shoulder relocation

[forrest_m]

learned a neat trick this weekend for relocating a dislocated shoulder in the field and thought i'd pass it on. (i am not a doctor, nor any kind of medical professional, just an impressed observer.) as some of you may know from experience, a dislocated shoulder is about the most painful non-life-threatening injury out there.

we were descending from the base of synchronicity, up in lillooet, and came across a guy who had taken a long tumble down the steep and icy approach gully. he had stopped himself by grabbing onto a tree, which had wrenched his shoulder out of joint. after checking him for other injuries, we tried several techniques to get it back in (raising the arm over the head, etc.) but without success. as darkness was falling and it is several miles back to the car, we immobilized his arm by in a sling and concentrated on getting him down to flat ground.

just as we reached the creek, we were joined by another team coming down from the climb, and one of them, a week after finishing his WFR course, was able to relocate the shoulder in the following way:

one assistant kneels behind the victim, and a sling or triangular bandage is passed around both their chests and tied fairly snugly. assistant #2 kneels about 105 degrees from the first, i.e. not straight in a line with the injured arm, but about 10-15 degrees more towards the front. he ties a sling aroung his chest and the crook of the injured arm. all the victim has to do is concentrate on relaxing while both assistants simultaneouly lean gently backwards. we could clearly see the humorus moving beneath the skin like an alien baby, until it suddenly snapped back into place. (creepy!) immediate relief followed for the victim; we replaced his arm in the sling to protect it from further damage, and he was able to walk the rest of the way out to the car with minimal assistance.

it occurred to me that in a pinch (like, say, there is only one person), the first assistant could be replaced by an immovable object, like a tree. don't know if this would work.

[erik]

forrest one thing to note with shoulder dislocations is you should see what direction the should came out.....i had the dislocation problem for two years before i got it fixed and i learned and used several different methods for putting it back into place....

another thing to note is do not try to put a shoulder back into place unless you have skilled instruction.....i have heard of people damaging nerves and other tissues by attempting to rejoint it.......

thanks for the beta though

[Courtenay]

I definitely agree with Erik; make sure if you're going to do this that you've had the appropriate instruction and have either seen it done several times, or have practice doing it with supervision. Those people who commonly have this happen may be able to guide you through what they need, but I know from the description alone I'd be concerned about having to do it myself. Neat trick, though, wish they included stuff like that in today's MOFA courses...

[Figger_Eight]

I've never seen it done that way before. Cool.

[dr._jay]

most (>95%) of all shoulder dislocations are anterior, meaning that a lateral force is applied to the head of the humerus (the part that sits in the shoulder joint) while the arm is out away from the body. the head slips forward out of the joint space and ends up in front and below of the shoulder when looking straight on.

its pretty easy to diagnose because you can usually feel the round end of the humerus sitting in front where its not supposed to be. also the now empty joint feels hollow and even concave where the bone came from. sometimes its not so straightforward if there is big shoulder muscles but if you're noct convinced the shoulder is dislocated then it probably isn't.

nerve damage can be assesed by checking strength and sensation in the hand and fingers.also the deltoid should be checked because the nerve that goes to it is the most commonly injured one. if there is any loss of function the quicker the shoulder can be relocated the better. fractures are pretty uncommon and usually not significant if they happen.

the key to any successful reduction is adequate muscle relaxation, so unless you've got some pretty big guns in your first aid kit this will be the limiting factor. no amount of tugging and pulling will get a shoulder back in if the muscles are too tense. using gentle movements and slow, gradual increases in force, the idea is to pull the head of the humerus over the rim of the shallow cup and back into the normal joint space.

there are many methods or reduction but the general idea is all the same, it just depends on which ones you've seen or used before and how much pain the patient is in. the easiest and most gentle one especially for people with no experience uses gravity to do the work so you can't do any additional damage by pulling the wrong way. the patient has to get themselves laying face down on something high enough in the air to allow the arm to hang straght down, like a fallen tree or rock. then grab something heavy (like a pack)or better hang it from the arm with a sling, and relax. this one is harder with buff patients and also usually takes the most time, but it also requires the least amount of experience. a little medial pressure on the bottom of the shoulder blade can help align the joint space better so it doesn't take as much force to realign things.

once the joint is back in place it can be prety easy to slip out again becasue the ligaments are so loose so its important to keep the arm down by the body, and it can be easily stabilized this way without hindering the ability to get around.

now i'll just take a moment for a little disclaimer: all i'm trying to do here is give you all a little more information about a relatively common injury. it isn't a lesson plan so use it at your discretion. this being said i hope you never have to do it yourself but it never hurts to have as many tricks up your sleeve as you can remember. and please don't sue me if something goes wrong.

Cheers,

Jay

[ 02-11-2002: Message edited by: dr. jay ]

[taz]

i dislocated my shoulder once, but it was posterior my friend and i has set a TR on a 5.hard route our first year, then when i greased off... pop! i had him lower me off while i cradled my arm. when i got down i couldn't move it or curl my fingers. when i turned around so my back faced him i heard an alarming "holy shit!". "duuuude your arm". so i looked over that shoulder and saw a bump the size of a baseball under my shirt and above my shoulder blade so he's like "well, you know what you've got to do...". yep. so in preparation for the big pull i tried to relax and gave my wrist a little tug/roll then slurp... it was in! ahhhh the relief. then i laid down and passed out about 30min later i awoke to see my friends (above mentioned buddy and 3 girls that were with us) climbing another route. so i got up, straightened my shit out, gave the shoulder a little roll test, and got back on the rock! i swear having the girls there had nothing to do with my lack of responsible decision making

[ 02-11-2002: Message edited by: taz ]

[W]

Erik,

Yes in fact this shoulder dislocation was anterior, and quite obvious upon visual inspection of the bare shoulder.

