External Rotation and Abduction Bracing in the Management of First-Time Anterior Shoulder Dislocation: Letter to the Editor

AbstractTraumatic anterior shoulder dislocation is a common injury in young and active patients and the proper treatment is still a matter of debate. The recurrence rate after conservative management remains high and, therefore, primary surgical intervention is sometimes recommended in very young patients whose risk of recurrences is highest. Immobilization in external rotation, first described by Itoi, is a promising conservative option as it provides adequate labral reduction and low recurrence rates. Recent meta-analyzes could not unequivocally demonstrate its superiority over internal rotation immobilization. However, biomechanical and early clinical results show a better effect on reduction of the labrum and lower recurrence rates for immobilization in a combination of abduction/external rotation than for external rotation alone. The present article aims to provide an overview of the conservative management of first-time traumatic shoulder dislocation in order to provide the treating physician or surgeon with the best current evidence as a basis for developing the appropriate treatment strategy for the patient.

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Which labral lesion can be best reduced with external rotation of the shoulder after a first-time traumatic anterior shoulder dislocation?

Archives of Orthopaedic and Trauma Surgery ◽

10.1007/s00402-008-0618-6 ◽

2008 ◽

Vol 129 (3) ◽

pp. 299-304 ◽

Cited By ~ 23

Author(s):

Dominik Seybold ◽

Benedikt Schliemann ◽

Christoph M. Heyer ◽

Gert Muhr ◽

Christoph Gekle

Keyword(s):

Shoulder Dislocation ◽

External Rotation ◽

Anterior Shoulder Dislocation ◽

Labral Lesion ◽

Traumatic Anterior Shoulder Dislocation ◽

First Time

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External Rotation and Abduction Bracing in the Management of First-Time Anterior Shoulder Dislocation: Response

The American Journal of Sports Medicine ◽

10.1177/0363546515597220 ◽

2015 ◽

Vol 43 (8) ◽

pp. NP24-NP25

Author(s):

Eiji Itoi ◽

Toshio Kitamura ◽

Shin Hitachi ◽

Taku Hatta ◽

Nobuyuki Yamamoto ◽

...

Keyword(s):

Shoulder Dislocation ◽

External Rotation ◽

Anterior Shoulder Dislocation ◽

First Time

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Survey of the Management of Acute Traumatic First-Time Anterior Shoulder Dislocation Among Trauma Clinicians in the UK

Annals of The Royal College of Surgeons of England ◽

10.1308/003588406x117115 ◽

2006 ◽

Vol 88 (5) ◽

pp. 454-458 ◽

Cited By ~ 30

Author(s):

Mark Chong ◽

Dimitris Karataglis ◽

Duncan Learmonth

Keyword(s):

Shoulder Dislocation ◽

External Rotation ◽

Postal Questionnaire ◽

Controlled Clinical Trial ◽

X Rays ◽

Anterior Shoulder Dislocation ◽

Trauma Society ◽

Arthroscopic Stabilisation ◽

The Uk ◽

First Time

INTRODUCTION The aim of this work was to survey how acute traumatic first-time anterior shoulder dislocation (AFSD) is managed among trauma clinicians in UK using a postal questionnaire. PATIENTS AND METHODS A total of 150 questionnaires were sent out to active consultant members of the British Trauma Society in the UK. Questions were laid out in two ‘workgroups’. In Workgroup One, an assortment of questions was included regarding choices and methods of analgesia, methods of monitoring used, methods of reduction, and position of immobilisation. In Workgroup Two, three different case scenarios were analysed to look into the ‘post-reduction’ management. RESULTS The response rate was 60%. Of respondents, 22% have a local protocol for managing AFSD. Almost all respondents recommended pre- and post-reduction X-rays as standard practice. Most respondents favoured systemic analgesia and sedation with airways' monitoring, as opposed to intra-articular anaesthesia (68 versus 9). Eighty-four respondents advocated immobilisation in internal rotation compared to six in external rotation. Only 19% (16 of 84) of respondents would perform an immediate arthroscopic stabilisation in young, fit patients presenting with this type of injury. CONCLUSIONS This survey revealed variations among trauma clinicians in managing AFSD on the ‘front-line’. There is a need to address the issue of intra-articular analgesia, immobilisation technique and management of AFSD in the young patient with regards to immediate surgical intervention. We suggest that these issues be revised and clarified, ideally in a randomised, controlled, clinical trial prior to the introduction of a protocol for managing this problem.

