by Paul Auerbach, M.D.
reposted with permission
This
post is contributed by Dr. Jeremy Joslin, an avid outdoor enthusiast
who is currently training to become an emergency physician.
Here goes:
After
a long day trekking through Utah's canyon country, you decide to start
heading back to camp. Three days from a car, and an hour away from
camp, your hiking partner slips while stepping over a downed tree and
catches his arm on the large trunk while falling. As he scrambles back
to his feet, he cries out in pain and cannot seem to move his right arm
at the shoulder. He knows the feeling, and tells you exactly what's
happened: he's dislocated his shoulder again.
Anterior
dislocation (where the head [or “ball” of the ball-and-socket joint at
the shoulder] of the humerus, which is the large bone of the upper arm,
is dislocated forward in relationship to the socket) is the most common
type of shoulder dislocation and happens when the arm gets pulled away
from the body quickly (abduction), as in the scenario above. Shoulder
dislocations are quite painful, and if you are near medical attention,
that's where you'll want to head. In the meantime, if you're sure the
shoulder is dislocated, waste no time in “reducing” it (putting it back
into place). Prompt reduction is beneficial for the joint.
In
order to help determine if a shoulder has, indeed, been dislocated, I
will reference the Wilderness Medical Society Practice Guidelines for
Wilderness Emergency Care (2nd edition)
(1), which lists these four features:
• Restriction of motion through the joint's normal range
• Obvious deformity in comparison with the uninvolved side
• Crepitus, or grating, of bone fragments is absent
• Often a typical, identifiable posture of the dislocated joint, which the patient will maintain to minimize pain
Once
you've determined that the shoulder has been dislocated, you may want
to attempt reduction. There are numerous methods of reduction for an
anterior shoulder dislocation. My favorite technique for reduction is
the Milch technique. Have the injured person sit, stand, or lie flat on
his or her back, and then slowly reach, using the hand of their
dislocated shoulder, behind their head and try to touch the opposite
shoulder. Somewhere on the very slow, steady reaching, the shoulder
will align itself and pop back into place. Another way to describe the
positioning is to pantomime a pitcher's "wind up" before a pitch using
the affecting side. Have the patient take their time and slowly reach
upward and backwards as if they were going to pitch a baseball. If the
"wind up" is slow enough, with plenty of rest if needed, you'll get the
shoulder to pop back into place. This maneuver can be done solo or with
assistance. If you are assisting, cup the victim’s elbow, giving it
support and guiding their arm through the maneuver. Your other hand can
be placed on their shoulder to apply support to the joint as it goes
through the motion.
Why do I appreciate this maneuver so much? Here are my specific reasons:
• Compared with other maneuvers to reduce shoulders, this one seems to be the least painful.
(2) •
Some medical providers swear that if the technique is done correctly
and slowly, then the patient doesn't even need pain medication.
(3)(4) • It is easily described and easy to remember (the baseball pitch).
• It can be done for self rescue (just take your time and go as slow as possible).
• In my hands, this maneuver has been more successful than other techniques.
I'd
like to hear about your favorite technique), or if you've ever needed
to reduce a shoulder in the wilderness setting, how you achieved
success. Finally, if you're interested in reading more about this very
historic subject, begin by following the
link to an interesting article.
Posted
Dec 11 2007, 11:41 PM
by
Outdoor Ed