‘To Pull or Not To Pull’

Abstract

Shoulder dislocations are the most common joint dislocations seen in the emergency department. It is estimated that 14,000 people with a shoulder dislocation are seen in the emergency department each year in the Netherlands. The dislocation causes a lot of pain for the patient, rapid reduction of the shoulder reduces the pain and prevents further tissue damage. Since ancient times, many different techniques have been described and are still used today. The founder of 'Western' medicine, Hippocrates, has given his name to one of the most well-known reduction techniques. Frequently used reduction techniques are based on traction and/or leverage. Although these techniques provide a good chance of success, they are often painful and require sedation of the patient, which is time consuming and has the need for additional personnel. In recent years, therefore, alternatives have been sought and more attention has been paid to biomechanical reduction techniques. These techniques are based on muscle relaxation and seem to cause less pain. The central question in this thesis was: “What is the preferred technique for reducing anterior shoulder dislocation without the use of additional analgesic techniques?” In this thesis we looked at which techniques are used in the emergency department, which factors influence the duration of the emergency department visit, compared the existing literature on reduction techniques, and compared a number of biomechanical reduction techniques in a controlled study with outcomes relevant to the patient. The outcome is that it is particularly important for the patient that the practitioners have insight into the cause of the pain and reason for persistence of the dislocation. In addition, there must be knowledge about the mechanism of action of the various reduction techniques. The difference between the groups of reduction techniques is limited on the bases of success, yet since biomechanical reduction techniques on average cause less pain they are therefore the preferred primary technique with lever techniques as a second option.