Description of a new modified Milch technique in acute shoulder antero-inferior dislocation: a multicenter study
Objective. We present a new modified Milch technique to reduce anterior dislocation of glenohumeral joint.
Methods. We conducted a prospective multicenter study at first orthopedic aid in 79 patients.
Results. We achieved closed reduction at first attempt with this technique without traction or sedative drugs in 71 patients (90%).
Conclusions. The aim of the present study is to describe this technique which is safe, painless, atraumatic, and requires one operator.
Shoulder dislocation is the most common dislocation between the major joints in the human body and the most frequent form is antero-inferior 1. A variety of techniques to reduce glenohumeral dislocation have been described 2,3, performed with or without sedative medication or intra-articular anesthetic injection: traction-countertraction (in adduction, in forward flexion, in elevation), scapular manipulation (in prone o seated position), leverage, and combinations of these. Traction in adduction in Hippocratic method is no longer popular nowadays because of the risks of complications (brachial plexus and vessel injuries). The “strap” method is safer, but needs two operators. Traction in forward flexion by Stimson is described in prone position which is uncomfortable and the patient may be non-compliant. The Spaso method in supine position is a safe procedure but it needs vertical traction and externally rotation of the arm by the operator. The Eskimo technique (defined hanging patient method) requires two operators for traction against gravity. Scapular manipulation in prone or seated position is safe, fast, atraumatic, and relatively painless but uncomfortable (above all in prone position). In the Kocher technique, external rotation, adduction, and internal rotation provide reduction of the shoulder, but several complication are described such as recurrent dislocation, spiral humeral fractures, axillary nerve injuries, and traction increased pain. In the original Milch’s technique the patient is supine and as the arm is abducted it is eternally rotated while the physician pushes the humeral head over the glenoid rim with his thumb. The procedure is safe, painless, and no axial traction is originally described, but it is quite complex. Recent studies 4,5 demonstrated that the Milch technique should be preferred, at first attempt, to traditional ones, because it is reported to be painless, atraumatic, requires one operator, and is performed without patient sedation or analgesia. The aim of the present study is to describe this modified Milch technique and report the success rate in a prospective and multicentric study performed in three different emergency departments.
Materials and methods
We included 79 patients in the study from August 2013 to December 2015. We conducted a prospective study at first orthopedic aid in the Emergency Department of three different Hospitals: IRCCS-Arcispedale Santa Maria Nuova (ASMN) in Reggio Emilia, Policlinico di Modena, and Ospedale Civile di Baggiovara (OCB) in Modena. Four orthopedic surgeons (from these three different emergency departments) used this method in the treatment of acute anterior dislocations of the shoulder. Only in case of failure was the traction-countertraction reduction method used. Inclusion criteria are all anterior dislocation of glenohumeral joint arrived in Hospital at first orthopedic aid. We evaluated associated fractures of the tuberosities or other fractures; any previous history of ipsilateral dislocation (including the number of episodes), age, laterality or dominance, patient’s BMI; mechanism of injury; pre and/or post reduction neurovascular complications; time elapsed between dislocation occurrence and orthopedic consultation; time needed to obtain the reduction; mean hospital stay time; pain level before and immediately after reduction, measured with VAS. Exclusion criteria were patients with difficulties in collaboration and muscle relaxation (i.e. dementia, anxiety and psychiatric illness, Parkinson’s disease), and dislocation associated with homolateral neck humeral fracture. Diagnosis was confirmed by clinical examination and radiographic evaluation with use of anteroposterior and axillary radiographs 6. The original Milch maneuver is performed by initially abducting the arm, then extension of the elbow, and finally applying external rotation of the arm and pressure on humeral head to slip it back into the glenoid 7. The rationale for Milch’s original description is to bring the muscles of the humerus, scapula, and thoracic wall in a position of conical symmetry. This more linear alignment relaxes muscles 8,9 and provides reduction. Several authors have modified this technique 10,11. We report a new modified Milch technique described by Gazzotti et al. based on 4 steps. The reduction is performed with the patient lying in the supine position. The treating physician stays on the side of the affected extremity facing the patient. No traction is used at the beginning. First step: the elbow is extended to 0° with the arm adducted to the side of the chest (Fig. 1). Second step: the wrist is completely supinated (Fig. 2). These maneuvers are not painful and the patient is more compliant. Third step: the physician holds the patient’s wrist with one hand, stabilizes the elbow with the other and gently abducts the shoulder. Fourth step: minimal up and down movements are applied during abduction of the arm (Fig. 3). These movements facilitate muscle relaxation. The operator explains the maneuver to the patient who must be completely relaxed, compliant, and constantly reassured no pain will be felt. When resistance to motion is encountered, the physician should stop, wait for the patient to relax, and then continue. Once reduction is achieved at approximately 100° degrees of abduction, the arm is gently internally rotated to bring the forearm to lie across the chest. If maneuver is not successful, the operator uses a gentle traction and/or sedative or analgesic drugs.
We treated 38 patients in Arcispedale Santa Maria Nuova (Reggio Emilia), 17 patients in Policlinico (Modena), and 24 patients in Ospedale Civile Baggiovra (Modena). The data are summarized in Table I.