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Immobilisation in external rotation after first-time traumatic anterior shoulder instability reduces recurrent instability: a meta-analysis

Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine ◽

10.1136/jisakos-2020-000511 ◽

2020 ◽

pp. jisakos-2020-000511

Author(s):

Eoghan T Hurley ◽

Jordan W Fried ◽

Michael J Alaia ◽

Eric J Strauss ◽

Laith M Jazrawi ◽

...

Keyword(s):

Internal Rotation ◽

Shoulder Dislocation ◽

Randomised Controlled Trials ◽

External Rotation ◽

Rate Of Return ◽

Controlled Trials ◽

Anterior Shoulder Dislocation ◽

The Mean ◽

Randomised Controlled ◽

First Time

ImportanceCadaveric and MRI findings have demonstrated significantly less labral separation and displacement when the shoulder is placed in external rotation as compared with internal rotation.ObjectiveThe purpose of the current study is to meta-analyse the randomised controlled trials in the literature to compare immobilisation in external versus internal rotation after first-time anterior shoulder dislocation.Evidence reviewA literature search of MEDLINE, EMBASE and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomised controlled trials comparing immobilisation in external rotation versus internal rotation for first-time anterior shoulder dislocation were included.FindingsNine randomised controlled trials with 795 patients were included. The mean age of included patients was 29 years, 82.4% were male and the mean follow-up was 25.5 months. As compared with immobilisation in internal rotation, compliance was significantly higher (74.5% vs 67.4%, p=0.01), and the rate of recurrent dislocations was significantly lower (22.2% vs 33.4%, p=0.02) with immobilisation in external rotation. Additionally, in patients 20–40 years old the rate of recurrent dislocations was significantly lower in those treated with immobilisation in external rotation than internal rotation (12.1% vs 31.4%, p=0.006). Immobilisation in external rotation also resulted in a higher rate of return to preinjury level of play (60.1% vs 42.6%, p=0.0001).Conclusions and relevanceImmobilisation of the shoulder in external rotation after a traumatic first-time anterior shoulder dislocation results in a higher compliance rate, a lower recurrent dislocation rate and a higher rate of return to play as compared with immobilisation in internal rotation.Level of evidenceLevel I.

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Treatment of first-time traumatic anterior shoulder dislocation: the UK TASH-D cohort study

Health Technology Assessment ◽

10.3310/hta23180 ◽

2019 ◽

Vol 23 (18) ◽

pp. 1-104

Author(s):

Jonathan L Rees ◽

Anjali Shah ◽

Katherine Edwards ◽

Maria T Sanchez-Santos ◽

Danielle E Robinson ◽

...

Keyword(s):

Risk Factors ◽

Shoulder Dislocation ◽

Recurrent Dislocation ◽

Incidence Rates ◽

Anterior Shoulder Dislocation ◽

Traumatic Anterior Shoulder Dislocation ◽

The Uk ◽

First Time ◽

Residual Confounding ◽

Age And Sex

Background Shoulder dislocations are the most common joint dislocations seen in emergency departments. Most traumatic cases are anterior and cause recurrent dislocations. Management options include surgical and conservative treatments. There is a lack of evidence about which method is most effective after the first traumatic anterior shoulder dislocation (TASD). Objectives To produce UK age- and sex-specific incidence rates for TASD. To assess whether or not surgery within 6 months of a first-time TASD decreases re-dislocation rates compared with no surgery. To identify clinical predictors of recurrent dislocation. Design A population-based cohort study of first-time TASD patients in the UK. An initial validation study and subsequent propensity-score-matched analysis to compare re-dislocation rates between surgery and no surgery after a first-time TASD. Prediction modelling was used to identify potential predictors of recurrent dislocation. Setting UK primary and secondary care data. Participants Patients with a first-time TASD between 1997 and 2015. Interventions Stabilisation surgery within 6 months of a first-time TASD (compared with no surgery). Stabilisation surgery within 12 months of a first-time TASD was also carried out as a sensitivity analysis. Main outcome measure Re-dislocation rate up to 2 years after the first TASD. Methods Eligible patients were identified from the Clinical Practice Research Datalink (CPRD) (1997–2015). Accuracy of shoulder dislocation coding was internally validated using the CPRD General Practitioner questionnaire service. UK age- and sex-specific incidence rates for TASD were externally validated against rates from the USA and Canada. A propensity-score-matched analysis using linked CPRD and Hospital Episode Statistics (HES) data compared re-dislocation rates for patients aged 16–35 years, comparing surgery with no surgery. Multivariable Cox regression models for predicting re-dislocation were developed for the surgical and non-surgical cohorts. Results Shoulder dislocation was coded correctly for 89% of cases in the CPRD [95% confidence interval (CI) 83% to 95%], with a ‘primary’ dislocation confirmed for 76% of cases (95% CI 67% to 85%). Far fewer patients than expected received stabilisation surgery within 6 months of a first TASD, leading to an underpowered study. Around 20% of re-dislocation rates were observed for both surgical and non-surgical patients. The sensitivity analysis at 12 months also showed little difference in re-dislocation rates. Missing data on risk factors limited the value of the prediction modelling; however, younger age, epilepsy and sex (male) were identified as statistically significant predictors of re-dislocation. Limitations Far fewer than the expected number of patients had surgery after a first-time TASD, resulting in an underpowered study. This and residual confounding from missing risk factors mean that it is not possible to draw valid conclusions. Conclusions This study provides, for the first time, UK data on the age- and sex-specific incidence rates for TASD. Most TASD occurs in men, but an unexpected increased incidence was observed in women aged > 50 years. Surgery after a first-time TASD is uncommon in the NHS. Re-dislocation rates for patients receiving surgery after their first TASD are higher than previously expected; however, important residual confounding risk factors were not recorded in NHS primary and secondary care databases, thus preventing useful recommendations. Future work The high incidence of TASD justifies investigation into preventative measures for young men participating in contact sports, as well as investigating the risk factors in women aged > 50 years. A randomised controlled trial would account for key confounders missing from CPRD and HES data. A national TASD registry would allow for a more relevant data capture for this patient group. Study registration Independent Scientific Advisory Committee (ISAC) for the Medicines and Healthcare Products Regulatory Agency (ISAC protocol 15_0260). Funding The National Institute for Health Research Health Technology Assessment programme.

