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Three Part Question

In an [adult patient presenting with a anterior shoulder dislocation] which of [Kochers or FARES method] is the [safest and most effective] reduction technique.

Clinical Scenario

A 36 year-old man presents to the Emergency Department with a painful, deformed left shoulder after falling from his bike on the way to work. Your clinical examination is suggestive of an anterior shoulder dislocation and shoulder X-rays confirm your suspicions. There is no associated fracture or neurovascular deficit. You are aware that there has been much debate about the best method of reduction of anterior shoulder dislocations and have recently been taught how to perform the FARES method. You wonder whether this method or the more traditional Kocher’s method would be the most effective and least painful.

Search Strategy

Medline 1966-Sept 2010 using the OVID interface.
Cochrane Reviews 2010
Medline: ([exp shoulder dislocation OR shoulder AND dislocation.mp.] AND [exp manipulation orthopedic OR manipulation AND orthopaedic.mp. OR manipulation.mp. OR reduction.mp. or shoulder AND reduction.mp.OR Kocher$.mp. OR FARES$.mp.]) LIMIT to human and English languageCochrane: Shoulder dislocation

Search Outcome

Medline: 747 papers were found and abstracts were looked at. Only one addressed the question
Cochrane: 39 citations. No paper that addressed the above question was found

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fares, E et al 2009 Greece	154 patients who met all inclusion criteria, were randomly assigned to one of the three study groups (FARES, Hippocratic, and Kocher) and underwent reduction of the dislocation by first or second-year orthopaedic surgery residents.	Prospective Randomised Controlled Study	Success rate of reduction	Reduction was achieved with the FARES method in 88.7% of the patients, with the Hippocratic method in 72.5%, and with the Kocher method in 68%. This difference was significant, in favor of the FARES method (p = 0.033).	1. The study was unblinded 2. The patients were not examined in order to detect generalised ligament laxity and this is a potential source of bias 3. The power of the study was low and only a relatively small number of patients were enrolled 4. There was no long term follow up of patients
			Mean duration of reduction manoeuvre	The mean duration of the reduction manoeuvre was significantly shorter for the FARES method (2.36 ± 1.24 minutes for the FARES method, 5.55 ± 1.58 minutes for the Hippocratic method, and 4.32 ± 2.12 minutes for the Kocher method; p < 0.001)
			Intensity of pain felt by patient (measured by visual analogue scale)	The mean visual analog pain score was significantly lower for the FARES method (1.57 ± 1.43 for the FARES method, 4.88 ± 2.17 for the Hippocratic method, and 5.44 ± 1.92 for the Kocher method; p < 0.001). No complications were noted in any group.

Comment(s)

Only a single paper was found that addressed the question. The paper was a prospective randomized controlled study and produced statistically significant results. The FARES method was found to be significantly more effective, faster and less painful than both the Hippocratic and Kocher methods. The authors have noted several potential sources of bias and it is possible that the differences between reduction methods would be eliminated if sedation were employed. Due to the nature of the study it was not possible to employ blinding. It was also noted by the authors that far larger numbers of patients would need to be evaluated before the safety and efficacy of the FARES method could be commented upon.

Clinical Bottom Line

The FARES method for reduction of anterior shoulder dislocations is more effective, faster and less painful than the Kocher method.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Fares, E et al Reduction of Acute Anterior Disclocations: A Prospective Randomised Study Comparing a New Technique with the Hippocratic and Kocher Methods The Journal of Bone and Joint Surgery 2009;91:2775-82