Report by Helen R Ashton, SpR in Emergency Medicine
Checked by Zia Hassan, SpR in Emergency Medicine
Preston Royal Infirmary, Preston, UK
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]?
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.
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.
A total of 304 papers were found on Medline of which only one addressed the question (table 33).). There were a total of 97 Cochrane citations; the same paper was found.
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.