Reduction Techniques

Part of Surgery

Methods for manipulating displaced bones and dislocated joints back into correct anatomical position.

Why This Matters

A dislocated shoulder, hip, or knee that remains out of joint causes ongoing damage to the joint cartilage, nearby blood vessels, and nerves. Every hour of delay worsens the outcome. A displaced fracture that is not reduced heals in wrong alignment, producing deformity and loss of function.

Reduction — the manual manipulation of bones back into correct position — is a fundamental skill that can be performed without surgical opening in most cases. It requires knowledge of normal anatomy, understanding of the forces involved, adequate analgesia, and technique. Done correctly, it is a dramatic intervention: a patient in agony with a shoulder out of socket can walk away, pain largely resolved, minutes after a successful reduction.

Pre-modern healers were skilled at joint reduction. The Ancient Greek, Islamic, and Ayurvedic medical traditions all describe specific reduction maneuvers for common dislocations. These techniques work because they are based on anatomy and physics, not on technology.

General Principles

Why Joints Dislocate

A joint dislocates when the normal bone-in-socket relationship is disrupted by a force exceeding the surrounding ligament and muscle strength. The joint capsule tears. Muscle spasm around the dislocated joint creates forces that prevent spontaneous reduction — this spasm must be overcome for reduction to succeed.

Overcoming muscle spasm:

1. Analgesia: reduce pain → reduce pain-driven spasm
2. Steady traction: apply gradual, sustained force in the appropriate direction — muscles fatigue under sustained load (30-60 seconds of steady traction)
3. Positioning: position the patient so gravity assists, reducing the work required
4. Time: do not rush. Slow steady pressure allows muscle fatigue; rapid jerking movements increase spasm.

Confirming Successful Reduction

After any reduction attempt:

• Does the joint look anatomically correct?
• Did you feel or hear a “clunk” (the joint re-engaging)?
• Does range of motion feel normal (no blocked endpoint)?
• Did pain decrease immediately?
• Is the patient’s neurovascular status preserved or improved?

If reduction is uncertain, immobilize and reassess within 24 hours.

Shoulder Dislocation

The shoulder is the most commonly dislocated joint. The humeral head (ball) dislocates anteriorly (forward) in 95%+ of cases. Posterior dislocation (rare but occurs in seizures and electric shock) requires different technique.

Classic presentation:

• Sudden severe pain after a fall on an outstretched arm or a direct blow
• Shoulder appears “squared off” (normal rounded contour replaced by flat appearance)
• Arm held slightly away from the body in a fixed position
• Patient resists any movement

Check neurovascular status first: the axillary nerve wraps around the surgical neck of the humerus — check sensation over the lateral upper arm (badge area). The axillary artery can be compromised in severe dislocations.

External Rotation Method (Hennepin)

Gentle, effective, requires minimal force. Patient sitting or lying.

1. Hold the elbow at 90 degrees of flexion (upper arm against body, forearm pointing forward)
2. With one hand stabilizing the elbow, use the other hand at the wrist
3. Very slowly rotate the forearm outward (external rotation) — as if slowly pouring out a jug
4. Stop if severe pain or resistance; wait for relaxation, then continue
5. Continue rotating until the forearm is pointing laterally or the shoulder reduces
6. Often the shoulder reduces during external rotation with a palpable clunk

This technique can be performed single-handed if no assistant is available.

Traction-Countertraction Method

Requires two operators. Most reliable technique in limited-resource settings.

1. Patient supine
2. Assistant wraps a folded sheet around the patient’s chest (under the axilla of the affected side), holds ends firmly — countertraction
3. Operator grasps the forearm (not the wrist — avoids damaging wrist if patient jerks)
4. Apply steady longitudinal traction along the arm axis — pull firmly but gently
5. Maintain traction for 30-60 seconds without interruption
6. Slight internal and external rotation during traction can help disengage the humeral head
7. The shoulder should reduce with a clunk; the arm relaxes into normal position

Stimson Method

For a cooperative patient without assistant.

