Dislocation Field Reduction: Shoulder, Finger, and Hip Techniques

Before Any Reduction Attempt

Rule Out Fracture

A fracture-dislocation is common for the shoulder: the humeral head can dislocate and fracture simultaneously. Reducing a shoulder with a fracture-dislocation using standard technique can displace the fracture and damage the axillary nerve or artery.

Examination findings suggesting fracture:

• Point tenderness over the humeral head or glenoid rim
• Obvious deformity beyond what dislocation alone explains
• Crepitus on gentle palpation
• High-energy mechanism

When uncertain, treat as fracture. Splint. Evacuate.

Check Neurovascular Status

Before reduction:

• Sensation: The axillary nerve wraps around the humeral head — anterior shoulder dislocations frequently cause deltoid numbness (lateral shoulder and upper arm area). Check.
• Pulse: Brachial and radial pulses. Axillary artery involvement is uncommon but serious.
• Motor: Can the patient move fingers normally?

Document what you find. This is your baseline for evaluating post-reduction status.

Pain Management

A significant contributor to reduction failure is muscle spasm. Pain causes guarding; guarding causes spasm; spasm prevents reduction.

Adequate analgesia before reduction:

• Ibuprofen 600mg — takes 45 minutes to work but reduces muscle inflammation
• Ice over the joint — reduces local pain and spasm
• Calm, unhurried technique — patient anxiety dramatically worsens spasm. Explain what you are doing. Speak calmly.

Nitrous oxide, intravenous benzodiazepines, and ketamine are the ED tools. You probably do not have them. Technique, patience, and patient cooperation replace pharmacology.

Shoulder Dislocation

The shoulder is the most commonly dislocated joint. More than 95% are anterior dislocations — the humeral head displaces anteriorly, below and in front of the glenoid. The patient typically presents holding the arm slightly away from the body, unable to internally rotate.

Classic sign: Loss of the normal rounded contour of the shoulder, replaced by a squared-off appearance.

Method 1: FARES Technique (Recommended)

The FAst Reliable Safe (FARES) method has the highest success rate in clinical studies and can be performed without an assistant. It works through rhythmic oscillation that gradually fatigues the spastic muscles.

1. Position the patient lying on their back. Stand on the affected side.

2. Hold the patient's wrist with your dominant hand. Use a firm, comfortable grip. Your other hand is free to assist.

3. Begin gentle traction: Apply continuous, gentle longitudinal traction along the arm axis. Start with the arm by the side.

4. Slowly abduct the arm while maintaining traction. Move the arm outward and upward (abduction) at approximately 2 degrees per second. Very slowly.

5. Begin gentle oscillation: While moving the arm upward, gently bounce the arm up and down in small rhythmic oscillations — roughly 1-2cm amplitude, about 2 cycles per second. These oscillations gradually overcome muscle spasm.

6. Continue until 90 degrees of abduction is reached. At this point, externally rotate the arm slowly (turn the palm to face the ceiling) while maintaining traction and oscillation.

7. The reduction is felt as a clunk — a palpable and audible click as the humeral head seats back into the glenoid. This is usually associated with immediate relief for the patient.

Success rate: approximately 80-85% in clinical studies, with most failures being in patients with significant fracture-dislocations.

Method 2: Scapular Manipulation

Works well for patients who cannot lie down. Requires an assistant.

1. Patient seated or standing, assistant provides forward traction on the arm (pulling the arm forward and down with gentle force).

2. You stand behind the patient. Place your thumbs on the inferior angle of the scapula (the bottom tip of the shoulder blade).

3. While the assistant maintains gentle traction, rotate the inferior angle of the scapula outward (away from the spine) while pushing the superior aspect toward the spine. This changes the orientation of the glenoid, allowing the humeral head to slip back in.

This requires finding the scapula anatomy reliably — practice on an uninjured person first to learn the landmarks.

Method 3: External Rotation Method (Cunningham)

Low-force technique, no assistant required.

1. Patient seated. Elbow at 90 degrees, arm adducted (held against the side).

2. Massage the biceps, deltoid, and pectoral muscles to reduce spasm. Spend 3-5 minutes on this step.

3. Slowly externally rotate the arm (turn the elbow outward, palm facing forward, then upward). Move at a rate the patient can tolerate — stop if resistance or significant pain.

