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How To Reduce Anterior Shoulder Dislocations Using the FARES Method
Step by Step Description of the FARES Method
Neurovascular examination Do a pre-procedure neurovascular examination of the affected arm, and repeat the examination after each reduction attempt. Generally, testing motor function is more reliable than testing sensation, partly because cutaneous nerve territories may overlap. Assess the following: Distal pulses, capillary refill, cool extremity (axillary artery) Light touch sensation of the lateral aspect of the upper arm (axillary nerve), thenar and hypothenar eminences (median and ulnar nerves), and dorsum of the 1st web space (radial nerve) Shoulder abduction against resistance, while feeling the deltoid muscle for contraction (axillary nerve): However, if this test worsens the patient's pain, omit it until after the shoulder has been reduced. Thumb-index finger apposition ("OK" gesture) and finger flexion against resistance (median nerve) Finger abduction against resistance (ulnar nerve) Wrist and finger extension against resistance (radial nerve) Intra-articular analgesia If a cooperative patient chooses to try reduction without analgesia, only one such attempt should be made. To give intra-articular analgesia: The needle insertion site is about 2 cm inferior to the lateral edge of the acromion process (into the depression created by the absence of the humeral head). Swab the area with antiseptic solution, and allow the antiseptic solution to dry for at least 1 minute. Optional: Place a skin wheal of local anesthetic (≤1 mL) at the site. Insert the intra-articular needle perpendicular to the skin, apply back pressure on the syringe plunger, and advance the needle medially and slightly inferiorly about 2 cm. If any blood is aspirated from the joint,hold the needle hub motionless, switch to an empty syringe, aspirate all of the blood, and re-attach the anesthetic syringe. Inject 10 to 20 mL of anesthetic solution (eg, 1%lidocaine). Wait for analgesia to occur (up to 15 to 20 minutes) before proceeding. Reduce the shoulder—FARES method Grasp the wrist of the affected arm and slightly pull the arm to provide gentle axial traction. (The FARES method uses no countertraction.) Begin smoothly and cyclically (about 2 cycles per second) moving the arm up and down, about 5 cm above and below the horizontal plane. Continue these arm oscillations throughout the procedure. Gradually abduct the arm. At 90° of abduction, if the joint has not reduced, add gentle external rotation (turning the palm up) and continue abducting. Reduction is expected to occur by 120°. Signs of a successful reduction may include a lengthening of the arm, a perceptible “clunk,” and brief deltoid fasciculation. 