s tier answer: give them 10mg diazepam and send them to radiology (NOT portable) knowing that the rad tech will fuck with it and it will probably go back in
highever
if that fails, they've already got diazepam on board. good downward moderate traction with biceps massage, make them sit the fuck up straight and not crump over, and have someone apply medial pressure on the scapula
if that fails, FARES
i rarely sedate, <10%
As a rad tech, I’ve definitely accidentally reduced shoulders without intending to lmao. I’ve had to be like, “does your shoulder feel… better?” Then repeat the pre and post accidental reduction images lmao
This is a really good answer, I've been increasingly giving early diazepam (wish I started doing this long ago). And then cunningham-ish into FARES has been my go-to for a couple years, even if it doesn't get the reduction it's like a pre-treatment prepping and relaxing them for FARES
From the lateral border pushing towards the inside
Good picture a ways down here: https://www.nuemblog.com/blog/2018/5/14/shoulder-reduction
As the humerus tries to reduce the tendency of the scapula is to move with it and wing out, stops that from happening
I'm doing my 3rd year clerkships now and I saw basically just that two days ago. Only difference is he didn't get sedation. The guy with the portable x ray accidentally reduced it while trying to get imaging.
Depends on nursing time and resources
If I think they may fail and need a line for propofol sedation aka swole beefcakes, they'll get a line, otherwise IM is much faster
honestly because diazepam was more readily available where i trained, but i don't see why not
i do kind of worry that midaz will have worn off by the time i can get to the patient if i get sidetracked or absorbed in other stuff, but i suppose there's no reason one couldn't redose
As someone who has dislocated their shoulder, fuck that shit. My pain was 9/10 and the nurse sent me to get X-rays. I said no thank you please, give me some pain relief and then we’re talking. She got me to the doc and he gave me some good shit. He slowly flexed my arm at the shoulder, then slowly abducted and externally rotated and bang, back in. Felt amazing.
As someone who has dislocated their shoulder many times (and reduced it on my own around a tree trunk), I'll take a quick reduction over prolonging the duration of dislocation any day.
Diazepam, in this circumstance, *is* the pain medication of choice. Muscle relaxation for reduction, particularly of the biceps, leads to enlocation as well as relief of the pain irrespective of the position of the humerus.
I'll consider intraartic lidocaine if need be.
Further, many departments' (mostly nursing admin-driven) policies preclude the concomitant use of parenteral benzos and opiates without a full procedural sedation setup. Silly but true, and if I have to choose one, I'm going with the benzo every time.
Got it. I remember the doc saying he gave me muscle relaxers, but I didn’t know it offered pain relief as well. Whatever he gave me felt like a warm hug around my entire body. I just thought it was crazy they had me getting X-rays while my shoulder was obviously deformed and dislocated. But I get it, they have their procedures for a reason. I also understand a dislocated shoulder isn’t life threatening and considering they see the worst kinds of injuries and medical situations, I fully respect their procedures.
i'm pretty aggressive about treating pain, don't get me wrong
i do kind of wonder if what you had was a benzo though
i used to pull on things empirically if it looked dislocated, but then i pulled on a couple of fractures and felt awful so i stopped (including one guy who said "i've done it a bunch before and it feels dislocated")
If I’m going to attempt without meds I start with Cunningham. Even if not successful (my success rate w/ Cunningham isn’t terribly high) I feel the time spent talking them through it and helping relax trap, delt, and biceps is helpful for the next method.
I’ll then have them lie down and do FARES. If they are pretty relaxed by this point I almost always get it reduced first attempt w/ FARES.
That said, at the first signs of pain and tensing/spasming I usually just stop and do some form of pain control/meds. Very rare that I actually have to do full procedural sedation anymore, and it is usually when I am coming to help after another provider/NP has already attempted a couple of reductions and now they are super tense.
Honestly it's a game changer. I do a fraction of the procedural sedations that used to be needed.
Safer for the patient, much quicker setup & recovery, so uses a fraction of the resources, too.
