Article, Orthopedics

A new autoreduction method for anterior shoulder dislocation: the GONAIS method

Reduction method for anterior “>Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 34 (2016) 120.e5-120.e7

A new autoreduction method for anterior Shoulder dislocation: the GONAIS method?,??

Abstract

Although techniques for autoreduction of anterior shoulder disloca- tion have been developed, no reports have detailed an autoreduction method using the zero position and traction on the affected arm. There- fore, we developed a new autoreduction technique using the zero posi- tion and gentle autotraction. The objective of this study is to present our experience with a new method for autoreduction of anterior shoulder dislocation called the GONAIS (a backronym for “Grasp a waist-high ob- ject, Opposite arm assists, Nonsedated, Autoreduction/autotraction, Im- mobilize the grasped object, and Squatting and stooping”) method. A 41-year-old healthy woman with a history of left shoulder dislocation presented to the emergency department with left shoulder pain while attaching her seatbelt. The X-ray examination revealed subcoracoid dislo- cation of the left shoulder. The patient tried the GONAIS method after simple guidance and demonstration. Although she felt pain once when weakening traction, she achieved autoreduction successfully in only 2 min and 50 s. Clinical examination after autoreduction revealed normal neurovascular findings and appearance of the shoulder. The X-ray re- vealed Glenohumeral joint reduction and no fracture. Here, our patient using the GONAIS method achieved shoulder autoreduction in a short time. The GONAIS method does not require lying down or sitting on the ground, does not necessarily require the opposite arm, and is minimally invasive. This method would likely be helpful for those who cannot quickly reach a hospital for treatment of anterior shoulder dislocation.

Some patients experience Recurrent anterior shoulder dislocation, which typically requires them to visit the emergency department (ED) for reduction after each dislocation. Although techniques for autoreduction of anterior shoulder dislocation have been developed [1,2], no reports have detailed an autoreduction method using the zero position and traction on the affected arm. Therefore, we developed a new autoreduction technique using the zero position and gentle autotraction.

The developed method is called the GONAIS method, “GONAIS” being a backronym for “Grasp a waist-high object, Opposite arm assists, Nonsedated, Autoreduction/autotraction, Immobilize the grasped ob- ject, and Squatting and stooping.” The GONAIS method consists of five steps. First, the patient or physician immobilizes an object for the pa- tient to grasp that is at their waist height, such as a gurney or handrail. Immobilization of the object is crucial because the patient could be in- jured if the object falls over during the GONAIS method. Second, the

? Sources of support: none.

?? Conflicts of interest: none.

patient grasps the immobilized object. The patient may bend backward, stand on tiptoes or bend the ipsilateral elbow when grasping the object (Fig. 1A). The patient applies gentle traction on the affected arm and gradually steps back and stoops to flex forward and abduct the dislocated shoulder (Fig. 1B). The affected arm is mainly on the scapular plane throughout the entire autoreduction. Third, when the angle of the trunk and the affected arm is roughly 90?, the patient begins to squat. The angle should be kept at roughly 90?, and the traction on the affected arm should be maintained throughout the entire time while squatting (Fig. 1C-E). Fourth, after squatting completely, the patient stoops and moves a few steps backward while remaining in a squat to assume the zero position (Fig. 1F). Fifth, if the dislocated humerus does not success- fully reduce after keeping the affected arm in the zero position, the pa- tient should use the opposite hand to apply pressure to push the humerus backward and reduce the dislocation (Fig. 1G). Physicians should subsequently judge the reduction of shoulder dislocation by clin- ical and radiologic examination.

A 41-year-old healthy woman with a history of left shoulder disloca- tion presented to the ED with left shoulder pain while attaching her seatbelt. The X-ray examination revealed subcoracoid dislocation of the left shoulder (Fig. 2). The patient attempted the GONAIS method for autoreduction after simple guidance and demonstration (Fig. 3). Although she felt pain when traction was weakened, she achieved suc- cessful autoreduction in only 2 min and 50 s. Clinical examination after autoreduction revealed a normal appearance of the shoulder and nor- mal neurovascular findings. The X-ray revealed that her glenohumeral joint had been reduced and fracture was absent.

