Amitabh Mitra*
Retired Head of Emergency Medicine and Gender Based Violence in a tertiary hospital in Mdantsane, Eastern Cape, South Africa
Received:11 September, 2024; Accepted: 29 October, 2024; Published: 05 November, 2024.
Citation: Amitabh Mitra. “Reduction of Anterior Dislocation of Shoulder in Mdantsane, a South African Township by Mitra’s modification of Kocher’s Technique.” J Neur Imag Neur Med (2024): 107. DOI: 10.59462/ JNINM.2.1.107
Copyright: © 2024 Mitra A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Kocher’s technique is widely used for reduction of Anterior Dislocation of shoulder by Orthopaedic Surgeons and Emergency Medicine Physicians. Due to a wide frequency of patients coming to the Emergency Medicine Department, I tried a modification of Kocher’s technique and taught my junior colleagues’ ways to reduce easily an Anterior Dislocation of shoulder within minutes.
History
Mdantsane is the second biggest African township after Soweto in South Africa. The struggle for the fight against Apartheid started from these two townships. Democracy came in 1994 after the fall of Apartheid government. From 1994 onwards till this date, alcohol related injuries and interpersonal violence related to alcohol is on the rise. 3) Various dislocations of the body is related to alcohol and motor vehicle accidents.
Emil Theodor Kocher ((25 August 1841 – 27 July 1917) was a Swiss Physician, known for his works on the thyroid gland. He received the Nobel Prize in Medicine and Physiology in 1909. In 1870, he became famous for the technique he used for reduction of Anterior Dislocation of Shoulder [1]. Known as the Kocher’s technique, it’s still being used by Orthopaedic Surgeons and Emergency Medicine Physicians. 4.
1. Recurrent Anterior Dislocations due to enlargement of the Capsular Sac
2. Habitual Anterior Dislocations due to the need of the pleasure of sedative. Age – 30 and above
3. Acute Anterior Dislocations
Injury – Fall on an outstretched hand but more due to pub fights causing extreme turning at the shoulder and a tear of the capsule. Externally rotated and extended arm assaulted by a trauma. Rotator Cuff Tears and fractures of the Glenoid Labrum are usually associated with acute dislocations of the shoulder.1)
Some anterior dislocations present in the Emergency Medicine Department, within half an hour of its occurrence and some may come hours and days after dislocation. Those who come late are not possible to reduce because of development of fibrous tissue and clotted blood within the joint. They have a better chance in opening and reducing the shoulder by surgical techniques. Therefore, a detailed history and examination of neurovascular deficit is essential.
Patients present themselves with abduction and external rotation of the affected arm, held by the uninjured hand. Movements are restricted and a neuromuscular deficit of the axillary nerve
Prominence of the head of humerus, anteriorly and the feeling of empty glenoid, when examined posteriorly.
Injury to the axillary nerve and even brachial plexus is a neuropraxia and is reversed after reduction.
Anteroposterior, lateral, oblique and axillary views are taken.
Relaxation with conscious sedation, the use of intravenous Pethidine 100 mg and Valium 10 mg is used. The dose is increased with muscular, alcohol dependence and reduced with poor musculature and the age of 60 plus.
Waiting for 20 minutes after intravenous injection and proper sedation is seen and felt. Its important to have an Intravenous Normal Saline 10 percent line be given on the other uninjured arm.
1. Kocher’s technique should not be used in patients over the age 70 The bony osteoporosis of the humerus may cause a secondary fracture while externally rotating, one should confirm beforehand that the patient is sedated and relaxed [2].
2. Remove clothes over the injured shoulder.
3. Kocher gives us the following directions.
4. Hold the 90 degrees flexed forearm at the elbow with your left hand and the hand with your right hand.
5. Using a slight traction, externally rotate the injured shoulder and at the same time adduct the shoulder by pushing the elbow towards the abdomen.
6. Continue the external rotation and adduction to the extreme, pushing the elbow towards beyond the chest or abdomen.
7. The hand is internally rotated and and placed on the opposite shoulder.
8. There will be a sudden click and and one can feel the head going inside the Glenoid cavity
9. There will be a sudden reduction in pain and the shoulder curvature looks normal.
10. Rest, Cuff and Collar Sling and Check Xray of Post reduction.
1. Being a shallow joint, its most prone to dislocations in teenagers.
2. Numbness, weakness and tingling due to the involvement of Axillary nerve from dislocation of the shoulder.
3. Blood vessel damage showing as bruising around the shoulder.
4. Tearing of muscle, ligaments and tendons around the shoulder joint 5.
I have been using the Kocher’s technique for reduction of Anterior Shoulder since 1979, in India, Kingdom of Bhutan, Niamey, Niger, Bulawayo, Zimbabwe, Mthatha, Republic of Transkei and at Cecilia Makiwane Hospital, Mdantsane, Ciskei [3].
The problems I faced, at all times:
1. The patient shifted from the couch during reduction
2. Some patients fell to the floor and the need for nurses to lift the sedated patient back on the bed
3. The sedation came off and the patient needed to be resedated and waiting again till the patient is stable
4. Re triaging needs to be done to check clinical parameters
5. Darkening of the skin of the shoulder due to axillary nerve damage and hemorrhage
6. To counter these, I realized that a stabilization of the Acromioclavicular joint is needed.
1. Check Sedation and stable clinical parameters
2. Request a nurse or a junior doctor to use the thin plastic body shield
3. Turn it into a rope
4. Ask your assistant to go towards the head of the patient and gently turn it around the axilla.
5. Tell your assistant, not to apply any traction.
6. This will hold the acromioclavicular joint and the shoulder joint.
7. The body will continue to lie in a supine position and will not turn or fall off the stretcher
8. Continue with the Kocher’s technique.
9. It would be much easier to reduce than
I have taught this simple modification to thousands of doctors and nurses who do the reduction of Anterior Shoulder Dislocation within minutes of the patient’s arrival in the Emergency Medicine Department. This is the first time that such a method is being used and no literature based on stabilizing the Acromioclavicular Joint before trying the Kocher’s technique is ever found. I humbly acknowledge using my name, Mitra’s Modification of the Kocher’s Technique for reduction of Anterior Dislocation of Shoulder.
You can find more information about me from the link https://en.m.wikipedia.org/wiki/Amitabh_Mitra