The Davos (Boss-Holzach-Matter) technique uses self-administered traction-countertraction. Patients control the forcefulness of the procedure, thereby minimizing their pain, anxiety, and muscle spasms without using analgesia. Once taught, patients can often use the Davos technique without medical assistance.
(See also Overview of Shoulder Dislocation Reduction Techniques, Overview of Dislocations, and Shoulder Dislocations.)
Indications for the Davos Technique
Anterior dislocation of the shoulder in a calm, cooperative patient
Reduction should be attempted soon (eg, within 30 minutes) after the diagnosis is made.
Reduction should be attempted immediately using a technique other than the Davos technique if an associated neurovascular deficit or skin tenting (due to a displaced bone fracture or, less commonly, a fracture-dislocation, with potential for skin penetration or breakdown) is present. If an orthopedic surgeon is unavailable, closed reduction can be attempted, ideally using minimal force; if reduction is unsuccessful, it may need to be done in the operating room under general anesthesia.
Open dislocations require surgery, but closed reduction techniques and immobilization should be done as interim treatment if the orthopedic surgeon is unavailable and a neurovascular deficit is present.
Contraindications to the Davos Technique
Contraindications to simple closed reduction:
Greater tuberosity fracture with > 1 cm displacement
Significant Hill-Sachs deformity (≥ 20% humeral head deformity due to impaction against glenoid rim)
Surgical neck fracture (below the greater and lesser tuberosities)
Bankart fracture (anteroinferior glenoid rim) involving a bone fragment of over 20% and with glenohumeral instability
Proximal humeral fracture of 2 or more parts
These significant associated fractures require orthopedic evaluation and management, because of the risk of the procedure itself increasing displacement and injury severity.
Other reasons to consult with an orthopedic surgeon prior to reduction include
The joint is exposed (ie, an open dislocation)
The patient is a child, in whom a physeal (growth plate) fracture is often present; however, if a neurovascular deficit is present, reduction should be done immediately if the orthopedic surgeon is not available.
The dislocation is older than 7 to 10 days, due to an increased risk of damaging the axillary artery during the reduction, especially in older patients
Complications of the Davos Technique
Increased displacement of associated fractures
Equipment for the Davos Technique
Elastic bandage
Shoulder immobilizer or sling and swathe
* Patients usually do the Davos technique without analgesia; however, only one reduction attempt without analgesia may be done.
Additional Considerations for the Davos Technique
Patients who are calm and can relax are likely to be able to do the Davos technique.
Procedural sedation and analgesia (PSA) should not be used with the Davos technique.
Relevant Anatomy for the Davos Technique
In most anterior dislocations, the humeral head is trapped outside and against the anterior lip of the glenoid fossa. Reduction techniques must distract the humeral head away from the lip and then return the humeral head into the fossa.
Deficits of the axillary nerve are the most frequent nerve deficits with anterior shoulder dislocations. They often resolve within several months, sometimes soon after the shoulder reduction.
Axillary artery injury is rare with anterior shoulder dislocations and suggests possible concurrent brachial plexus injury (because the brachial plexus surrounds the artery).
Positioning for the Davos Technique
Position the patient supine on the stretcher with the ipsilateral hip and knee flexed and the foot flat on the bed.
Step-by-Step Description of the Davos Technique
Neurovascular examination
Do a pre-procedure neurovascular examination of the affected arm, and repeat the examination after each reduction attempt. Generally, testing motor function is more reliable than testing sensation, partly because cutaneous nerve territories may overlap. Assess the following:
Distal pulses, capillary refill, cool extremity (axillary artery)
Light touch sensation of the lateral aspect of the upper arm (axillary nerve), thenar and hypothenar eminences (median and ulnar nerves), and dorsum of the 1st web space (radial nerve)
Shoulder abduction against resistance, while feeling the deltoid muscle for contraction (axillary nerve): However, if this test worsens the patient's pain, omit it until after the shoulder has been reduced.
Thumb-index finger apposition ("OK" gesture) and finger flexion against resistance (median nerve)
Finger abduction against resistance (ulnar nerve)
Wrist and finger extension against resistance (radial nerve)
Intra-articular analgesia
If a cooperative patient chooses to, try the Davos reduction method without analgesia; however, only one such attempt should be made. To give intra-articular analgesia:
The needle insertion site is about 2 cm inferior to the lateral edge of the acromion process (into the depression created by the absence of the humeral head).
Swab the area with antiseptic solution, and allow the antiseptic solution to dry for at least 1 minute.
Optional: Place a skin wheal of local anesthetic (≤ 1 mL) at the site.
Insert the intra-articular needle perpendicular to the skin, apply back pressure on the syringe plunger, and advance the needle medially and slightly inferiorly about 2 cm.
If any blood is aspirated from the joint, hold the needle hub motionless, switch to an empty syringe, aspirate all of the blood, and re-attach the anesthetic syringe.
Wait for analgesia to occur (up to 15 to 20 minutes) before proceeding.
Reduce the shoulder — Davos method
Have the patient come to a sitting position on the flat stretcher and maximally flex the hip and knee of the affected side.
Place the patient's elbows on the sides of the thigh, and with the palms facing each other, tightly wrap the wrists together (anterior to the tibial tuberosity) using an elastic bandage.
Sit sideways on the stretcher, on top of the foot of the flexed leg.
Instruct the patient to relax, gradually lean backward with the spine straight, extend the head, shrug the shoulders, and straighten the relaxed arms. Leaning backward applies traction to the shoulder, with countertraction supplied by the patient's bound wrists around the tibia.
The patient adjusts the amount of traction to maintain relaxation and tolerable pain levels.
Signs of a successful reduction may include a lengthening of the arm, a perceptible “clunk,” and brief deltoid fasciculation.
Aftercare for the Davos Technique
Successful reduction is preliminarily confirmed by restoration of a normal round shoulder contour, decreased pain, and by the patient's renewed ability to reach across the chest and place the palm of the hand upon the opposite shoulder.
Immobilize the shoulder with a sling and swathe or with a shoulder immobilizer.
Because the joint can spontaneously dislocate after successful reduction, do not delay immobilizing the joint.
Do a post-procedure neurovascular examination. A neurovascular deficit warrants immediate orthopedic evaluation.
Do post-procedure x-rays to confirm proper reduction and identify any coexisting fractures.
Arrange orthopedic follow-up.
Warnings and Common Errors for the Davos Technique
Instruct patients to allow sufficient time for muscle spasm to resolve before abandoning the procedure.
Apparent shoulder dislocation in a child is often a fracture involving the growth plate, which tends to fracture before the joint is disrupted.
Tips and Tricks for the Davos Technique
Keeping the spine straight and maintaining relaxed shoulders are key to the success of this maneuver.
In patients who return with increased pain within 48 hours after a reduction, hemarthrosis is likely (unless the shoulder has again dislocated). Aspirate the blood from the joint space (see How to Do Arthrocentesis of the Shoulder).
