To Reduce or Not To Reduce? [77/78]

by Shaan Gresser

‘Here it comes, prepare to brace, starting to lean… the wave starts to break… crash! Arrhh! What went wrong? Why am I upside down in the surf? Try to roll up — but my left arm doesn’t want to reach for the paddle. Time to wet exit — ouch, with one arm. It’s shallow, only up to my waist. Ouch, my shoulder. Umm, something’s not quite right.’

I’ll never forget that feeling when I stood up after surfacing from under my kayak. Gravity instantly took hold and yanked at my left arm and shoulder. I instinctively grabbed hold with my right arm to support it. And then it happened — the pain — no not the physical, but the emotional. Somehow I knew that this was going to impact my life in a big way. I felt instant grief, knowing I had more than likely dislocated my shoulder. I was also nervous for my follow paddlers and the impact that it was about to have on their day because we were on a remote beach. Not to mention that I was in the middle of my Seas Skills assessment, and it was the start of summer. Hmm, what have I done!

From my experience following the accident, a few key themes became apparent to me: the shared fear other kayakers have of this common accident; the lack of and varied knowledge about the subject and finally, and perhaps the most controversial, is the issue ‘to reduce or not to reduce’ the shoulder when it happens. By this, I mean whether to attempt to put the shoulder back into place as soon as possible or wait until the person is in professional medical care.

Hopefully by sharing my story and what I have learnt from the experience it will help alleviate some of the fear (not all — a little fear is a good thing!) by arming you with some useful knowledge. I also hope it may help the unfortunate few who may one day find themselves in a similar situation. My story is also a typical example of what can happen, how easily it can happen and some of the decisions you might face on the day.

These issues are so important that a face-to-face workshop is really the best way to explore them further and in a detail that will be useful. I have arranged a workshop with experts in the field to discuss many of the issues raised in this article. See the section at the end of this article for further details.

The accident

On 7 December 2008 I nervously paddled off from Bonnie Vale (Bundeena) with my fellow Sea Skills aspirants Cathy Miller, Paul Layton and Alan Thurman with Sea Instructor and Assessor Stuart Trueman. Little did I know that what I should have been most anxious about that day was making the return paddle.

We headed south along the Royal National Park coastline to Marley Beach, approximately 10 km. Along the way Stuart had us demonstrate various skills such as rolling, various paddling strokes and self-rescue. We chose to land at Marley Beach and all landed without incident. As we took a little break, Stuart briefed us for the surf zone assessment task which involved us paddling in and out of the surf zone in pairs, demonstrating techniques to safely control the kayak — skills such as bracing, stern rudder and rolling.

Cathy and Alan were first up. They both made the job look pretty easy and it wasn’t too long before they were back on the beach looking somewhat relieved. On the back of earlier training that I had been doing in the surf, I headed out feeling pretty good about the exercise.

Upside down and in my kayak is basically where I ended up next. To my frustration, it is difficult for me to explain how it actually happened, because I’m not entirely sure myself! More than likely there were several variables involved, but one thing was certain — the shoulder was exposed and enough force was applied to pull the arm from the shoulder joint anteriorly. I know what you’re thinking, and you should be: keep those elbows in! This is wise advice and something to always remember and practise (i.e. limiting shoulder exposure by keeping the arms tucked in close to the body).

In addition to prior practice and training I had attended two surf-training sessions in the previous week, focusing on good bracing technique and the associated dangers… and yes, it still happened. Darwin’s natural selection you may say!

The issue of what may make some of us more prone to this type of injury is important. However, an injury is usually the collusion of several variables — a combination of the paddler’s physical susceptibility, experience and the external factors on the day.

In my case, it wasn’t even large or powerful surf — in fact the surf that day was relatively small with an average wave period. However I did do something I would not normally do that probably contributed to the accident.

