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13 Articles in Volume 11, Issue #6
A Diet for Patients With Chronic Pain
A Practical Approach to the Management Of Diabetic Neuropathy
Book Review: Handbook of Pain Assessment, Third Edition
Diagnosis of Neck and Upper Extremity Pain
Diet and Nutrition For Patients With Pain—The Time Is Here
Dislocated Shoulder: Approaches to Lessen The Pain of Reduction Techniques
Guide to Dietary Supplements Most Commonly Used in Pain Management
New Device Combines Acupuncture With Four Other Technologies to Alleviate Pain
PPM Editorial Board Outlines Nutritional Advice for Chronic Pain Patients
Prospective Study of a Lumbar Back Brace In an Interventional Pain Practice
Q&A: The Legal Implications Of Medical Marijuana
Smoking and Pain
The Skeptical Radiology Nurse

Dislocated Shoulder: Approaches to Lessen The Pain of Reduction Techniques

Clinicians should not underestimate the severity of shoulder dislocation pain. Painless reduction techniques and local anesthesia can be quickly applied in an emergency room arena.

The extensive mobility of the glenohumeral joint lends itself to frequent injury, particularly anterior shoulder dislocations. Shoulder dislocations account for 45% of all joint dislocations.1 Routine treatment involves reduction of the humeral head back into the glenohumeral joint. Many reduction techniques are available, including the Milch, Kocher, Stimson, and Bosley techniques. If one technique fails, physicians can switch to another technique without having to reposition the patient, thus avoiding additional pain.2

For many patients, the most urgent complaint in the emergency department (ED) is excruciating pain during reduction. Several methods are available to relieve this pain, including IV medication with midazolam-fentanyl (conscious sedation) or propofol (deep sedation), intra-articular lidocaine, inhaled nitrous oxide and oxygen (Entonox), and brachial plexus blocks.

Currently, there is no consensus among physicians as to which technique provides the most effective and least harmful medication for reduction. A combination of factors are considered when choosing analgesia, such as cost; need for monitoring after the procedure; available personnel; physician’s preference, experience with reduction technique, and experience using analgesia; and any comorbidities the patient may present with, such as osteoporosis and/or humeral fractures.2 Certain reduction techniques, however, require no premedication because they do not inflict pain on the patient while being performed.3,4

The objective of this article is to evaluate the various methods and medications for managing pain when reducing dislocated shoulders.

Painless Reduction Without Anesthesia

In managing a patient with an anterior dislocated shoulder, a few techniques have been shown to be effective without the use of any medication for pain relief. These include the Kocher and Milch techniques.5 Theodore Kocher described his technique in 1870 by saying, “Bend arm at the elbow, press it against the body, rotate outwards until resistance is felt. Lift the externally rotated upper arm in the sagittal plane as far as possible forwards and finally turn inwards slowly.”5-7 These movements physiologically help to relax the biceps and stretch the internal rotators, which allows the humeral head to fall into place.7 In a study by Anand et al, 16 of 16 shoulder dislocations were successfully reduced using the Kocher technique without the need for sedation or analgesia.5


Kocher, Milch techniques

Although it generally is performed without analgesia, modifications in the technique have required the use of analgesia and sedation at times. Kocher did not include traction in his original technique, and when applied it generates excessive pain by stretching soft tissue and inducing muscle spasms, which necessitate the use of medication.5-7

The Milch technique is another painless method used to reduce anterior dislocated shoulders. First described in 1938, this technique combines abduction, traction, and pressure on the humeral head. In order to reduce a dislocated shoulder using the Milch technique, the physician stands on the side of the dislocated shoulder and first places the elbow into flexion. The arm is then abducted and externally rotated as the physician grasps the humeral head to keep it steady. The humeral head is then pushed back into the axilla with direct pressure from the physician’s grasp. The idea behind these maneuvers is that the forces created by the muscles cancel each other out, thus reducing stress and creating a resultant force that is parallel to the shaft of the humerus.2,7,8 A 1986 study by Beattie et al found that 72% of patients treated with the Milch technique were successfully reduced on first attempt, did not require medication, and had no postprocedural complications.9

When the two techniques are compared, the Kocher method has been associated with complications such as surgical neck fractures due to physicians attempting to overcome muscle spasms. Other disadvantages of this technique include difficulty in positioning obese patients, spiral fractures in the shaft of the humerus, axillary nerve injuries, and increased likelihood of recurrent dislocations (see Table 1). Alternatively, the Milch method has been reported to be a painless procedure that does not cause various complications and trauma to the humerus.7 However, both techniques offer the advantages of quick recovery, less time spent in the ED, and a decreased need for medical staff to monitor patients.10