1. Patient lies prone (face down) on a table with the affected arm hanging freely over the edge
2. Tie a weight of 2-5 kg (stone, pot of water) to the wrist
3. Leave for 15-20 minutes — gravity provides continuous traction, muscles fatigue progressively
4. Often reduces spontaneously without any manipulation

After shoulder reduction:

• Immobilize in a sling for 3-6 weeks
• Do not attempt range of motion exercises for at least 3 weeks
• Recurrence rate is high especially in young patients — counsel about this

Hip Dislocation

Hip dislocations are typically high-energy injuries (vehicle accidents, falls from height). Posterior dislocation (90%+ of cases): leg appears shortened, internally rotated, hip slightly flexed.

Emergency: the blood supply to the femoral head comes from vessels that are stretched across the dislocation. Every hour without reduction increases risk of avascular necrosis (bone death). Attempt reduction immediately.

Check sciatic nerve function: hip dislocation commonly injures the sciatic nerve. Check sensation on the sole of the foot and ability to flex the ankle.

Allis Method (Posterior Hip Dislocation)

Requires an assistant. Needs strong traction force.

1. Patient supine on a firm surface
2. Assistant kneels on the floor, holds the patient’s pelvis firmly down with both hands on the iliac crests
3. Operator: flex hip and knee to 90 degrees each
4. Apply steady upward traction along the femur axis (pull the knee straight up toward the ceiling)
5. While maintaining traction, gently internally and externally rotate the hip
6. The femoral head should slip back with a palpable clunk

This requires substantial force — it is one of the more physically demanding reductions. Adequate analgesia and muscle relaxation are essential.

After hip reduction: bed rest for several days, then cautious mobilization. Risk of avascular necrosis of femoral head remains for months — watch for return of pain and limping.

Ankle and Knee Dislocations

Ankle dislocation (usually accompanies fracture): distorted ankle appearance, foot displaced to one side. Reduce urgently — skin pressure over the dislocated malleolus dies quickly.

Reduction: steady longitudinal traction on foot, then guide back to anatomical position.

Knee dislocation (high energy — often with vascular injury): the popliteal artery (behind the knee) is commonly torn in knee dislocation. Check pedal pulse (top of foot) before and immediately after reduction. Absent pulse after reduction = vascular surgery emergency.

Digit (Finger/Toe) Dislocations

Among the most common dislocations. Usually dislocate at the interphalangeal joint (knuckle).

Technique:

1. Grasp the distal segment (beyond the dislocation)
2. Apply firm longitudinal traction
3. While pulling, slightly hyperextend the dislocated segment (this disengages it from the proximal edge)
4. Then flex into reduction — it usually snaps back into place

Warning: do not manipulate if there is associated fracture visible on clinical exam (bone deformity beyond joint). A “jammed finger” that does not reduce with gentle traction should be immobilized and allowed to heal — forced reduction of a fracture-dislocation can displace the fracture.

After reduction: buddy tape the reduced finger to its neighbor for 3-6 weeks.

Patella (Kneecap) Dislocation

The kneecap dislocates laterally (to the outside). Knee is bent, prominent bony lump on the lateral side of the knee.

Technique:

1. Patient sitting with leg extended (some patients will extend it themselves reflexively)
2. Extension of the knee itself often reduces the patella automatically
3. If not: with the leg extended, apply medial (inward) pressure on the patella while having the patient actively contract the quadriceps (try to extend the knee)
4. The patella slips back into the trochlear groove

After reduction: immobilize in extension for 3-4 weeks, then progressive rehabilitation.

Spine: When NOT to Reduce

Spinal fracture-dislocations require IMMOBILIZATION, not reduction attempts, unless a trained surgeon is available with neurological monitoring. An improperly attempted spinal reduction can convert a partial spinal cord injury into a complete one — paralysis.

If spinal injury is suspected:

• Maintain the spine in neutral position
• Log-roll only with multiple handlers (one dedicated to head/neck stabilization)
• Immobilize on a flat board
• Transport with utmost care

The rule: if you are not certain you can make it better, at minimum do not make it worse.