I had already demonstrated several low and high braces as we made our way in and out of the surf zone. I remember thinking I should demonstrate at least one more high brace and I actually paddled into the breaking zone of the surf and waited for the next set. This meant that when the wave broke I was stationary. The consequence of doing this is twofold. Generally speaking, by moving with the wave you take on less of the energy and therefore impact of the wave at the point when it breaks. (Tip: Don’t hang around in the crunch zone!) Basically, by moving with the wave, you take on its energy more gradually, allowing yourself time to respond with effective strokes. In my case, being stationary may have encouraged me to reach out further, over-compensating for the breaking wave. I don’t remember doing this but it is likely.

The other variable, which probably contributed most, is the depth of the water. I was not aware of how shallow the water was until after I capsized. It is likely that the blade of my paddle connected with the bottom as I leaned and braced into the wave. The problem of doing something like this means that you create a dangerous lever, transferring all the pressure going onto your kayak from the breaking wave and onto your shoulder, possibly levering it out of place.

Surprisingly, in the actual moment I don’t remember feeling any strain or pain on my shoulder. After I made my way onto the beach clutching my arm and crying out ‘oh no’ several times, it became clear to everyone that something was wrong. Paul apprehensively stuck his hand under my cag to check my shoulder. He flatly announced it was definitely dislocated. Sigh. Even though I knew deep down, I was still holding onto the hope it had only been strained.

Interestingly, it was only after Paul’s announcement that I really began to feel the pain! I instantly felt light-headed and asked to sit down. I was helped up over the sand dune out of the wind. In the hour or so that followed, Stuart, Paul, Cathy and Alan leapt into rescue mode and expertly organised my evacuation and care. It seemed that everyone just fell into a natural roll on the day and it worked.

As there was no mobile reception on the beach, Paul ran up the nearby Marley headland to the north and managed to get a call out. As the strength of the reception wasn’t great, it took a couple of attempts to get the details through. The only details received from the first call were about a sea kayaker being injured off of Royal National Park. This triggered a helicopter to be deployed as they assumed that I was still in the water. Also dispatched was an ambulance, which travelled along a fire trail above the headland.

Of course I was oblivious to the action going on around me. By now, the pain had really started to set in. Initially we thought I might have to walk to a road to get out. However, just sitting down took all my effort, with all my energy focused on not passing out. In terms of first aid, all that could really be done was trying to support my arm in a position that was most comfortable and trying to keep warm. There was never any discussion of reducing the shoulder.

About the dislocation itself

Dislocations hurt. When the humerus is pulled out of the socket, cartilage, muscle, and other tissues are stretched and torn. I have read since my accident that ‘The patient will experience significant pain and will often resist the smallest movement of any part of the arm’. Significant pain indeed! As time passes it gets worse because when the joint is dislocated, the muscles surrounding it are stretched and go into spasm. These muscles spasms cause a lot of pain and in my case I found it difficult to even sit upright because my neck and shoulder muscles had contracted so much.

What is a dislocated shoulder?

The shoulder joint is made of three bones that come together at one place. The arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle) all meet up at the top of the shoulder.

A shoulder dislocation occurs when there is an injury to the joint between the humerus and scapula. The joint between the humerus and scapula, also called the glenohumeral joint, is a ball-and-socket joint — the ball is on the top of the humerus, and this fits into a socket of the shoulder blade called the glenoid. This joint is incredible because it allows us to move our shoulder though an amazing arc of motion — no joint in the body allows more motion than the glenohumeral joint. Unfortunately, by allowing this wide range of motion, the shoulder is not as stable as other joints. Because of this, shoulder dislocations are not uncommon injuries.

How does a shoulder dislocation happen?

A shoulder dislocation generally occurs after an injury such as a fall or a sports-related injury, such as the force of the water in an overextended paddle brace. About 95% of the time when the shoulder dislocates, the top of the humerus is sitting in front of the shoulder blade — an anterior dislocation. In less than 5% of cases, the top of the humerus is behind the shoulder blade — a posterior dislocation. Posterior dislocations are apparently seen after injuries such as electrocution or after a seizure.