4. When the forearm reaches 90 degrees of external rotation (pointing toward the ceiling), the shoulder typically reduces.

Post-Reduction: Shoulder

1. Confirm reduction by palpating the normal rounded shoulder contour.
2. Recheck neurovascular status.
3. Apply a sling with the arm across the chest.
4. No heavy lifting or overhead activity for 4-6 weeks.
5. Immobilize for 2-3 weeks minimum — repeated dislocations occur without adequate healing time.

Finger Dislocation

Finger dislocations are typically at the proximal interphalangeal (PIP) joint — the middle knuckle. The finger deforms dorsally (middle section of the finger pointing backward).

Contraindications

Do not attempt reduction if:

• A fracture is suspected (crepitus, obvious angulation at the joint, high-energy mechanism)
• The joint is locked open with a skin interposition
• The dislocation is volar (the finger bends forward rather than backward) — volar dislocations often have a trapped volar plate

Reduction Technique

1. Explain the procedure. This will hurt briefly.

2. Provide whatever anesthesia you have. A digital nerve block is ideal: inject 1-2ml of lidocaine on each side of the finger base where the digital nerves run (at the 2 and 10 o'clock positions at the base of the finger). This eliminates most pain.

3. Hold the hand firmly. Have the patient, or an assistant, hold the hand stable.

4. Grasp the tip of the dislocated finger. Apply firm, steady longitudinal traction along the long axis of the finger.

5. While maintaining traction, push down on the dorsal surface of the middle segment — exaggerating the deformity slightly before reducing it. This disengages the bone from the locked position.

6. While maintaining traction, flex the finger to reduce it. A click confirms reduction.

7. Confirm: The finger should now have a normal contour and improved range of motion.

Post-Reduction: Finger

Buddy-tape to the adjacent finger for 3-4 weeks. The patient can use the finger for light activity immediately — buddy-taping allows movement while protecting against re-dislocation.

Hip Dislocation

Hip dislocations are 85-90% posterior — the femoral head is forced behind the acetabulum. Caused by high-energy mechanisms: car crash with a knee striking the dashboard, falls from height, sports injuries.

This is the most serious dislocation for field reduction. Posterior hip dislocations have a 10-15% incidence of avascular necrosis of the femoral head (blood supply interrupted) — a complication largely related to time from injury to reduction. Every hour the hip remains dislocated increases the risk. Reduction within 6 hours substantially reduces avascular necrosis risk.

Assessment: The leg is shortened, internally rotated, and adducted (knee pointing toward the midline). The patient is in significant pain.

Contraindication: Femoral neck fracture. A fracture-dislocation of the hip requires surgical reduction. Assess for fracture tenderness.

Reduction Technique (Requires Assistant)

1. Patient on the ground, on their back. You need to work over the patient.

2. Assistant stabilizes the pelvis — hands placed on the iliac crests, applying downward pressure to prevent the pelvis from moving.

3. You position over the patient. Bend the patient's hip to 90 degrees (knee pointing at the ceiling) and bend the knee to 90 degrees. The patient's lower leg points horizontally.

4. Grasp the proximal lower leg or back of the knee. Apply in-line traction along the axis of the femur — pulling upward (toward the ceiling) from your position over the patient. This requires standing or kneeling over the patient and using your body weight for traction rather than just arm strength.

5. While maintaining traction, gently internally then externally rotate the hip — this facilitates disengagement. Reduction is felt as a clunk.

6. Alternative: Allis maneuver (may be easier with very limited setup): Patient supine, you stand over them with your foot planted beside their hip, grabbing their flexed knee with both hands, and applying upward traction using leg drive.

Post-Reduction: Hip

Once reduced, the patient needs immediate imaging to verify reduction and assess for acetabular fracture. Non-weight-bearing with evacuation. Hip dislocations require orthopedic follow-up for a minimum of 6 weeks.

Watch for: femoral nerve or sciatic nerve symptoms (numbness down the leg, weakness in knee extension or ankle movement). These may be present from the injury and should improve post-reduction, or they indicate nerve entrapment that requires urgent surgical attention.