Table 1. Advantages vs Disadvantages of Pain Management Techniques

Interscalene Brachial Plexus Block

Interscalene brachial plexus blocks, first described in 1970, are a relatively new method of anesthetizing the shoulder prior to surgery and reduction of dislocated shoulders. Underhill et al performed interscalene brachial plexus blocks on 30 dislocated shoulders, of which 29 were anterior and 1 was posterior.11 The block was performed by turning the patient’s head away from the affected side and then palpating for the interscalene groove along the lateral aspect of the anterior scalene muscle, which contains elements of the brachial plexus nerves that are necessary to block for anesthesia to the shoulder and arm. Of the 30 cases that were performed, 26 blocks were successful at abolishing or relieving pain, muscle relaxation, and reducing the dislocated shoulder using a mixture of 1% lidocaine, adrenaline, and 0.5% prilocaine. Many of the blocks had worn off before the patients left the ED and did not require intense monitoring by medical staff.11

Many anesthesiologists perform interscalene blocks for shoulder surgeries and use nerve stimulators that produce twitches of the biceps, triceps, and deltoid muscle, which helps to identify the proper location to administer the block. Newer technology has allowed for ultrasound guidance when administering interscalene blocks rather than the use of less accurate landmarks in determining the site of the block.12 Complications of the block (see Table 1) include transient Horner’s syndrome, hoarseness due to recurrent laryngeal nerve palsy, phrenic nerve palsy, and vascular bleeding due to the misplacement of the needle.11 These nerve blocks also have a potential risk for joint infection if sterile technique is not used.2 Several benefits include the relatively quick onset; lack of need for continuous or long-term monitoring; absence of conscious sedation, which may predispose a patient to aspiration and hypoxia; and the ability to also relax the muscles surrounding the joint.11


Entonox, a combination of 50% nitrous oxide and 50% oxygen, is another option for reducing dislocated shoulders in the ED. The gas is delivered from a gas cylinder to a face mask, which requires the patient to create an airtight seal when self-administering.13 This method was used by Gleeson et al, who compared the effects of Entonox with intra-articular lidocaine when reducing shoulders in 31 patients. Of the 16 patients who received Entonox, 10 reported having a painless reduction compared with 5 of 15 patients in the lidocaine group.14 The only reported adverse event (AE) that developed in the group of patients who received Entonox was the formation of a hematoma due to traction, which resolved spontaneously after IV sedation and analgesia were given to complete the reduction.14

Like all treatments, Entonox presents with its own unique advantages and disadvantages (see Table 1). Potential problems that could arise include nausea, vomiting, inhaling foreign contents such as gastric particles, theoretical risk for infection, and a decrease in respiratory drive. This lower respiratory drive occurs in patients with chronic bronchitis who rely on the low oxygen concentration within their bodies in order to breathe. This “hypoxic respiratory drive” diminishes once a patient receives a steady flow of oxygen via the administration of the 50% oxygen in Entonox. Elderly patients and those who lose consciousness are not able to create the tight seal, which can lead to the mask falling off and improper use. Patients also must have a patent airway and be capable of producing enough negative pressure for the flow of gas from the face mask. Some advantages of Entonox that have been reported include a decrease in anxiety and nausea triggered by pain.13

IV Medication


Ample studies have shown propofol to be effective in a variety of ED procedures, such as chest tube placements, cardioversion, and several orthopedic techniques.3 Because of its rapid onset and short-acting sedative, anesthetic, and muscle relaxant qualities, it is becoming more popular in reducing dislocated shoulders. Taylor et al performed a study comparing the “wakening times, muscle tone, ease of reduction, reduction failure rates, and adverse effects” of propofol with the benzodiazepine and opioid combination of midazolam-fentanyl during reduction.3 The study showed that of the 48 patients who received propofol, there was only 1 failed reduction, with a mean time to first awakening of 3.4 minutes and a mean time to full wakefulness of only 7 minutes. The mean score of ease of reduction was reported to be 2 out of 5, with 2 representing an “easy” and 5 a “very difficult” reduction. The muscle tone as reported by the physicians was noted to decrease when using propofol, thus making the reduction easier.3

However, propofol is not without its drawbacks. Of the 48 patients, 11 experienced respiratory depression, 4 experienced a decrease in respiratory rate, 4 had a drop in oxygen saturation, 6 suffered from partial airway obstruction, 3 experienced pain at the infusion site, and 1 vomited with no aspiration.

Although the rapid sedation and wakening times make it an ideal choice, propofol possesses the risk for AEs such as these and others, including deep sedation, respiratory depression leading to possible apnea and hypoxia, pain on injection, and bacterial contamination. Ultimately, the most advantageous qualities of propofol are its fast onset and short half-life, which decreases the time and resources needed for observing and monitoring the patient after reduction.3

Not only is propofol beneficial because of its fast onset, but according to Rosenberg et al, who analyzed the cost-effectiveness of desflurane versus propofol, the cost of propofol was reported to be relatively inexpensive at $0.05/mL (see Table 2).15


The combination of midazolam and fentanyl is commonly used to provide outstanding sedation and analgesia despite its potential AEs. In 2002, Miller et al conducted a study comparing this combination with intra-articular lidocaine in 30 patients with dislocated shoulders using the Stimson technique for reduction. Miller evaluated the patient’s pain, the number of successful reductions, the average time in the ED, and the cost of using the medications.16 Of the 14 patients who received midazolam and fentanyl, 11 were successfully reduced on the first attempt and remained in the ED for approximately 185 minutes. Miller reported that the average time for reduction took 8.5 minutes in this group.