Recognising a dislocated shoulder

Paul confirmed my dislocated shoulder by feeling the deformity which was hidden under my cag. A lot of the time, you will observe the casualty trying to relieve the pain by supporting the weight of the injured arm with the other hand. As the majority of shoulders are dislocated anteriorly, the shoulder will appear ‘squared off’ since the humeral head has been moved out of its normal place in the glenoid cavity or socket. Often, it may be seen or felt as a bulge in front of the shoulder joint.

What should you do?!

Many would advise you to care for yourself or the casualty as best you can until professional help is available. This might include stabilising the affected arm with a sling. In many cases, and in my case, the casualty will find the most comfortable position possible for them.

Rarely however, will you have heard the advice to attempt to reduce the shoulder yourself. Most first aid practitioners would advise that you do not attempt to reduce a dislocated shoulder. However, as I discovered after my accident from talking to specialists in the field, there are many good reasons why you may want to consider having the knowledge and reducing a shoulder yourself. There is much interest and opposition to this notion and so it deserves some exploration.

To reduce or not to reduce: the pros and cons

If you are close to medical attention you may not consider this option at all. Not because the procedure for reducing a shoulder is necessarily dangerous, but it can be stressful — for everyone involved — and if you don’t feel comfortable doing it or having someone else attempt it then that is enough.

However it is important to understand the consequences of reducing and not reducing the shoulder as soon as possible after dislocation. The strong opposition in the first aid community about attempting to reduce the shoulder is due to the possibility of further injury. There is concern that vascular or neurological damage may occur when the shoulder is reduced or not reduced correctly. There are circumstances where this risk is increased and reducing the shoulder could be an issue — even in professional care. These circumstances generally involve the situation where the shoulder has dislocated due to an impact — falling on the ground, car accident or something running into you. In these types of situations because there has been an impact involved there is the risk of fracture or multiple fractures.

For the sea kayaker however, the situation can be different. In the majority of cases, the dislocations that occur during sea kayaking and white water kayaking involve the force of the water only — operating on the paddle and the kayak and then onto your shoulder. This means that there is much reduced risk of fractures and therefore complications.

The actual known risks and injuries as a result of reducing the shoulder where complications are absent are very scarce. The only study looking at this issue reported that injury to the axillary artery following anterior shoulder dislocation was a very rare occurrence. In fact, in circumstances where fractures have occurred, the two common fractures, if present, do not hinder the relocation of the shoulder. They are the Hill-Sachs deformity, a compression fracture of the humeral head and a Bankart lesion, a chip fracture of the glenoid fossa (Wedro, 2009).

What is perhaps more important however, is the damage that may occur as a result of the actual dislocation, and furthermore, the damage that will continue to occur the longer it remains dislocated. In some situations it may become critical that the shoulder is reduced as soon as possible. For example, because the movement is so extreme, nerves, blood vessels, muscles, tendons and ligaments are all stretched. Because of this there is going to be a degree of trauma that may affect the blood and nerve supply to the arm and hand. You might check this by asking if the arm/hand is numb or tingling. Looking for colour or lack of it can indicate a cut of oxygen supply. Under these circumstances and if far from help you may want to consider reducing immediately to prevent long-term damage. In this situation, the damage that occurs as a result of dislocation and in particular the long-term damage from a sustained dislocation, is often far greater than the damage that may occur when it is reduced. The longer the shoulder remains dislocated, the greater the chance that there can be serious problems in the long-term. This is the fundamental reason why reducing the shoulder immediately should be considered. This point is strongly supported in the medical industry where I have had discussions with surgeons and specialists in the field (personal communications with Prof. George Murrell and Dr Michael Lee).

There are other important reasons why it is worth having the knowledge and considering reducing a dislocated shoulder immediately. As sea kayakers, we often find ourselves in remote or semi-remote locations. Picture this: you are in the middle of your 10-day kayak adventure. Someone in your party has dislocated their shoulder on the way into a beach landing — not uncommon. You are far from medical support and there are no roads. You are unsure of how long it maybe before help arrives. As time progresses their condition becomes weaker due to the trauma and stress of the dislocation. At this point you realise that not only are you managing the dislocation, you now have to manage the secondary issues. Dislocations are traumatic injuries and as such often have a large impact on the overall wellbeing of the casualty.

