A systematic comparison of the closed shoulder reduction techniques

Fast treatment of anterior shoulder dislocations with two sedation-free methods: The Davos self-reduction method and Arlt method

Background

Various reduction techniques exist to treat traumatic shoulder dislocation, but best management remains unclear.

Aims

To investigate the reduction rate of traumatic anteroinferior shoulder dislocations using two sedation-free techniques and success rates of subgroups.

Methods

A single-center study was performed analysing shoulder dislocations in a two-year period. Adult patients with anteroinferior shoulder dislocation were included. Two sedation-free reduction techniques were used: the Davos self-reduction technique and the Arlt-chair technique. Two attempts were performed before sedation. All patients gave informed consent to study participation.

Results

The investigated 106 patients (106 shoulder dislocations) had a mean age of 48 ± 18 years (74% male patients). The majority occurred during winter sports (76%). The overall success rate for both sedation-free reduction techniques was 82% (87 reduced shoulders, two attempts). A significantly increased success rate was found in patients without greater tuberosity fracture (86% without vs. 68% with fracture, p = 0.002) and for patients with repeated dislocation (93% vs. 80% for primary dislocation, p = 0.004). Time for reduction was 5 minutes (Davos technique) and 1 minute (Arlt-chair-technique). Associated injuries were mostly Hill Sachs lesions (78%). There was no major complication and no new-onset sensory deficit.

Conclusion

Davos and Arlt reduction techniques allowed sedation-free and fast treatment for anteroinferior shoulder dislocation during winter sports.

Ultrasound-Guided Peripheral Nerve Blocks for Shoulder Dislocation in the Emergency Department: A Systemic Review

BACKGROUND

Shoulder dislocations are among the most common orthopedic emergencies encountered in the emergency department (ED). Ultrasound-guided peripheral nerve blocks (USG-PNBs) are increasingly being used for acute pain management in the ED, but clinical evidence supporting their utility for shoulder dislocation is limited and often conflicting.

OBJECTIVE

The aim of this review was to summarize and evaluate the utility of USG-PNB for analgesia during closed reduction of dislocated shoulders in the ED.

METHODS

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search of the PubMed, Scopus, and Cochrane databases was performed from database inception to September 2022. We included clinical studies examining USG-PNB for pain management of dislocated shoulders in the ED. Information collected from eligible studies included patient demographic characteristics, USG-PNB approach, alternate analgesia techniques, anesthetic regimens, clinical outcomes, and adverse events.

RESULTS

Five studies met inclusion criteria, all of which were randomized controlled trials comparing USG-PNB with procedural sedation and analgesia. Pooled patient satisfaction scores were similar for both analgesia methods (3.5 ± 0.6 vs. 3.9 ± 0.6 out of 5; p = 0.76). Patients managed with procedural sedation and analgesia achieved higher rates of overall shoulder reduction (100% vs. 67%; p < 0.001) and successful reduction on the first attempt (86% vs. 48%; p < 0.001). The USG-PNB groups in all but one study had shorter lengths of ED stay. Overall, USG-PNB was associated with a lower risk of adverse events and complications (3.9% vs. 24.9%; p < 0.001), especially adverse respiratory events (0% vs. 14.7%; p < 0.001).

CONCLUSIONS

USG-PNBs performed by adequately trained emergency physicians should be considered a safe and effective alternative for analgesia during closed reduction of dislocated shoulders in the ED, particularly in patients with cardiorespiratory comorbidities.

A Systematic Review With Pairwise and Network Meta-analysis of Closed Reduction Methods for Anterior Shoulder Dislocation

STUDY OBJECTIVE

To review closed reduction methods for anterior shoulder dislocation and perform the first comprehensive comparison of the individual methods in terms of success rate, pain, and reduction time.

METHODS

We searched MEDLINE, PubMed, EMBASE, Cochrane, and ClinicalTrials.gov for randomized controlled trials registered until December 31, 2020. We performed a pairwise and network meta-analysis using a Bayesian random-effects model. Two authors independently performed screening and risk-of-bias assessment.