This method has four advantages. First, our case was able to autoreduce her shoulder using the GONAIS method in a short time, ap- proximately 3 min. The shortest Reduction time in a group of 32 patients treated with the Dudkiewicz method [2], which also uses the zero posi- tion, was 6 min. The shorter time is a salient advantage of the GONAIS method. Although the success rate of the method cannot be determined from just one case, it might be reliable as is usually true of other tech- niques using the zero position [2-6].

Furthermore, in order to improve the reduction time and the success rate, it might be effective to adopt the arm motions of other reduction techniques such as the oscillations movement of the FARES method or the forward elevation movement of Janecki’s method into the autoreduction motion of the GONAIS method [7,8].

Second, the method does not require the patient to lie or sit down on the ground, unlike other techniques such as the Boss-Halzach-Matter autoreduction technique or Dudkiewicz method [1,2]. These methods are undesirable in areas such as narrow places, among crowds, or drenched or icy floors. However, as patients using the GONAIS method only have to squat, they can perform the method in such areas.

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Fig. 1. Details of the GONAIS method. A, The patient grasps an immobilized waist-high object. The patient may bend backward, stand on tiptoes or bend the ipsilateral elbow when grasping the object. The angle between the lines indicates the angle between the trunk and the affected arm on the scapular plane. B, The patient applies gentle traction on the affected arm and gradually steps back (gray arrow) and stoops to flex forward and abduct the dislocated shoulder (blank arrow). The affected arm is mainly placed on the scapular plane throughout the entire time of autoreduction. C to E, When the angle of the trunk and the affected arms becomes roughly 90?, the patient begins to squat (blank arrow). The angle should be kept at roughly 90?, and the traction on the affected arm should be maintained throughout the entire time while squatting. F, After squatting completely, the patient stoops (blank arrow) and moves a few steps backward (gray arrow) while remain- ing in a squat to assume the zero position. G, If the dislocated humerus does not successfully reduce after keeping the affected arm in the zero position, the patient should use the opposite hand to apply pressure to push the humerus backward and reduce the dislocation (blank arrow).

Fig. 3. The patient attempted the GONAIS method and achieved successful autoreduction in 2 min and 50 s without sedation or analgesia.

Fig. 2. The X-ray revealed subcoracoid dislocation.

The third advantage is minimal discomfort. An excessive amount of traction or force is not needed to reduce the dislocation. Patients can stop the procedure when they feel pain.

The fourth advantage of the method is that the opposite hand is free to stabilize posture or assist the affected arm when squatting and stooping but is not absolutely required for the technique to work. If pa- tients cannot use their opposite hand for some reason, patients can per- form autoreduction with only the affected hand. The humeral head can be pushed by the ipsilateral knee.

There are some limitations to this GONAIS method. First, the GONAIS method cannot be used, unless there is an approximately waist-high ob- ject available for the patient to grip, although if necessary, another person’s hand could be grasped instead of a waist-high object. Further- more, the GONAIS method is not possible for patients who cannot easily squat or stoop down.

In summary, our case of a patient using the GONAIS method achieved shoulder autoreduction in a short time. The GONAIS method does not require lying down or sitting down on the ground, is minimally invasive, and does not strictly require the opposite arm. It would likely be helpful for those who cannot quickly make it to a hospital for treatment of anterior shoulder dislocation.

Shiro Gonai, MD? Emergency Department, Higashi Totsuka Memorial Hospital, 548-7 Shinano-cho, Totsuka-ku, Yokohama, Kanagawa, Japan

* Corresponding author. Tel.:+81 45 825 2111; fax: +81 45 824 7626

E-mail address: [email protected]

Yoshito Kamio, MD, PhD Emergency Department, Showa University Northern Yokohama Hospital 35-1, Chigasaki-Chuo Tsuzuki-ku, Yokohama, Kanagawa, Japan

E-mail address: [email protected]

Tomoyuki Matsuoka, MD Orthopedics Department, Higashi Totsuka Memorial Hospital, 548-7 Shinano-cho, Totsuka-ku, Yokohama, Kanagawa, Japan

Manabu Harunari, MD Yutaka Saito, MD

Kiyotsugu Takuma, MD, PhD Emergency Department, KawasakiMunicipal Hospital, 12-1 Shinkawadori, Kawasaki-ku, Kawasaki, Kanagawa, Japan

E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2015.05.053

S. Gonai et al. / American Journal of Emergency Medicine 34 (2016) 120.e5120.e7 120.e7

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