Imagine you are you are canoeing or kayaking along in some pretty active whitewater, and you go to do a high brace, or catch a tight eddy, and your arm suddenly goes dead, you can’t use it, and you are now a one handed paddler. That is what a shoulder dislocation might be like. Below I will describe what a shoulder dislocation is, why it might happen, and what you can do about it if you or someone in your party has one.

The shoulder is a ball and socket joint, and when the ball slips out of the socket, that is called a dislocation. Medically speaking, the shoulder is the glenohumeral joint; the glenoid is the socket, and the head of the humerus (the long bone in your upper arm) is the ball.

The glenoid happens to be pretty shallow, which is why the shoulder has such a great range of motion, but the penalty is the potential for instability. It is like a golf ball sitting in a soup spoon. There are several types of dislocation, depending on the direction the ‘ball’ moves, with anterior being the most common, but for purposes of this discussion, it would not matter, because the end result for the paddler is the same.

Typically, the shoulder would be at risk for dislocation when the arm is placed back in the ‘passer’s position’, and then pushed a little further by an opposing force. Maybe your paddle hits an unexpected rock just as you are making a tight turn, or maybe your arm just happens to be in an awkward position at that moment. Immediately, there will be an obvious deformity at the shoulder (unless you are very muscular), and it may seem as if a divot were taken out, plus your arm is pointing out in an unacustomed direction, and you can’t bring it across your chest. You certainly can’t paddle! Oh, I forgot to mention…’s very painful too!

When the shoulder goes out, the capsule (which is rich with nerve endings) is stretched or even torn, and it is kept under tension, so….it hurts. The shoulder muscles quickly go into spasm to protect against painful movement, but that too becomes painful. So, the best thing to do is to splint the arm to prevent motion, and get to an Emergency Room! Unless your hand become numb and your circulation shut off , this is not an extreme emergency, other than the pain. If it stays out beyond 6 to 8 hours, the reduction is going to be more difficult, due to all the spasm and swelling.

At this point, let me digress. It matters if this is the first dislocation, or if it has happened before (we call this a recurrent dislocation). People prone to recurrent dislocation would not likely be paddling. Their shoulder often come out very easily, but the flip side is that it usually goes back in easily as well, so much so that many know how to do a maneuver and reduce it themself. For this discussion, I am talking about an initial, primary dislocation.

Back to treatment. I have reduced many dislocations, all in an emergency room where I had lots of help, plus intravenous sedation and analgesia for the victim. Even then, they were not all easy. It is also imperative to get an Xray before you try to reduce the shoulder, as a certain percentage will have an associated fracture of the humeral head, and sometimes the glenoid as well. Once reduced, you place the arm across the chest in a ‘Red Cross’ sling, and the individual is usually comfortable. I have never confronted a dislocation while canoeing, but imagine the best opportunity to try to reduce it in wilderness conditions would be immediately, before too much pain and swelling and spasm intervenes. I don’t think this is something a non-medically trained person should consider, but see my comments on the Milch technique below.

I am aware of several methods that I would know to try myself, and there is one I have seen on the internet, the Milch technique, that looks particularly intriguing and would be ideal for the paddler who dislocates. Supposedly, you can even do this yourself if you are alone, and it does not require anesthesia, and could be tried by anyone. I have no experience to recommend it, but it does look interesting. It would seem a safe thing to try while waiting for help to arrive. Do a Google Search of “milch technique shoulder dislocation ” If you want to know more about this problem in general, I suggest a Google Search of “wilderness medicine shoulder dislocation”.

So put this information somewhere in the back of your mind, just in case. Hopefully you will never need it, but it is a good thing to know.

by Dick Hurd, MD
September 7, 2010