WILDERNESS & ENVIRONMENTAL MEDICINE, 21, 357-361 (2010)

BRIEF REPORT

Safety and Efficacy of Attempts to Reduce ShoulderDislocations by Non-medical Personnel in theWilderness Setting

Jack Ditty, MD; Dugald Chisholm, MD; Stephen M. Davis, MPA, MSW; Mary Estelle-Schmidt

From the West Virginia University Department of Emergency Medicine. Morgantown, WV (Drs. Ditty and Chisolm, and Mr. Davis): andWest Virginia University School of Medicine, Morgantown. WV (Ms. Estelle-Schmidt).

Objective.—The objectives of this study were to explore the success rate and the complication ratefor shoulder reduction attetnpts by non-medical personnel in the wilderness setting, and to compare theaverage time to reduction for those done on scene versus those that waited for reduction at a medicalfacility.

Methods.—In this study we solicited online survey responses from users of wilderness sports forumsbetween October 2008 and April 2009. These surveys a.sked respondents to describe previous wilder-ness sports injuries they experienced. Descriptive statistics were calculated, and the Mann Whitney Utest was used to compare average reduction times, with an alpha of .05 selected as the significancethreshold.

Results.—Overall, there were 112 responses with 56 describing shoulder dislocations that werereduced either on scene or at a medical facility. Reduction on scene, in the absence of a medicallytrained person, was attempted in 39 of these 56 cases with a success rate of 71.8% (28/39). The mediantime to reduction on scene was 5 minutes, compared to 135 minutes from the time of injury for thosethat were reduced at a medical facility (P <.(X)1). Other than pain during the reduction, there were noreports of serious complications associated with the reduction attempts.

Conclusions.—These data suggest that reduction of dislocations in the wilderness setting bynon-medical personnel may be safe and effective, and significantly decreases the time to reduction.These findings may help guide future instruction of participants in high-risk wilderness sports.

Key words: shoulder dislocation, wilderness medicine, reduction

Introduction Medical procedures performed in the wilderness envi-c,. , . .• 1 .• • ij _, ronment by non-medical personnel can be a controversialShoulder dtslocations are common in wtldemess sportssuch as kayaking, skiing, mountain biking, and climb- *''P"-'' ^.th confitcttng recomtnendations in the medicaling.'-^ Participants in these activities, with no formal '"^rature. ' Many urban emergency medical servicesmedical training, have often attempted reduction of these ^^MS) protocols dtctate that injuries such as a shoulderdislocations on scene, with an unknown degree of sue- dislocation should be immobilized and transported to acess and safety. Many wilderness tnedicine education medical facility for radiographie evaluation and reduc-courses teach shoulder reduction as part of their currie- tion by a physician, rather than incur the risk of furtherulum, but the safety and efficacy of on scene reduction injury from undiagnosed fractures and inappropriate tna-by non-medical personnel is currently unknown. nipulation attetnpts.^ However, it is generally accepted

that early reduction of the dislocated shoulder dramati-Presented at the Wilderness Medicine Conference & Annual Meet- cally relieves the patient's pain, and may reduce the risk

ing, Snowmass, Colorado. July 24-29, 2009. of vascular and neurologic complications.' A reducedCorresponding author: Stephen M. Davis, Adiunct Associate Profes- • • • • • i i i-i • i- .•

„ ^. r-,-, „ u >A D ni.,n 1 r shoulder tnay mcrease the ltkelthood of a Sate evacuattonsor. Co-Director. Chnical Research. PO Box 9149, Department of -Emergency Medicine, West Virginia University, Morgantown, WV ^om the wilderness environment. It can itlipR)ve the26506-9149 (e-mail: sdavis@h.sc.wvu.edu). patient's ability to assist in the evacuation, decrease the

358 Ditty et al

need for complicated devices to support and immobilizethe extremity, and limit the need to involve and endangerother rescue personnel. Potential risks of inappropriatereduction attempts for non-dislocated shoulders includeiatrogenic shoulder dislocations, displacement of fracturefragments, or neurovascular injury, which could lead tothe need for surgical repair, shoulder instability, orchronic pain.**

In our experience, many patients with this injury areoften able to identify the diagnosis of shoulder disloca-tion prior to evaluation by a medical professional. Thereis evidence that for some patients in the emergencydepartment setting, radiographs may not be necessaryprior to reduction when the mechanism of injury andexam findings suggest this diagnosis."* Furthermore,when reduced in a medical facility, complications relatedto shoulder reduction are rare.' This suggests that clini-cally evident dislocations might be safely managed in thewilderness setting by medical personnel. However, med-ical personnel are often not on scene during these inci-dents. We have heard many anecdotal reports of success-ful and unsuccessful reduction attempts on scene bynon-medical personnel. Knowledge of the safety andefficacy of this practice might help guide our teaching ofparticipants in high-risk wilderness sports.