I'm a former EMT and my protocol told me not to attempt to reduce the dislocation (my EMT was not a wilderness oriented course). I had seen a shoulder dislocation once before, and the guy raised his arm over his head because it gave him comfort- the relaxation it gave him caused his arm to pop back in suddenly. After trying that very gently with this guy, we decided to act no further, immobilize it, and simply get him down to flat ground. It was very fortunate that Wes from Vancouver showed up with his partner Paul. Wes, who did the relocation, very clearly had practiced what he performed, and knew what he was doing.

I agree that stuff like this should not be attempted without prior training, which is to say I would highly recommend a WFR or Wilderness EMT course for all climbers.

One of my climbing partners is a former wilderness EMT and was trained how to decompress a tension pneumothorax. They essentially tell you-

"you shouldn't ever do this to someone in the city, however...if it's your buddy in the middle of nowhere, here's how to save his/her life" and they proceed to show you how to plunge a knife and a hollow pen or tube between ribs #1 and #2 intercostal spaces and let the air out.

So there is a great deal of benefit from taking one of these courses. Until I get a chance to renew my EMT and retrain, I will say that if I see this injury again in the middle of nowhere, I would have to at least consider trying it given that I assisted in one already. Meanwhile- I think I may look into taking some more courses in advanced mountain medicine. Believe me, there is nothing worse than facing a serious medical situation when help is nowhere near.

[erik]

nice work boyz(w, forrest & other dudes)

and i thing to note is that a good friend 'with experience' tried to relocate it once and all that happened is that i passed out from the pain.....so i am leary when anyone wants to relocate a shoulder......

[W]

Erik,

As the patient you have every right to be wary of someone who claims to be experienced. Even if someone insists they are a paramedic or an EMT, you have the right to refuse treatment. If that person is really in fact trained properly, they will do nothing more than suggest that you allow them to treat you, but ultimately, if you refuse treatment that is the last word on the matter. An EMT is actually required by code to obtain permission to treat, doing otherwise is not only unethical from a human standpoint but opens them up to all sorts of liability issues. For others, there is the so-called "good-samaritan" law which means that if you give Joe-schmoe permission to treat you and he screws you up despite his best intentions, it would be very hard for you to obtain damages in court if he is not an EMT or licensed care provider. So ultimately, whether to let someone treat you is your call; having a high degree of training yourself is not only useful for helping others but will help you to determine if someone trying to treat you actually knows what they are doing.

[hakioawa]

I have quite a bit of experience in this area. I've dislocated my left shoulder about 20 times and had 2 surguires. The second one seems to have taken. Here are my sugestions.

First forget what you saw in lethal weapon. You cannot simply slam it back in. If you do it is likely to do trememdous dammage! Second, time is of the essance. the quicker the relocation happens the better. With time, the muscles tend to tense up and it becomes much harder to relocate. I'd say if you are more than 2 hours from medical attention trying to relocate a shoulder is a good option. But be aware that you may fail.

The most important thing is for the patient to relax. It is really really painful. But relaxation helps a lot. Sit them down, give them a dirnk of water. Talk to them. Tell them to relax every muscle in thier body. Feel for tense muscles and tell them to relax them. Make them WORK at relaxing them. If you have any pain killers give them to the patient (with mophine my shoulder generally goes in by itself!). They may not help but the placebo effect will be in full swing.

Whatever method you choose two things are important. Go Slow and listen to the patient. The relocation process should not be terribly painful. At least not much more so them just sitting around with a dislocated shoulder. For me the relocation can take 15 minutes of slow steady pressure/motion. It takes time. And the slower you go the more likely you are to suceed.

What ever you do, once the shoulder is re-locatied, or you give up, stabilize the shoulder with a sling or two.

Good luck

[speed]

I took a WFA course for Solo in NH a while back. Here's what I was taught: Assess the patient. Do they have circulation? (e.g. check for distal pulse) Is there any nerve damage? (e.g. can they move their fingers?) If they lack circulation in the limb, it is an emergency and something needs to be done soon. What I was taught was that after 6-8 hours without circulation, the limb will die and usually have to be amputated. If you can get the person out and to a medical facility in short order (i.e. 1-2 hours), don’t relocate the joint in the field. Let a trained medical person do that if possible. This is where MOFA and urban first aid differ. In the outdoors, you generally cannot get the person to the hospital in time so you need to perform the relocation in the field. The choice is usually, “risk further damage by attempting to relocate” or “loose the limb”. Again, as someone previously stated, this is the patient’s choice. Most people will opt, in that situation, to risk the relocation. Give the person the information and choice and let them decide. Respect their wishes.

I looked over a couple of books I have and found an interesting note. In “NOLS Wilderness First Aid” they say that primary thing to worry about is circulation. More specifically, ensure that they patient has circulation to the limb. This is because of the risk of permanent damage done over time if blood does not flow to the limb. Nerve damage is not as urgent. Damage to a nerve is usually immediate and may be irreparable (especially in the field).

NOTE: I am not a medical professional. This was what I was taught, take it as such.

speed