The cost of midazolam-fentanyl was approximately $97.64, with $87.57 due to observation and monitoring by nurses for 3 hours postreduction.Although this combination has been reported to have many AEs, there were no complications in this study, and no additional medications were needed during the reduction.16

This study was complemented by Taylor et al, who reported that 35 of 38 attempted reductions with IV sedation using midazolam-fentanyl were successful, with first awakening occurring at 8 minutes and full wakefulness at 28.5 minutes.3 AEs with the benzodiazepine-opioid combination included respiratory depression in 6 patients, a decrease in respiratory rate in 1 patient, a drop in oxygen saturation in 2 patients, partial obstruction in 5 patients, pain at the IV site in 1 patient, and hypotension in 1 patient.

Contraindications to using IV sedation, whether propofol or midazolam-fentanyl, include having ingested food or fluids within 4 hours prior to administering medication, use of recreational drugs or alcohol within 6 hours, airway difficulty, and pregnancy. Although the AEs of the combination medication are possible, these side effects are rare.3

Intra-articular Lidocaine

Recent studies have shown intra-articular lidocaine to be an effective muscle relaxant as well as to provide adequate analgesia when used. Its analgesic effect comes from its ability to stabilize nerve cell membranes, thus inhibiting afferent pain signals. In a study conducted by Paudel et al, 15 patients with dislocated shoulders were treated with intra-articular lidocaine.17 These patients received 20 mL of 1% lidocaine, which was administered into the glenohumeral joint via a 20-gauge needle. Patients were required to wait 15 minutes for the lidocaine to stabilize the nerve fibers before any form of reduction was attempted. In the end, all 15 patients were successfully reduced, and Paudel noted that patients who were reduced within 3 hours after dislocation were easier to reduce. None of the patients had AEs, and none were hospitalized.17

Miller et al reported that of 16 patients who received intra-articular lidocaine, 14 were successfully reduced on first attempt, with an average time of 11.4 minutes until reduction was complete.16

The total cost of intra-articular lidocaine was shown to be considerably lower—only $0.52 for the reduction, with patients spending an average of 75 minutes in the ED.16 Advantages of this method include the low cost, lack of IV access needed, a shorter duration of hospital stay, and lack of need for medical staff to observe and monitor the patient after reduction (see Table 2).17 There are many advantages, and very few, if any, disadvantages have been reported. Theoretical and potential AEs that may occur include septic arthritis and lidocaine toxicity in traumatic shoulder dislocations where lidocaine could possibly enter the systemic system.18


Although shoulder dislocations are commonly treated with closed reduction techniques, many different methods of relieving pain can be used during reduction. In order to effectively treat patients, it is imperative that physicians not underestimate the severity of patients’ pain. Current studies suggest that intra-articular lidocaine is an effective means of reducing pain, with minimal AEs and extremely low costs. Its plethora of benefits, such as not requiring patient monitoring after reduction, makes it an ideal choice because it leaves medical staff available to handle other emergencies.

As illustrated in Table 2, intra-articular lidocaine is extremely cost-effective, with a low price of $0.32 versus $6.21 for the combination of midazolam-fentanyl. The need for observation time by nurses with the use of midazolam/fentanyl contributes to an increase in cost. In addition, the amount of time required for patients to remain in the ED is much shorter in those receiving intra-articular lidocaine (75 vs. 185 minutes with the benzodiazepine-opioid combination).16

Table 2. Cost Comparison of Medications Used in Reducing Dislocated Shoulders

Physicians who are familiar and comfortable with using painless reduction methods, such as the Milch and Kocher techniques, may have very favorable outcomes because AEs from medications will not be an issue. Understanding the anatomy of the shoulder is crucial in order to cancel out the forces exerted by the muscles and reduce the humeral heal without eliciting pain. When performed correctly, these methods, especially the Milch technique, result in minimal AEs.

It is important to note that patients must constantly be assessed after medications are given and before reduction is performed to ensure muscle relaxation and a painless reduction. Physicians should be experienced in various reduction techniques and in administering several medications and should be cognizant of patients who are at risk for AEs from certain medications. More studies and evaluations with larger sample sizes are needed to get a better understanding of the effects of the medications and the reasons doctors are choosing more expensive and problematic medications. Ultimately, the use of medications will be dictated by the availability of resources to the physician and his or her prior experience and knowledge with the medication at hand.

Last updated on: September 2, 2011
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