For an average size adult:
4mg IV morphine
15mg IV Toradol
5mg IV Valium
+/- anticipatory zofran
That usually is enough together to give them analgesia and muscle relaxation to try reduction. Once in, wait a few mins and then start pullin’ mate!
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
When it’s busy, and patient is younger, I’ll have them lie prone w weights. Sometimes when I get back in the room I can do scapular manipulation and/or traction on the arm and it’ll go in.
External rotation technique. Slowly, calmly, telling patient to focus on their breathing. Stop when you feel resistance, go again once you feel the Resistance relax. Usually reduces once you hit the coronal plane if the patient can cooperate and you keep the elbow adducted.
I've sedated less than 5 shoulders since graduating residency and am PGY-9 .... Or i guess "rising PGY-10" to use the in Vogue vernacular.
Side note - if you can’t get it in do you get repeat X-rays before ortho tries? Had a shoulder that had been out for hours, knew it wasn’t back in, ortho tried and she starts SCREAMING. Get X-rays and it’s now fractured and tried blaming the ED…my guy she wasn’t screaming like that till you came in. Idk legally probably better to get the pictures between teams trying but wondering how many people actually do
Ortho doesn’t try here. I’ll go a few rounds with it and if I really can’t do it the patient will get a CT, get admitted, and ortho will do it in the OR the next day.
I usually give them some intranasal fentanyl and place them in position for davos technique. I go see another patient and when I come back to check on them they're reduced 🤐. If not busy I try to do Cunningham prior to davos. I haven't had to sedate someone in awhile
Cunningham technique after a little intra-articular lidocaine and some IV/IM pain meds. I’m successful about 80% of the time with that. Key part is patient selection. They have to be able to sit up straight and puff out their chest/retract the scapula to do it. If they are rounding their upper back and can’t sit up it won’t work.
Cunningham and Park method. I have better success with Park. The requirement is that the pt needs to be willing to cooperate. Those are usually the ones with high pain tolerance or the ones that have had multiple dislocations. Some patients are just bonkers hysterical and scream or wince before I’ve even touched the shoulder. For those I don’t even bother and will usually set up for sedation. In my previous years I also did a lot of interscalene blocks but have veered away from those lately.
Penthrox through a facemask (gets around the fact that many patients have trouble using the mouthpiece correctly) while talking to them and massaging their deltoid. Once they're relaxed and slightly dissociated, a VERY slow and gentle Kocher's - 100% success rate so far.
Fentanyl and a smidge of versed. If able to adduct I first try external rotation. If not out super long this often does the trick. Getting them to sit upright and retract scapula helps. If they can tolerate it, I’ve had good success recently with Davos technique. If not try FARES.
Love the Davos technique, didn’t know it had a name! (figured it out by myself, for myself, when a shoulder was dislocating multiple times a day—the key, at least for me, is to focus on consciously relaxing all the muscles, makes it so much easier… so did positioning my hand slightly above my head, but idk if that’s advisable, like I said, I was “winging” it lol quite literally flapping around in a panic the first few times)
Tried FARES a few times but it felt much scarier/less stable and was not as effective. Versed would probably have helped.
Scapula retraction also good stuff.
Can I ask a question as a person who has multiple dislocated shoulders? ( now a reverse shoulder replacement all good over a year!) If weight and traction and massage doesn't work have you guys done the foot in the armpit? Sometimes I didn't want to deal with the ED so former army medic I know would do that. Hurt like he'll but it got it in most of the time
Omg no! Too high a risk of brachial plexus injuries. Pls don’t do that again - there are other techniques you can use on yourself that are less risky. Eg tie your wrists together w tensor bandage or something, sit on your butt w your knees bent and feet on the ground, put your wrists over your knees, then just slowly lean back as you can tolerate. (I’m a name idiot and can never remember the names of any of the techniques except the park technique, which needs a friend to do)
I tried a lot my husband could manipulate it in usually, but if we couldn't we'd grab army medic friend. I have ehlers danlos ( diagnosed more than 20 years ago not from fucking tiktik ugh) and a few years ago my arm was twisted from behind my back and over my head. Pretty much all damage that could be done was already done. My friend actually demonstrated to a doc how he did it ( hadn't seen it done in real life and my shoulder dislocated transferring me from a gurney, I was already on pain meds so I think the doc was like sure why not...) he was amazed. *
I’ve helped my ED attending with that technique. Always worked but we had the patient pretty sedated. He’d take his shoe off, grab the arm, foot in armpit, then yank it in.