The mechanism of injury was traumatic in 68 patients: 54 simple falls, 10 contact sports, and 4 motor-vehicle accidents; it was atraumatic in 11 patients. There were 55 males and 24 females with a mean age of 43 years (range 19-80). In particular, 45 right shoulders and 34 left shoulders were involved, 39 dominant and 40 nondominant. The mean BMI was 24 with a range of 21 and 34. The dislocation was subcoracoid in 60 patients and subglenoid in 19, while 7 had great tuberosity fracture, 3 patients the omolateral distal radius. Four patients had paresthesia on the deltoid region, while in two axillary neuroapraxia was resolved immediately after reduction. Pre- and post-reduction vascular complications are not noted. Mean elapsed time between dislocation occurrence and orthopedic consultation was 4 hours (range 1-48). Closed reduction at first attempt with the Milch modified technique described without traction or sedative drugs was achieved in 71 patients (90%): 36 in ASMN, 14 in Policlinico, 21 in OCB. At first attempt the modified Milch technique achieved closed reduction in 71 patients (90%), without traction or sedative drugs (Tab. II). In particular, 36 in ASMN, 21 in OCB, and 14 in Policlinico. Mean time to complete the maneuver was 2-4 minutes. Mean ordinary admission time was 93 minutes (range 30-1440) in patients with a successful Milch technique. It should be noted that two patients had special needs: a patient with a head injury that needed 24 hours observation time and another who needed a waiting time of 5 hours in order to perform X-ray due to technical problems in diagnostic radiology. Recurrent dislocation of the shoulder occurred in 15 patients and Gazzotti’s modification of the Milch technique was successful in reduction for 14 (93%). Mean VAS score pre-maneuver was 8, during reduction was 2, and on discharge was 1.
The method described was unsuccessful at first attempt in 8 patients. In detail, these different situations include:
- 2 patients: gentle traction associated with Milch modified technique was performed with successful reduction, one had a BMI of 25 and the other one was not very relaxed;
- 2 patients: reduction was achieved with traction-countertraction method without sedative drugs, one had a great tuberosity fracture and after the first failed attempt the maneuver was not repeated to avoid stress in rotation;
- 4 patients: they presented to the hospital 24 hours after the dislocation; the reduction was achieved with the traction-countertraction method without sedatives in 1 patient, while the other three needed sedative medications to achieve reduction using general anesthesia: propofol IV with anesthetic support. All these four patients required one night of hospitalization in the orthopedic department.
Table III and IV show that the maneuver achieves greater success when the patient is under 40 years and when the patient is over 40 years of age with a low BMI coefficient (possibly less than 24). However, there are also successful cases for patients with advanced age and high BMI.
Another important observation is the waiting time of the patient at the first access to the hospital. From Table V, in fact, it can be seen that most of the cases of unsuccessful (5 of 8) all had a waiting time for access to the hospital that was greater than 10 hours.
Thus, there was a strong correlation between the time of admission and waiting time for the first access to the hospital with a correlation parameter of 0.8. There was also a strong correlation between patients who had a negative outcome in the maneuver between BMI and waiting time at the first access to the hospital with a coefficient of 0.6. The confidence interval for BMI (in a standard normal distribution) to ensure the success of the maneuver is between 23.47 and 25.20 and guarantees a success of 95%, seen in Figure 1. With t-Student distribution this is between 23.76 and 24.90.
Finally, there were also a number of successes outside the calculated confidence interval (BMI = 26). This was especially true for patients under 40 years of age (8 of 12 patients) (Fig. 4).
