Experts' Eye View

An unusual complication of Kocher's manoeuvre

BMJ 2004; 329 doi: (Published 16 December 2004) Cite this as: BMJ 2004;329:1472
  1. A Pimpalnerkar, consultant in orthopaedics and sports1,
  2. A Datta, specialist registrar in orthopaedics1,
  3. D Longhino, orthopaedic resident2,
  4. N Mohtadi, consultant sports surgeon2
  1. 1 Royal Centre for Defence Medicine, Birmingham B29 6JD
  2. 2 Sports Medicine Centre, Calgary, Canada T2N 1N4

    A 25 year old man presented to the emergency room with a right anterior glenohumeral dislocation after a fall. He was attended to by a 30 year old, left hand dominant orthopaedic resident. Kocher's manoeuvre was attempted to reduce the dislocation.

    As the patient's arm was slowly externally rotated the patient resisted forcefully and suddenly internally rotated his arm. The resident immediately heard a “pop” in his own left shoulder, followed by a burning sensation with subsequent weakness.

    The resident was an active individual, who did regular weight training and played competitive ice hockey. He had no previous shoulder problems and denied using anabolic steroids.

    On examination there was a loss of the normal anterior axillary fold, bruising in the upper arm (figure), and weakness in adduction and internal rotation. Neurovascular examination was normal. Plain radiographs were unremarkable. Magnetic resonance imaging confirmed a near total rupture of the pectoralis major tendon from its humeral attachment. The marrow signal was normal.

    Embedded Image

    Loss of normal anterior axillary fold and contour of the pectoralis belly, along with substantial bruising around the axilla

    The resident had surgical repair of the tendon five days after the injury. The tendon was reattached to the lateral lip of the bicipital groove using Mitek anchors and number 2 Ethibond. At final follow up at 24 months, the functional range of shoulder movement had returned with good muscle strength and endurance as assessed with isokinetic and functional testing.


    Pectoralis major tendon injury, though rare, was first described in 1822 by Patissier.1 Such injuries are becoming more common owing to an increasing number of recreational and professional athletes. The mechanism is of a violent eccentric contraction and is associated with doing bench presses, wrestling, and water skiing.2

    The pectoralis major muscle is a powerful adductor, internal rotator and flexor of the shoulder. The sternocostal and clavicular heads insert at the lateral lip of the bicipital groove to form two separate laminae that are oriented perpendicular to each other. When the arm is abducted and externally rotated the sternocostal fibres are maximally stretched.

    Numerous reduction techniques for anterior glenohumeral dislocations have been described. They fall into three main categories: traction techniques (Hippocrates,3 Stimson4) leverage techniques (Kocher,5 Milch6), and scapular manipulation.7

    Kocher's manoeuvre was originally described in 1870.5 The affected arm is flexed at the elbow and adducted against the side of the body. The forearm is rotated externally and the upper arm lifted in a sagittal plane as far as possible and finally internally rotated. There have been many adjustments to this widely used technique, especially as the additional torque resulting from adduction and internal rotation have been associated with humeral shaft fractures in elderly people.8 9

    To perform Kocher's manoeuvre the surgeon must abduct and externally rotate his own arm, this means the fibres of the sternocostal head of his pectoralis major are maximally stretched. If a patient is not well sedated or has not received adequate analgesia he or she is more likely forcefully to resist the reduction. This results in a sudden uncoordinated eccentric contraction of the surgeon's pectoralis major muscle, which in our case resulted in a pectoralis major rupture. If adequate sedation and pain relief are not possible, reduction under general anaesthetic may be necessary to minimise the risk of complications for both the patient and the doctor.


    • Competing interests None declared.


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