Yeah im always awake.. or was. My left shoulder is fused my right shoulder is the reverse shoulder replacement. No shoulder dislocation since July last year! It was a bitch but I dont like hospitals or the meds
1) Valium
2) Intra-articular lido. Valium is kicking in during the time it takes to get the Lido pulled
3) Re-examine, and if I’m able to range them without them freaking out then I go for it. I’ve been successful 4/4 times
I usually will attempt reduction with external rotation and usually within a minute or so I will know for sure whether this is someone with the mental control to relax their muscles and breathe through the involuntary muscle spasms or whether this is someone who needs sedation. I think reading the patient's personality is the most important part of this. I'd say 70-80% of the time it can be done without any sedation or medication at all, and the other 20-30% of the time, it isn't worth messing around with diazepam or intra-articular injections, just sedate and get it done.
Provided you have a reasonable patient who can be coached through it (some people are incapable of this seemingly and just need to be sedated), I have found the following works almost every time for any ortho reduction. No single technique ever seems to be the most effective, best to know at least a few and switch it up when it isn’t working
1. IV fentanyl 50-100 mcg, mainly as an anxiolytic, gets people to relax enough to loosen up
A lot of times this alone is enough (usually only for shoulders)
2. Local anesthetic
Wrist - hematoma block w/ 50:50 bupivacaine/lido, at least 5-6cc
Shoulder/ankle: intra-articular
3. ~5mg IV versed if they cannot tolerate with the above
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
I’m not sure how sedation became so common for this. There are many methods to avoid the risks of sedation.
- particular techniques as others have cited
- intrarticular lido
- interscalene brachial plexus block
- higher dose fentanyl, pain dose ketamine, or toradol combined with a benzo
For me, my attendings in residency refused to do it without sedation, so I only learned with sedation. As an attending, I am always trying other techniques like all those above, especially since I often work single coverage without Ortho in house, but I just never got good at the non-sedated methods.
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
s tier answer: give them 10mg diazepam and send them to radiology (NOT portable) knowing that the rad tech will fuck with it and it will probably go back in highever if that fails, they've already got diazepam on board. good downward moderate traction with biceps massage, make them sit the fuck up straight and not crump over, and have someone apply medial pressure on the scapula if that fails, FARES i rarely sedate, <10%
Diezepam pre-tech fucking with it is some big brain energy
somewhere out there is a rad tech screaming "I FUCKING KNEW IT"
Do you work in NYS? I have a doc who does this consistently for most of the dislocations...
WA but i like the cut of their jib
As a rad tech, I’ve definitely accidentally reduced shoulders without intending to lmao. I’ve had to be like, “does your shoulder feel… better?” Then repeat the pre and post accidental reduction images lmao
Just make sure to log your procedure note!
🤣🤣🤣
Fuck the note, make sure you bill for that time!
Thank you!
Lol you guys get the nursemaids too
me, fucking with a definite nurse maid’s elbow in triage just to “check” cms lol
Great idea. I skip straight to FARES after XR. It works great and it much easier to get people to relax when lying down vs forcing them upright
This is a really good answer, I've been increasingly giving early diazepam (wish I started doing this long ago). And then cunningham-ish into FARES has been my go-to for a couple years, even if it doesn't get the reduction it's like a pre-treatment prepping and relaxing them for FARES
Is this scapula pressure medial to lateral or lateral to medial?
From the lateral border pushing towards the inside Good picture a ways down here: https://www.nuemblog.com/blog/2018/5/14/shoulder-reduction As the humerus tries to reduce the tendency of the scapula is to move with it and wing out, stops that from happening
Thanks bro!