Techniques to successfully reduce dislocation of glenohumeral joint are usually classified as traction-countertraction 5 (the Hippocratic method and the “strap method” in adduction; by Stimson and Spaso 12 in forward flexion and by Eskimos 13 in lateral elevation), scapular manipulation 14,15 (described by Bosley and Miles), leverage (described by Kocher 16-18 and Milch 19,20) and combinations of them 2. The Hippocratic method has been claimed to be the most effective for subglenoid dislocations and requires one operator, but it is painful, physically tiring for the operator, and worries the patient. Furthermore, brachial plexus and vessel injuries are common. The “strap” method uses a sheet or a strap around the patient’s chest; this technique is simple, easy, effective, quick, and less painful, but it requires at least two operators and is very important to pay attention to fragile skin in elderly patients which may be injuried by traction of the sheets. In the technique traction-countertraction in forward flexion by Stimson, the patient lies prone and the affected arm hangs free with appropriate weights (5-7 kg). It is suggested for elderly, obese, and apprehensive patients, but it may take 30 minutes for reduction to occur. It is also unsuitable for tall patients and requires compliance. In the Spaso method, the patient is in the supine position with minimal vertical traction and external rotation is required: it is simple, effective, atraumatic, safe, and requires minimal force and only one operator. The Eskimo (“hanging” patient) method is traction in lateral elevation while the patient is placed on the ground lying on the unaffected side. It is simple and atraumatic, but requires two operators for traction against gravity. Scapular manipulation method manipulates the scapula so that the glenoid rotates down to meet the humeral head while the patient is prone or seated. It is a simple, easy, fast, effective, and atraumatic method. The prone position is uncomfortable and the maneuver may be difficult in obese patients. Milch’s technique for shoulder reduction was first described by Milch in 1938 7,19 and has been widely studied and reviewed in the literature 26,27. With the arm in this forward flexion and extreme abduction position, the resultant force of all the muscles around the shoulder lies in a line which is parallel to the shaft of the humerus, thereby reducing the cross-stresses of the different muscles to a minimum. In this position, reduction is painless, safe, and without complications. In 1869, Kocher 16,21,22 published a technique: his method involved maneuvering the arm through a series of rotational movements to lever the humeral head over the rim of the glenoid without traction. The method is gentle, requiring one operator, with minimal discomfort. However, the maneuvers are more difficult in heavy patients, and not appropriate in the elderly. There is an increased incidence of complications compared to other techniques such as recurrent dislocation, spiral fractures of the humerus, and axillary nerve injuries 23-25. Beattie et al. 28 showed that the Kocher and Milch technique had similar results. Sayegh et al. 5, compared the Hippocratic technique, Kocher technique, and FARES (fast, reliable, and safe) technique (similar to Milch one: gentle traction, shoulder abduction, external rotation, and short-range oscillation). In their study, the success rate, reduction time, and subjective pain of the patients who underwent the FARES technique was superior to the others for these parameters. Janecki et al. 29 reported 50 successful consecutive reductions at first attempt with Milch technique, adding gentle overhead traction and final internal rotation when necessary to complete the reduction; no complications were noted. In 1989, Cortes 10 suggested a significant traction on the shoulder during the maneuver without anesthesia. Of 128 patients studied, reduction was achieved in 83%. Russell et al. 20, reported the Milch technique in injured skiers: 68 of 76 dislocations were reduced (89%). The abducted, externally rotated position was achieved with little pain and with gentle traction. O’Connor 4 in 2006 also suggested the use of gentle traction to obtain a 100% success rate on the first attempt. Amar et al. 30 showed a success rate of 83% at first attempt and 91% at second when the Milch technique was used without medication or sedation. Garnavos 31 held the affected limb by the thumb and placed the other hand on the upper arm so that any contraction of the biceps can be felt. The traction of the humerus was increased gradually after abduction was completed and pressure on the head of the humerus was applied with all fingers to reduce neurovascular damage. Singh7 provided a slight modification by adding a 30° forward flexion so that the humerus was in alignment with the scapular spine. Our results are similar to those reported in the literature; the main modifications that we have introduced are: first the elbow is completely extended and second minimal up and down movements were applied during the abduction of the arm. We believe that traction is not required to reduce the majority of antero-inferior shoulder dislocations and is likely to cause pain and distress to patients. We never used traction at first attempt, even if we recommend it in dislocations that occurred more than 24 hours ago or when first attempt has failed. Our technique is safe, easy, atraumatic, painless, and requires one operator without medications. The main limitations of our study are that it is not a comparative analysis and that a limited number of patients were included.
The abduction-external rotation method for the reduction of an acute anterior dislocation of the shoulder is a safe and reliable method that is relatively painless and can be performed for both subcoracoid and subglenoid dislocations. In fact, this technique is well tolerated by patients and has been shown to decrease pain during and after the procedure reaching a momentum zero position (abduction 100°). It is a fast and safe procedure that usually does not require medication. The procedure is easy to perform by one person without additional assistance. We strongly recommend this procedure, which can be used as a first-line reduction method in all anterior shoulder dislocations treated within a short time of the traumatic event and in fracture-dislocations only involving the greater tuberosity.
Conflict of interest statement
The authors declare no conflict of interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
All the Authors contribuited equally to this work. GG, RA, MC, LP: metodology; GG: designed, wrote the paper and analysed the data; RM, SB: contribuited to manuscript revision.
The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki.
Written informed consent was obtained from each participant/patient for study participation and data publication.
Figures and tables
|Age (years)||Mean 43 (range 19-80)|
|Sex (male/female)||55M (70%)/24F (30%)|
|Number of dislocation (first/recurrent)||64 (81%)/15 (19%)|
|Type of dislocation (subglenoid/subcoracoid)||19 (24%)/60 (76%)|
|Fracture associated (great tuberosity)||7 (9%)|
|Hand dominance||39 (49%)|
|BMI||Mean 24 (range 21-34)|
|Mechanism (traumatic/atraumatic)||68 (86%)/11 (14%)|
|Complications pre (neurologic- axillary neuroapraxia)||4 (5%)|
|Complication post||0 (0%)|
|Reduction success (N)||71 (90%)|
|Mean ordinary admission||93 min (30-1440)|
|Reduction time (min)||2-4 min|
|VAS on admission||Mean 8 (2-10)|
|VAS during reduction||Mean 2 (0-6)|
|VAS on discharge||Mean 1 (0-4)|
|Age - BMI||BMI|
|Age - BMI||BMI|
|Admission period (min)||60-119||120-179||180-239||600-659||1440-1499||Total|
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