Reducing the shoulder immediately will also give you a better chance to transport the casualty by kayak if need be. Once reduced the shoulder would be weakened but would give the ability to safely and with far less pain, tow a kayaker if necessary. And finally, if you are alone, you will be in a far better position to cope with and effect your rescue if you are able to reduce your own shoulder.

These scenarios highlight the bigger issue and why it is valuable to have the option to decide what to do right from the start.

Shoulder reduction

So how do you go about reducing a dislocated shoulder? First and foremost; as described earlier, the muscles will go into spasm soon after the dislocation. This means that if you are going to attempt to reduced it in situ it has to be done immediately following the injury. Even Hippocrates over 2000 years ago wrote that the shoulder dislocation should be reduced immediately or as soon as possible. Essentially the muscles around the shoulder have to be relaxed to allow the humeral head to slide back in. This is why medical practitioners use some form of muscle relaxant and painkiller before the shoulder is reduced back in the hospital. In my case it was morphine, and plenty of it! As time goes by the chances of easy reduction will diminish.

Basically there are numerous methods of reduction for an anterior shoulder dislocation. The key to the most successful and useful techniques is that they are simple and most importantly do not require force. After having a chat with a few people about my shoulder not only did it became obvious just how little we know about this issue but generally people assumed that there is much difficulty and force involved in reducing the shoulder. Indeed there are traditional techniques that use force. For example you may be thinking of an image of someone holding their foot on the casualty as they pull their arm — this was actually the method recommended by Hippocrates (traction-countertraction technique). These traditional reduction methods can involve strong force with potential injury. You won’t see this happening much nowadays as there are other options. In fact, my own shoulder was reduced without anyone touching it. I had the assistance of plenty of morphine and good instruction from the hospital staff and I was stunned just how easily it popped back in!

Possibly the largest issue to be faced when considering a shoulder reduction is the stress of it all. The casualty will probably be feeling quite distressed — perhaps an understatement! The hardest part may well be getting the person or yourself to relax as much as it will be possible.

There is no one particular technique that appears to stand out above others. There is much published material from different practitioners outlining why they prefer a certain technique. They also overlap quite a bit and thus can be modified to suit the situation. For example, a few can be modified for self-reduction. The most successful methods tend to follow the natural movement of the arm, as ultimately the shoulder will ‘want’ to pop back in if applied earlier enough.

Reduction examples

NB: In the interest of minimising the chance of confusion or misinterpretation, this article should not be considered as a guide for the various descriptions for the different reduction techniques.

I want to give a few examples of the type of manoeuvres that are possible with the primary aim of emphasising their benign nature.

One example is called the Milch technique. The injured person sits, stands, or lies flat on their back. They then slowly reach, using the hand of their dislocated shoulder, behind their head and try to touch the opposite shoulder. Somewhere on the very slow, steady reaching, the shoulder will align itself and pop back into place. This action has been described as a pitcher’s ‘wind up’ before a pitch using the affected side. Taking their time the casualty slowly reaches upward and backwards as if they were going to pitch a baseball. If the ‘wind up is slow enough, with plenty of rest if needed, the shoulder will pop back into place. This manoeuvre can be done solo or with assistance. It is said that if you are assisting, cup the victim’s elbow, giving it support and guiding their arm through the manoeuvre. Your other hand can be placed on their shoulder to apply support to the joint as it goes through the motion. Those who describe this technique emphasise the lack of force involved.