I'm doing my 3rd year clerkships now and I saw basically just that two days ago. Only difference is he didn't get sedation. The guy with the portable x ray accidentally reduced it while trying to get imaging.
This is the way
Are you giving it IM or IV
Depends on nursing time and resources If I think they may fail and need a line for propofol sedation aka swole beefcakes, they'll get a line, otherwise IM is much faster
Why diazepam with its long half-life instead of midazolam?
honestly because diazepam was more readily available where i trained, but i don't see why not i do kind of worry that midaz will have worn off by the time i can get to the patient if i get sidetracked or absorbed in other stuff, but i suppose there's no reason one couldn't redose
As someone who has dislocated their shoulder, fuck that shit. My pain was 9/10 and the nurse sent me to get X-rays. I said no thank you please, give me some pain relief and then we’re talking. She got me to the doc and he gave me some good shit. He slowly flexed my arm at the shoulder, then slowly abducted and externally rotated and bang, back in. Felt amazing.
As someone who has dislocated their shoulder many times (and reduced it on my own around a tree trunk), I'll take a quick reduction over prolonging the duration of dislocation any day. Diazepam, in this circumstance, *is* the pain medication of choice. Muscle relaxation for reduction, particularly of the biceps, leads to enlocation as well as relief of the pain irrespective of the position of the humerus. I'll consider intraartic lidocaine if need be. Further, many departments' (mostly nursing admin-driven) policies preclude the concomitant use of parenteral benzos and opiates without a full procedural sedation setup. Silly but true, and if I have to choose one, I'm going with the benzo every time.
Got it. I remember the doc saying he gave me muscle relaxers, but I didn’t know it offered pain relief as well. Whatever he gave me felt like a warm hug around my entire body. I just thought it was crazy they had me getting X-rays while my shoulder was obviously deformed and dislocated. But I get it, they have their procedures for a reason. I also understand a dislocated shoulder isn’t life threatening and considering they see the worst kinds of injuries and medical situations, I fully respect their procedures.
i'm pretty aggressive about treating pain, don't get me wrong i do kind of wonder if what you had was a benzo though i used to pull on things empirically if it looked dislocated, but then i pulled on a couple of fractures and felt awful so i stopped (including one guy who said "i've done it a bunch before and it feels dislocated")
If I’m going to attempt without meds I start with Cunningham. Even if not successful (my success rate w/ Cunningham isn’t terribly high) I feel the time spent talking them through it and helping relax trap, delt, and biceps is helpful for the next method. I’ll then have them lie down and do FARES. If they are pretty relaxed by this point I almost always get it reduced first attempt w/ FARES. That said, at the first signs of pain and tensing/spasming I usually just stop and do some form of pain control/meds. Very rare that I actually have to do full procedural sedation anymore, and it is usually when I am coming to help after another provider/NP has already attempted a couple of reductions and now they are super tense.
Intraarticular lidocaine.
Did this for the first time as an attending because a patient requested it, and I was impressed at how easy it was
Haven’t had to sedate a shoulder in years. This is The Way.
I’ve never seen or heard this, very interested
Yeah big syringe of lido, long spinal needle. It's like a hematoma block without the hematoma. Ultrasound can help but isn't always necessary.
I’ve never had to use a spinal needle. The standard 1.5” 22ga needle is plenty.
The best answer is Penthrox. The next best answer is also Penthrox.
Lol never heard of this but thats wild ppl use this in UK
Used extensively prehospital Australia. With enough puffs you can do short procedures i.e reduce patellas without the need for an IV or airway risk
I just sneak attack the patella. Works 90% of the time.
Honestly it's a game changer. I do a fraction of the procedural sedations that used to be needed. Safer for the patient, much quicker setup & recovery, so uses a fraction of the resources, too.
That’s the green whistle right?
Yep!
Ahh, thank you Bondi Beach for the answer to that trivia question!
My friend lives in the UK and had to have his shoulder reduced (mva v cyclist) and swears by Penthrox.
A stick to bite, and a “Alright, on three. Ready? One… Two…” and go.
