirm the information, but this method has reportedly been used for more than 20 years by US Navy Seals and US Marine Corps Reconnaissance. When shoulder dislocations occur during fast boat recovery, they go to the back of the Zodiac or combat rubber reconnaissance craft to reduce the dislocated shoulder using this technique, among others. (Personal communication.)

I would rank shoulder reduction techniques from greatest to least use of required force in this order:

9. Traction-countertraction technique
8. Stimson technique
7. Milch technique
6. External rotation technique
5. Spaso technique
4. Fares technique
3. Scapular manipulation
2. Davos technique
1. Cunningham technique (Read an article about this method in the June 2011 issue of EMN at http://emn.online/1OkBjFn.)

Two of these techniques can potentially be accomplished while the emergency physician continues managing the emergency department. Of course, any medicated patient still requires an emergency nurse carefully monitoring the reduction. Nevertheless, traction forces are set in motion by the Stimson and Davos techniques and don't necessarily move along faster with the physician in the room. Even though the Davos technique requires someone sitting on the patient's foot and stabilizing the bound wrists, it probably doesn't have to be the physician. Nevertheless, for safety reasons a member of health care team, not a family member, should fulfill this role.

Watch a video of the Davos technique being performed.
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Watch a second video showing 10 other ways to reduce a dislocated shoulder.
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