How to Reduce a Dislocated Shoulder in the Backcountry
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.
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.
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.
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.
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.