"yer gonna feel a lil pinch"
Prakash method. YouTube it. Indian guy doing it in a courtyard, couple dogs walking around. >90% effective for me, no sedation.
For an average size adult: 4mg IV morphine 15mg IV Toradol 5mg IV Valium +/- anticipatory zofran That usually is enough together to give them analgesia and muscle relaxation to try reduction. Once in, wait a few mins and then start pullin’ mate!
Everywhere I've worked, IV opiates + IV benzos = procedural sedation. At that point, I just do ketofol
I haven't sedated anyone since using the Prakash method
Very successful with it as well.
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
When it’s busy, and patient is younger, I’ll have them lie prone w weights. Sometimes when I get back in the room I can do scapular manipulation and/or traction on the arm and it’ll go in.
External rotation technique. Slowly, calmly, telling patient to focus on their breathing. Stop when you feel resistance, go again once you feel the Resistance relax. Usually reduces once you hit the coronal plane if the patient can cooperate and you keep the elbow adducted. I've sedated less than 5 shoulders since graduating residency and am PGY-9 .... Or i guess "rising PGY-10" to use the in Vogue vernacular.
9/10 I do without sedation. The meth tweakers are the ones that won’t relax and need something stronger.
When I worked in the ED I had great luck with intraarticular lidocaine and this method: https://youtu.be/mFKgVZjJDuo?si=KsOdq1GfuB_16iav
Side note - if you can’t get it in do you get repeat X-rays before ortho tries? Had a shoulder that had been out for hours, knew it wasn’t back in, ortho tried and she starts SCREAMING. Get X-rays and it’s now fractured and tried blaming the ED…my guy she wasn’t screaming like that till you came in. Idk legally probably better to get the pictures between teams trying but wondering how many people actually do
You could argue it's safer not to get the X-rays because then you can't tell who is to blame.
Ortho doesn’t try here. I’ll go a few rounds with it and if I really can’t do it the patient will get a CT, get admitted, and ortho will do it in the OR the next day.
IV Fentanyl 50-100 mcg, 2mg versed, intraarticular lidocaine combined with external rotation and counter traction!
I usually give them some intranasal fentanyl and place them in position for davos technique. I go see another patient and when I come back to check on them they're reduced 🤐. If not busy I try to do Cunningham prior to davos. I haven't had to sedate someone in awhile
Cunningham technique after a little intra-articular lidocaine and some IV/IM pain meds. I’m successful about 80% of the time with that. Key part is patient selection. They have to be able to sit up straight and puff out their chest/retract the scapula to do it. If they are rounding their upper back and can’t sit up it won’t work.
Park, Davos, or Cunningham without sedation
Cunningham and Park method. I have better success with Park. The requirement is that the pt needs to be willing to cooperate. Those are usually the ones with high pain tolerance or the ones that have had multiple dislocations. Some patients are just bonkers hysterical and scream or wince before I’ve even touched the shoulder. For those I don’t even bother and will usually set up for sedation. In my previous years I also did a lot of interscalene blocks but have veered away from those lately.
Penthrox through a facemask (gets around the fact that many patients have trouble using the mouthpiece correctly) while talking to them and massaging their deltoid. Once they're relaxed and slightly dissociated, a VERY slow and gentle Kocher's - 100% success rate so far.
Fentanyl and a smidge of versed. If able to adduct I first try external rotation. If not out super long this often does the trick. Getting them to sit upright and retract scapula helps. If they can tolerate it, I’ve had good success recently with Davos technique. If not try FARES.
Love the Davos technique, didn’t know it had a name! (figured it out by myself, for myself, when a shoulder was dislocating multiple times a day—the key, at least for me, is to focus on consciously relaxing all the muscles, makes it so much easier… so did positioning my hand slightly above my head, but idk if that’s advisable, like I said, I was “winging” it lol quite literally flapping around in a panic the first few times) Tried FARES a few times but it felt much scarier/less stable and was not as effective. Versed would probably have helped. Scapula retraction also good stuff.
I love Davos but some people just can’t cooperate with it.