The objectives of this study were to explore the suc-cess rate and the complication rate for shoulder reductionattempts by non-medical personnel in the wildernesssetting, and to compare the average time to reduction forthose done on scene versus those that waited for reduc-tion at a medical facility.

Methods

In this study we solicited online survey responses fromusers of wilderness spons forums between October 2008and April 2009. The survey (available at www.wemjoumal.org) asked respondents who had suffered shoulderinjuries during participation in wilderness sports to de-scribe details about their injury. Questions included themechanism of injury, type of injury, narrative descriptionof reduction attempts on scene, level of medical trainingof people involved, complications (immediate and de-layed), and time to reduction. The survey questions wereintentionally broad to attempt to capture reports of not onlydislcx;ations, but any injury such as a fracture that mighthave had misguided reduction attempts on scene. The spe-cific websites from which surveys were solicited were ww-w.boatertalk.com, www.mountainbuzz.com, www.rock-climbing.com, www.mtbr.com, and www.ridemonkey.com(all selected due to familiarity with these websites by theauthors).

STATISTICS

Descriptive statistics were calculated using SPSS version13.0 (SPSS, Inc, Chicago, IL), and the Mann-Whitney Utest was used to compare average shoulder reductiontimes (on scene vs at the hospital) due to the skeweddistribution of the time data, with an alpha of .05 selectedas the significance threshold. We excluded from finalanalysis reduction attempts on scene by medical person-nel, defined as physicians, nurses, physician assistants,nurse practitioners, and emergency medical technicians.

INSTITUTIONAL REVIEW BOARD APPROVAL

The West Virginia University Institutional ReviewBoard for the Protection of Human Subjects approvedthe research protocol and waived the requirement todocument informed consent.

Results

Overall, there were 112 responses, with 56 describingshoulder dislocations that were reduced either on sceneor at a medical facility. Reduction on scene, in theabsence of a medically trained person, was attempted in39 of these 56 cases with a success rate of 71.8% (28/39)(Figure 1). The median time from injury to reduction onscene was 5 minutes, compared to 135 minutes from thetime of injury for those that were reduced at a medicalfacility (P <.OO1).

In a separate analysis, we also reviewed all 112 sur-veys to determine if inappropriate reduction attemptsoccurred for injuries other than shoulder dislocations. Inall, there were 58 reports of reduction attempts on scene.Of these, 51 were identified by the participant as ashoulder dislocation, and 7 were identified as other in-juries: 1 as a fracture/dislocation, 2 as shoulder straininjuries, 3 as rotator cuff tears, and 1 as an acromiocla-vicular separation. Medical professionals were involvedin 3 of the.se 7 inappropriate reduction attempts. The 1report of fracture/dislocation was subsequently reducedat a medical facility with "pain" as the only significantcomplication related to the reduction attempts reportedby the respondent. It is unclear from the report if thefracture was a true proximal humérus fracture or a minorHill-Sachs deformity.

Other than pain during the reduction, there were noreports of serious complications associated with the re-duction attempts. Many respondents reported typical de-layed complications related to the dislocation, such asrecurrent dislocations, shoulder laxity, chronic pain, andneed for delayed surgery for labral tears.

Layperson Wilderness Shoulder Reductions 359

t t 2Surveys

48Other Injuries

64Shoulder

Dislocations

8Missing Data

CompleteRecords

Humérus fractureAcromioclavicular separationClavicle fraclureScapula fractureHumérus fracturc/disUKaliuiiRotator culT tearShoulder strainUnknownOther

I6I2213II1II

Attempted ReductionAt Medical Facility

Medically Trained Person Present

39IncludedRecords

Figure 1. Diugratn of respondents tTieeting tinal inclusion criteria for success rate analysis.

The majority of our respondents were injured duringWhitewater kayaking, with lesser numbers in skiing,clitnbing, inountain biking, or other activities (Figure 2).Those participants engaged in climbing (n = 4) had a75% Held reduction success rate, compared to mountainbikers and skiers (only 1 participant each) who both hada 100% success rate, and rafters (n = 2) who had a 50%success rate. When combined, the.se 8 participants had asuccess rate of 75% versus 71% for kayakers {P = .821by Fisher's exact test). Eighteen percent of those injuredhad experienced prior dislocations of the same shoulder(5 of 7 of these patients had successful on-scene reduc-tions). Traction/counter-traction, Stimson technique, andexternal rotation were the most common attempted re-duction techniques (Figure 3). Although not statisticallysignificant (P = .94), the Stimson technique had thehighest success rate of 77.8% versus 72.7% for externalrotation and 71.4% for traction.