Another technique is the external rotation method. This method begins by stabilising the elbow against the torso with one hand. With the elbow flexed at 90°, the forearm is gradually allowed to move laterally (away from the body?) to the extent that muscle relaxation allows. Force is never used. The shoulder will likely reduce before the forearm reaches out to the side. With a slight modification, this technique can also be attempted solo. Beginning with elbows at their sides, sitting or lying down, the casualty raises both hands toward their head and slowly attempts to place both hands behind their head. The unaffected arm can be used to assist the affected arm. If the hands-behind-head position can be achieved, the shoulder will likely reduce. This is very similar to the Milch technique and again is simple, quick, easy to remember and involves no force. Experts emphasise that the key to any of the techniques is the timing — they will only work in the period immediately following the dislocation or at a later time with the assistance of a muscle relaxant such as morphine.

And my shoulder? After the morphine had fully taken effect, I was sat on the edge of a bed and asked to lean over and allow my arms to dangle towards the floor whilst I was supported from behind. In the process, my shoulder slipped straight back in. No one was touching or pulling either arm or shoulder. A similar result may be gained by going on all fours and allowing the affected arm to dangle as described above.

Prevention and susceptibility

The topic of prevention and susceptibility could involve a whole article in itself. Prevention includes topics such as safe paddling techniques and awareness as taught by club instructors, practice, personal fitness and risk management. Susceptibility includes areas such as physical susceptibility to shoulder dislocation including shoulder mobility. No detail is provided regarding these related topics as they can hopefully be explored in a future workshop.

Workshop

To successfully explore all of these issues and get the best out of this article, a workshop lead by trained professionals has been arranged. They will guide us through the techniques mentioned in this article and answer specific queries or concerns. In addition, the questions of prevention and susceptibility will be explored with hopefully the opportunity to have your own shoulder mobility assessed. The date of this workshop will be announced in a forthcoming club e-newsletter.

Epilogue

I remember the overwhelming sense of relief when I heard the faint sound of the helicopter coming over the headland. Although it was barely over an hour, it had felt an eternity as the pain just seemed to increase with every minute. I was in the emergency ward in St George Hospital within minutes of taking off. I remember the fleeting glances below of the coastline we had paddled that morning — difficult to enjoy the view given the overwhelming pain at the time!

Almost 12 months on and after doctor’s appointments, scans, physio and active release therapy I can say that I’m about as good as new. I do regular strengthening and stretching exercises to maintain the physical integrity of both shoulders.

Four months after the accident I successfully re-attempted the Sea Skills qualification — this time enjoying the paddle back with no helicopter assistance!

References

Wedro. B.C (2009) Dislocated Shoulder.

Source: www.medicinenet.com/script/main/art.asp?articlekey=100331

NOTE: I want to emphasise that in no way by writing this article am I questioning the actions of those involved on the day. Even in the circumstance that the knowledge of shoulder reduction was held by anyone involved, it may well have been that the decision on the day was not to do anything different. In my case I had no complications and was in the hospital relatively quickly given the location and circumstance.

Thanks

I’d like to give special thanks to my very dear kayaking companions for looking after me on the day and managing to organise my rescue as quickly as they did; Stuart Trueman and Paul Layton, Cathy Miller and Alan Thurman. All I might add successfully passed their Sea Skills assessment on the day!

I’d also like to give special thanks to John Piotrowski who after receiving a concerned phone call from Stuart, leapt out from his swimming pool and travelled to my bedside at St George Hospital, only to spend hours waiting for the morphine to wear off before he could drive me home!

I received much support and well-wishes from many club members — something that has made me acutely aware of the real value and strength of the club; many thanks to all of you and I hope there has been something valuable for you here.

This article has received the editing magic of Cathy Miller and her valuable comments have improved this article immensely.

Also huge thanks to Jacqui Stone, NSW Sea Kayaker editor, for her patience as this article has developed over the last few months.

And finally, a special thanks to Dr Michael Lee (School of Medical Sciences, University of NSW) and Professor George Murrell (Director of Orthopaedic Surgery at St George Hospital) for their valuable advice and comments with regard to the technical aspects of this article. Dr Lee has also been successfully treating me since February 2009. Both Dr Lee and Prof. Murrell have agreed to give their time and expertise by attending the workshop and I thank them both in advance.

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