May 2023

Authors: Rob Hirst, Andy Neill, Dave McCreary / Codes: / Published: 02/05/2023


Clinical Question

Which shoulder relocation technique is best?

Title of Paper

A Systematic Review With Pairwise Network Meta-analysis of Closed Reduction Methods for Anterior Shoulder Dislocation

Journal and Year

  1. Annals of Emergency Medicine.

Lead Author

Shiro Gonai.


  • Anterior shoulder dislocation. Its common and I doubt theres many of you listening that dont light up a little when you see it pop up on the triage screen. Why is that? Well, we all love a procedure, particularly one that provides instant relief of your patients injury.
  • There are over 20 reduction methods, as well as variants of those. They vary between muscle balance/relaxation, traction, rotation/leverage and combinations.

  • If you ask ten emergency physicians, youll probably get 10 different answers as to what their favourite technique for relocation is.
  • But which is best?
  • There have been a few studies, and even SRs and MA in the past looking at this. This is the first to perform both pairwise and network meta-analysis.
  • What is a network MA, I hear you (and myself when I read this) ask?
    • Where a pairwise meta-analysis compares two interventions or treatments by pooling the results of multiple studies. A network meta-analysis compares three or more interventions or treatments by creating a network of studies that compare different treatments and estimating their relative effect sizes.

Study Designs

  • Systematic review and meta-analysis of RCTs and quasi RCTs including network MA:


  • Acute anterior shoulder dislocation
  • First or recurrent


  • Closed manual reduction


  • Another closed manual reduction


One or more of:

  • Success rate
  • Pain during reduction
  • Reduction time
  • Complications

Summary of Results

  • 1833 results screened 14 studies eligible for inclusion
  • 1189 total patients
  • 18 reduction methods:
    • Boss-Holzach-Matter/Davos
    • Cunningham
    • External rotation (Eachempati)
    • Modified external rotation (Hennepin)
    • FARES
    • Hippocratic
    • Kocher
    • Milch
    • Double-traction method
    • Scapular manipulation
    • Manipulative reduction
    • Modified scapular manipulation
    • Self-assisted BHM
    • Self-assisted Mulch
    • Self-assisted Stimson
    • Spaso
    • Stimson
    • Traction-countertraction

Paired Analysis

The only two techniques directly assessed in more than one trial to be suitable for MA were the Hippocratic and Kocher techniques:

  • Success Rate: Hippocratic vs Kocher: 2 RCTs, no difference
  • Pain: Hippocratic vs Kocher: 2 RCTs, no difference
  • Time to reduction: Hippocratic vs Kocher: 2 RCTs, no difference

Network Analysis

Success Rate

Kocher used as reference as most studied

  • No significant difference between methods
  • FARES consistently first or second in SUCRA (surface under the cumulative ranking curve)

OK now what is SUCRA, again I hear you say

  • ? SUCRA, or surface under the cumulative ranking curve, is a statistical method used to rank the effectiveness of different interventions or treatments in a network meta-analysis. It provides a percentage value between 0 and 100 that represents the likelihood of each intervention being ranked first, with a higher SUCRA value indicating a higher probability of being the most effective intervention.

FARES, Spaso, external rotation and Milch were significantly more effective than Stimson


  • FARES had significantly less pain that Kocher
  • FARES always had the highest SUCRA
  • External rotation, scapular manipulation and modified external rotation were ranked in the middle of the SUCRA plots

Reduction Time

No difference between Kocher and the rest on network forest plots.

Modified external rotation and FARES had high SUCRA values


One fracture of humeral neck reported of 85 year old female with Kocher method with added traction.

Authors Conclusion

We have found evidence suggesting the benefits of several closed reduction methods for anterior shoulder dislocation. BHM and FARES demonstrated the most favourable value for success rates, whereas FARES and modified external rotation were more favourable in reduction times. FARES had the most favourable SUCRA for pain during reduction. Direct comparisons of FARES, BMH, Spase, modified external rotation, external rotation, and scapular manipulation technique would be informative to identify which methods are ideal for which patients.

Clinical Bottom Line

Im still a lover of the Kocher technique, though in fairness the shoulder most often pops back in during the external rotation portion of the technique – which is a lot like the modified external rotation technique.

Ive not used FARES much (because of my success with the aforementioned Kocher), but I think the authors make a fair point that this is one of the techniques with which we should be familiar.

Re the reported complication:

  • Be cautious of rotational techniques in the elderly.
  • ALWAYS get an X-ray first in older patients or if theres a sniff of trauma involved.
  • If in doubt use a non-rotational technique – dont let the ice-cream slip off the cone, dont be that guy.

Other #FOAMed Resources / References:

A good few of the mentioned techniques are summarised here

Clinical Question

  • Should we give TXA IV or nebulised in haemoptysis


  • Nebulized vs IV Tranexamic Acid for Haemoptysis – A Pilot Randomized Controlled Trial


  • Gopinath, Chest


  • Now I’m being naughty because the actual question we should be asking is should we be giving this stuff at all in haemoptysis and that is by no means proven. But signfiicant haemoptysis is a scary acute presentation and we’re usually keen to give anything that might stop the bleeding. Of note there is a preceding trial (wand 2018) that suggested it was of some use.
  • We give TXA for so many other things it’s probably worth considering here.


  • ED based study in a single centre in India
  • Open label but it was randomised
  • All amounts of blood included but excluded immediately life threatening bleeds (which is a problem)
  • 500mg nebs vs IV TXA
  • Given for 72 hrs until discharge or stopped bleeding
  • Primary outcome of cessation of bleeding in patients


  • 110 pts
  • Figure 2A is somewhat misleading looking like 5L of blood over 24 hs when actually its all patients all combined
    • 80% TB which is very different from our population
  • It does look like neb group had less bleeding but table 3 is a give away. Despite being an RCT 2/3 of the IV group were admitted and only 1/3 of the neb group were admitted. Given that discharged patients were simply assumed to have stopped bleeding and couldn’t possibly have the volume of blood measured then its hardly surprising that the outcome favoured TXA. Shows the importance of blinding as i suspec the insertion and prescription of IV TXA led to a change in disposition rather than TXA nebbed being magically better
  • Very little intervention, a little bronch, a little angio


  • I have been using TXA nebs for a while and will continue to do so, I don’t think this trial is great evidence in support of one route versus the other.

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