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Paper 21: Primary Repair versus Conservative Treatment After First Time Traumatic Anterior Shoulder Dislocation

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2012.05.308 ◽

2012 ◽

Vol 28 (8) ◽

pp. e83-e84

Keyword(s):

Conservative Treatment ◽

Shoulder Dislocation ◽

Primary Repair ◽

Anterior Shoulder Dislocation ◽

Traumatic Anterior Shoulder Dislocation ◽

First Time

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Shoulder Management of the First Time Anterior Shoulder Dislocation

Arthroscopy and Sport Injuries ◽

10.1007/978-3-319-14815-1_16 ◽

2016 ◽

pp. 119-122

Author(s):

Stefano Boschi ◽

Gianezio Paribelli ◽

Mario Perretti ◽

Alfonso Massimo Cassarino

Keyword(s):

Shoulder Dislocation ◽

Anterior Shoulder Dislocation ◽

First Time

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The Efficacy of External Rotation Method for The Reduction of Acute Anterior Shoulder Dislocation With and Without Greater Tuberosity Fracture

Birat Journal of Health Sciences ◽

10.3126/bjhs.v3i2.20935 ◽

2018 ◽

Vol 3 (2) ◽

pp. 408-412 ◽

Cited By ~ 1

Author(s):

Gopal Prasad Gnawali ◽

Indra Dhakal ◽

Kishor Khatri ◽

Shanta Sharma

Keyword(s):

Shoulder Dislocation ◽

External Rotation ◽

Reduction Process ◽

Anterior Dislocation ◽

Emergency Setting ◽

Anterior Shoulder Dislocation ◽

Greater Tuberosity ◽

Rotation Method ◽

Cause Of Failure ◽

Successful Reduction

Introduction: Several methods of reduction technique have been described for the anterior dislocation of shoulder but none technique is said to be ideal. The aim of this study was to show the efficacy of external rotation method which could be safe and painless method for the reduction of the acute anterior shoulder dislocation with or without fracture of the greater tuberosity and to search the cause of failure of reduction.Objective: Objective of this study was to assess the efficacy of the external rotation method for reduction of acute anterior shoulder dislocation and to find the cause of failure of reduction.Methodology: All cases of anterior dislocation encountered in emergency department reduced by external rotation method by consultant orthopedic surgeon using basic emergency setting for resuscitation were included in the study. Fifty cases of shoulder dislocation was treated by this method and prospective evaluation done with regard to type of dislocation, the effectiveness of the procedure in achieving reduction, the need for pre-medication, the ease of performing reduction and complication if any.Results: Out of 50 cases, successful reduction was achieved in 42 patients. Premedication was not required in 36 successful reduction. Average time of reduction was 2 minutes in 30 patients and 5 minutes in 8 patients. Four Patients complained severe pain during reduction process. This method was not successful in 8 patients 2 of whom had displaced greater tuberosity fracture.Conclusion: The external rotation method is reliable and safe method for the reduction of acute anterior shoulder dislocation which can be performed relatively with less pain for both subcoracoid and subglenoid dislocation provided there is no displaced fracture of the greater tuberosity. BJHS 2018;3(2)6: 408-412.

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