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Kocher’s Method

kocher's methodYou can also view a video demonstration of this method or for detailed information, read Kocher’s original article here.

Method

This technique externally rotates the humeral head, and then lifts it anteriorly past the glenoid rim back into place

How does it overcome the static and dynamic forces?

The humeral head is externally rotated presenting a greater articular surface superiorly allowing it to roll past the glenoid rim back into place. Reduction will often occur during external rotation if the patient is correctly positioned (“shoulders back, chest out, humerus fully adducted”) and there is nothing to gain by forcing external rotation once the limit is reached.

In full external rotation the posterior aspect of the greater tuberosity is in contact with the rim of the socket and this is then used as a fulcrum for the next two manoeuvres. The humerus is lifted in the sagittal plane (move the elbow anteriorly and up): this reduces the tension on the joint capsule; and part of the humeral joint surface is lifted onto the anterior rim of the glenoid. Internal rotation is then used to slide the head back into the socket.

Generalised spasm can be reduced by careful slow positioning of your patient.

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Step 1 – positioning

Where do I start?

The starting point for this is with the arm in the anatomical position (adducted), this can be difficult or impossible in obese patients.

Remember the scapula!

You may need to ask your patient to shrug the shoulders, bringing the scapulae together (as in the Cunningham technique) – if the scapula is fully anteverted and rotated around on the chest wall then the humeral head will not be able to “roll around” the humeral head even in full external rotation.

Don’t pull!

This method has been a reliable, successful technique since 1870 (perhaps longer) and does not mention traction. If you add traction, as many have done, you will inflict pain and you run the risk of stress on the humeral neck and shaft which may fracture. Also, you won’t be able to reduce your patient’s dislocated shoulder!

Anatomically, there is nothing to be gained by forcing external rotation other than pain and spiral fractures. There is usually a point at which either no further external rotation will occur, or the patient will say stop (as you have instructed them to do so!)

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