Kocher's or Milch's technique for reduction of anterior shoulder dislocations

Kocher's or Milch's technique for reduction of anterior shoulder dislocations

Report by Helen R Ashton, SpR in Emergency Medicine

Checked by Zia Hassan, SpR in Emergency Medicine

Preston Royal Infirmary, Preston, UK

Abstract

A short cut review was carried out to establish whether Kocher's or Milch's technique was better at reducing shoulder dislocations. A total of 304 papers were found of which one answered the three part question. The clinical bottom line is that the individual preference of physicians for either Kocher's or Milch's method of reduction is not supported by the evidence.

Three part question

In an [adult patient with an anterior dislocation of the shoulder] is [Kocher's or Milch's technique] best at achieving [a successful, uncomplicated reduction]?

Clinical scenario

A 25 year old man presents to your emergency department with a right shoulder injury following a rugby tackle. Clinical examination and a series of shoulder X rays reveal an anterior shoulder dislocation with no associated neuro‐vascular deficit or fracture. You wonder whether Kocher's or Milch's technique would be most successful in reducing the dislocation without complication.

Search strategy

Medline 1966 to May 2006 using the OVID interface: ([exp shoulder dislocation OR shoulder dislocation.mp OR dislocated shoulder.mp] AND [exp manipulation orthopedic OR manipulation orthopaedic.mp OR manipulation.mp OR reduction.mp OR Kocher$.mp OR Milch$.mp]) limited to human and English language. Cochrane, Edition 2, 2006: Shoulder dislocation.

Search outcome

A total of 304 papers were found on Medline of which only one addressed the question (table 3). There were a total of 97 Cochrane citations; the same paper was found.

Table 3.

Author, date, country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study weaknesses
Beattie et al, 1986, UK	111 consecutive patients (age range16–89) presentingto an accident andemergencydepartmentwith an anteriordislocation of theshoulder without afractured neck ofhumerus orneurovasculardamage	RCT with crossover design.Patients were randomisedbased on whether theypresented on an odd or evendate. Manipulation wasperformed by one of fourinvestigators, all of whomwere “experienced in eachtechnique”. It is not statedwhether analgesia±sedationhad been given to thepatients. On even dates a singleattempt of Kocher's methodwas performed (n = 55) andon odd dates a single attemptof Milch's method was performed (n = 56). If thefirst of either techniquewas unsuccessful, asingle second attempt wasmade using the alternativemethod. If the second attemptfailed, then furthermanipulation was performedunder GA. Reduction wasconfirmed both clinicallyand radiologically	Successfulreduction	Kocher's technique wasslightly more successful thanMilch's technique (77%compared to 75% includingfirst and second attempts(ie, combining pre and postcross over attempts)),however this failedto reach statisticalsignificance	1. No sample size estimates were performed, perhaps leading to the results failing to reach statistical significance2. There is no mention of ethical approval3. The method of randomisation used may have introduced bias4. The lack of information regarding analgesia and sedation makes it difficult to ascertain whether the results are valid and reliable5. The trial was unblinded, but this seems to have been unavoidable6. It is unclear whether the groups were comparable at baseline7. The results are largely presented in the form of percentages which have been rounded to the nearest whole number. There is a discrepancy in the number of patients documented to have gone on to require GA (n = 11) and the number seeming to have had a failed reduction on the second attempt (n = 6.104) (based on calculations performed using the percentages given in the paper)8. The statistical methods used have not been defined9. The authors' conclusions are not based on statistically significant results

GA, general anaesthesia.

Comment(s)

This was the only paper found that compared Kocher's and Milch's techniques in attempting to reduce an anterior dislocation of the shoulder. The data presented are not internally consistant and the results presented are not statistically significant.

No firm conclusions can be drawn from this paper. The results suggest, however, that Milch's technique should be tried initially as it is possibly less traumatic than Kocher's technique, albeit slighty less effective. Larger trials are needed to confirm this.

Clinical bottom line

The individual preference of physicians for either Milch's or Kocher's method of reduction is not supported by the evidence.