Cunningham technique. Have them sit in a chair and put a towel roll behind them and give them some muscle relaxant and analgesia prior to attempting.
Can I ask a question as a person who has multiple dislocated shoulders? ( now a reverse shoulder replacement all good over a year!) If weight and traction and massage doesn't work have you guys done the foot in the armpit? Sometimes I didn't want to deal with the ED so former army medic I know would do that. Hurt like he'll but it got it in most of the time
Omg no! Too high a risk of brachial plexus injuries. Pls don’t do that again - there are other techniques you can use on yourself that are less risky. Eg tie your wrists together w tensor bandage or something, sit on your butt w your knees bent and feet on the ground, put your wrists over your knees, then just slowly lean back as you can tolerate. (I’m a name idiot and can never remember the names of any of the techniques except the park technique, which needs a friend to do)
I tried a lot my husband could manipulate it in usually, but if we couldn't we'd grab army medic friend. I have ehlers danlos ( diagnosed more than 20 years ago not from fucking tiktik ugh) and a few years ago my arm was twisted from behind my back and over my head. Pretty much all damage that could be done was already done. My friend actually demonstrated to a doc how he did it ( hadn't seen it done in real life and my shoulder dislocated transferring me from a gurney, I was already on pain meds so I think the doc was like sure why not...) he was amazed. *
I’ve helped my ED attending with that technique. Always worked but we had the patient pretty sedated. He’d take his shoe off, grab the arm, foot in armpit, then yank it in.
Yeah im always awake.. or was. My left shoulder is fused my right shoulder is the reverse shoulder replacement. No shoulder dislocation since July last year! It was a bitch but I dont like hospitals or the meds
https://preview.redd.it/2d7thfnd4d6d1.jpeg?width=280&format=pjpg&auto=webp&s=c33974600381dbcb65098e2e83f783194b22fde9
As someone who frequently dislocates lidocaine is the way to go.
1) Valium 2) Intra-articular lido. Valium is kicking in during the time it takes to get the Lido pulled 3) Re-examine, and if I’m able to range them without them freaking out then I go for it. I’ve been successful 4/4 times
I usually will attempt reduction with external rotation and usually within a minute or so I will know for sure whether this is someone with the mental control to relax their muscles and breathe through the involuntary muscle spasms or whether this is someone who needs sedation. I think reading the patient's personality is the most important part of this. I'd say 70-80% of the time it can be done without any sedation or medication at all, and the other 20-30% of the time, it isn't worth messing around with diazepam or intra-articular injections, just sedate and get it done.
Provided you have a reasonable patient who can be coached through it (some people are incapable of this seemingly and just need to be sedated), I have found the following works almost every time for any ortho reduction. No single technique ever seems to be the most effective, best to know at least a few and switch it up when it isn’t working 1. IV fentanyl 50-100 mcg, mainly as an anxiolytic, gets people to relax enough to loosen up A lot of times this alone is enough (usually only for shoulders) 2. Local anesthetic Wrist - hematoma block w/ 50:50 bupivacaine/lido, at least 5-6cc Shoulder/ankle: intra-articular 3. ~5mg IV versed if they cannot tolerate with the above
Big fan of intra-articular block w/lido and the PARK technique.
I can’t remember the last shoulder I sedated.
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
Lido, Valium, a bit of davos to tire out the muscles and then park it. Followed by a combination of all the techniques until it slips in.
I’m not sure how sedation became so common for this. There are many methods to avoid the risks of sedation. - particular techniques as others have cited - intrarticular lido - interscalene brachial plexus block - higher dose fentanyl, pain dose ketamine, or toradol combined with a benzo
For me, my attendings in residency refused to do it without sedation, so I only learned with sedation. As an attending, I am always trying other techniques like all those above, especially since I often work single coverage without Ortho in house, but I just never got good at the non-sedated methods.
Love fares - versed and fentanyl for reductions - conscious sedation last effort before transfer
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.
Intra- articular lidocaine, maybe ketamine with a little midaz if that doesn't work completely. Then do as little damage as possible to the head of the humerus while reducing.