You’re in the middle of a busy Resus shift, no available beds, and someone asks you if they can bring back a patient for a procedural sedation to reduce a dislocated shoulder. “Arghhhhghgh” you think to yourself, “just what I need.” Tons of paperwork, consent forms, an extra nurse, getting the resident, attending, and patient all together in the same place at the same time, all while you have 4 million other things to do.
But, and so, before we set up the end-tidal CO2, draw up the Ketamine, etc, we should(er) try the FARES technique. FARES stands for FAst, REliable, and Safe. While the technique name reminds me of a poster that may be hanging up in a used car salesman’s office trying to pitch you a 2003 Honda Odyssey, this technique is super easy and really doesn’t require procedural sedation.
Here is a great video by VUMC Emergency Medicine. The technique is demonstrated in the first 2 minutes.
So, looks great, easy to do, but does it work?
Sayegh et al. looked at FARES compared to the Kocher and the Hippocratic method in “first-time” dislocations, both with and without greater humeral tuberosity fractures. All reductions were done without any sedation, anesthesia, or pain control (savage!), and in fact, patient were excluded if they had any analgesia or muscle relaxants prior to reduction attempts. Also, of note, dislocations could not have been more than 24 hours old. Reductions were done by first and second year Ortho residents.
The result were as follows:
“Reduction was achieved with the FARES method in 88.7% of the patients, with the Hippocratic method in 72.5%, and with the Kocher method in 68%. This difference was significant, in favor of the FARES method (p=0.033). The mean duration of the reduction maneuver was significantly shorter for the FARES method (2.36 ±1.24 minutes for the FARES method, 5.55 ± 1.58 minutes for the Hippocratic method, and 4.32 ± 2.12 minutes for the Kocher method; p < 0.001), and the mean visual analog pain score was significantly lower for the FARES method (1.57 ± 1.43 for the FARES method, 4.88 ± 2.17 for the Hippocratic method, and 5.44 ± 1.92 for the Kocher method; p < 0.001). No complications were noted in any group.”
Conclusion: This is a potentially great shoulder reduction technique that can be done without procedural sedation, is quick, and seems to work better than some well-known and popular methods. However, don’t be a monster and give your patient a Percocet before you do this.
References: Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am. 2009 Dec;91(12):2775-82. PMID: 19952238.