Of the 39 ca.ses that met our criteria to determine therate of successful reductions, 38% of sotneone on scene(either the survey respondent or another person presentduring the reported injury) had prior training in wilder-ness first aid (WFA) or wilderness first responder (WFR)

courses. For this subset, the success rate was not signif-icantly different at 73%. (11/15).

Discu.ssion i

These data suggest that reduction of dislocations in thewilderness setting by non-medical personnel may be safeand effective, and significantly decreases the time toreduction. The on-scene success rate of 71.8% is com-parable to success rates for single reduction attetnpts inthe etnergency department (70%-96% depending on thetnethod used for reduction).'" It is remarkable that this issuccessful without the aid of sedation and without thebenefit of a trained tnedical professional on scene. Thisresult was also comparable to the proportion of success-ful on-scene reductions that occurred in the presence ofa medically trained person (70%).

The time from injury to reduction was much faster forthose that were reduced on scene. This is not surprising,but the additional delay of tnore than 2 hours for thosethat were reduced at a medical facility highlights thebenefit of attempting treatment on scene.

360 Ditty et al

30

Mountain Biking

Activity

Rdltiny Skiing

Figure 2. Type of wilderness activity causing shoulder dislocation (N = 39).

There were no serious complications identified relatedto the reduction attempts. Nearly all of the respondentsreported delayed complications related to the dislocation,such as recurrent dislocations, chronic pain, joint laxity,and need for surgical repair of the joint capsule. This isconsistent with the expected prognosis for typical ante-rior shoulder dislocations. ' ' The sample size in this studyis small, and rare complications associated with reduc-tion may not be recognized. We attempted to capture allpossible shoulder injuries (including fractures, acromio-

clavicular separations, clavicle fractures, etc), which mayhave had inappropriate reduction attempts on scene, byadvertising the survey as a shoulder injury survey, ratherthan a survey specifically asking about dislocations.

Our data were collected from self-reported surveyssolicited from Internet forums, and therefore are subjectto recall and selection bias. There was no mechanism toverify any of the reported injuries or claims from respon-dents, and we did not have the ability to review actualmedical records to confirm the diagnosis of the re.spon-

'^"n

External Rotation Traction/countertraction

Technique

Figure 3. Shoulder reduction methods used on scene by laypersons (N = 39).

Layperson Wilderness Shoulder Reductions 361

dents. In many cases, the respondent did not seek med-ical care for the injury, so no such medical record wouldexist. There may be significant errors in self-diagnosis ofthese injuries, knowledge of the level of medical trainingof those present on scene, and recall of the events sur-rounding the injuries, and this must be taken into con-sideration when interpreting our results.

We attempted to collect surveys from multiple wilder-ness sports participants, but the majority of the respon-dents were injured during Whitewater kayaking. Dislo-cation is a common injury in kayaking,' and manykayakers may have some knowledge of reduction tech-niques, even if no formal medical training. The mecha-nism of shoulder injury in kayaking is more likely toresult in dislocation rather than fracture,' which also maylead to safer reduction attempts when the injury is asso-ciated with this activity. With higher velocity mecha-nisms, and direct impacts to the shoulder from sportssuch as mountain biking, rock climbing, or skiing, frac-tures may be more common. This could lead to a highercomplication rate for misguided reduction attempts. Inour study we found that of the 48 "other injuries" shownin Figure 1, 46% were injured during non-kayakingactivities such as mountain biking, skiing, and rockclimbing. The field reduction success rate of those in-jured in non-kayaking activities was 75% versus 71% forkayakers {P = ,821), However, more data are needed todetermine if the success rate and safety seen in this studywould be applicable to injuries incurred in all types ofwilderness sports.

While we excluded reduction attempts by medical pro-fessionals from the analysis, some of our respondents(38%) had received WFA or WFR training. These trainingcourses have variable amounts of teaching about shoulderredtiction, and a larger study would be needed to determineif WFA or WFR training leads to higher success rates.

Although the survey was not intended to determinelayperson knowledge of specific reduction techniques,we found it interesting that there were no reports ofscapular manipulation used in any of these reductionattempts. This is an ideal technique for use in the wil-demess setting, as it is often well tolerated by patients(requires little arm movement), is considered to be verysafe, and it can be combined with other methods such asthe Stimson technique to increase the likelihood of asuccessful reduction,'"

Shoulder dislocations and reductions performed bynon-medical personnel will continue to be a reality forpeople involved in a variety of wildemess activities. Ourfindings may help guide future instruction of participantsin high-risk wilderness sports, particularly in Whitewaterkayaking. Caution should be used in applying these datato other high-risk wilderness sports due to the low num-ber of responses from other groups in this study. Largerprospective studies should confirm these findings inother settings, to determine the factors that are mostassociated with success or failure of these reductions,and to evaluate for complications related to this practice.

Acknowledgment

The authors would like to thank Charlotte Firestone forcreating the online survey.

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