RESULTS

We found 14 studies with 1,189 patients. In a pairwise meta-analysis, no significant difference was found in the only comparable pair, namely, the Kocher method versus the Hippocratic method (success rate: odds ratio, 1.21; 95% confidence interval [CI], 0.53, 2.75: pain during reduction [visual analog scale]: standard mean difference, -0.33; 95% CI, -0.69, 0.02; reduction time [minutes]: mean difference, 0.19, 95% CI, -1.77, 2.15). In network meta-analysis, FARES (Fast, Reliable, and Safe) was the only method significantly less painful than the Kocher method (mean difference, -4.0; 95% credible interval, -7.6, -0.40). In the surface under the cumulative ranking (SUCRA) plot of success rate, FARES, and the Boss-Holzach-Matter/Davos method showed high values. For pain during reduction, FARES had the highest SUCRA value in the overall analysis. In the SUCRA plot of reduction time, modified external rotation and FARES had high values. The only complication was 1 case of fracture with the Kocher method.

CONCLUSION

Overall, Boss-Holzach-Matter/Davos, and FARES demonstrated the most favorable value for success rates, whereas both FARES and modified external rotation were more favorable in reduction times. FARES had the most favorable SUCRA for pain during reduction. Future work directly comparing techniques is needed to better understand the difference in reduction success and complications.

Surgical outcome of avulsion fractures of the distal fibula: a systematic literature review

PURPOSE

To provide a systematic overview of clinical and radiographic outcomes in patients who underwent surgical treatment of a painful avulsion fragment of the distal fibula also known as posttraumatic os subfibulare.

METHODS

A systematic literature search across two major sources (PubMed and Scopus) was performed. Twenty-seven studies were included and analyzed using the modified Coleman score to assess the methodologic quality.

RESULTS

The surgical treatment of symptomatic os subfibulare, with or without concomitant ankle instability, generally results in substantial improvement in clinical and radiographic outcomes with relative low complication rates. Clinical outcome measures may not be affected by the presence of ankle instability or by the fragment size. The methodological quality of analyzed studies was satisfactory.

CONCLUSION

Posttraumatic os subfibulare may result in chronic pain and ankle instability. If surgery is indicated, ankle instability should be concomitantly addressed when present. Based on available literature, satisfactory postoperative outcomes can be reliably expected following surgical treatment.

LEVEL OF EVIDENCE

Systematic Review of Level III and Level IV Studies, Level IV.

The effect of shoulder muscle succinylcholine injection on the foreleg raising power: Sion's local paralysis

Objective

We examined the change in foreleg raising power after Sion's local paralysis (SLP) with succinylcholine in the shoulder muscle.

Methods

A randomized, double blind, placebo-controlled, porcine study was designed and performed at a research institution. Ten male Korean native pigs were randomized into an intervention group (n = 5) and a control group (n = 5). The injection points were in the middle of the left trapezius muscle and the middle of the left deltoid muscle. The control group received 2 ml normal saline (NS), 1 ml injected in each point. The intervention group received 0.4 mg/kg succinylcholine diluted to 2 ml in NS, and 1 ml was injected in each point. To represent the foreleg raising power, the height of the left forelegs from baseline (experiment table) was measured. We measured the foreleg height and oxygen saturation at -4, -2, 0, +2, +4, +6, +8, +10, +20, +30, and +60 min.

Results

After SLP, foreleg height immediately declined in the intervention group. It recovered slightly for a few minutes and declined from 4 to 8 min. In the control group, foreleg height was relatively similar throughout the study period. A repeated-measure analysis of variance revealed a significant group × time interaction (F_10,80 = 2.37, P = 0.017), a significant main effect for group (F_1,8 = 6.25, P = 0.037), and a significant main effect for time (F_10,80 = 4.41, P < 0.001). Post hoc analysis demonstrated that the intervention group showed significantly less foreleg raising power than the control group at 0, 4, 6, 8, 20, and 30 min (P < 0.05).

Conclusions

Compared with the control group, the foreleg raising power in the intervention group immediately decreased significantly and persisted for a period after SLP, without hypoxia, in a pig model.

BRASD trial: biomechanical reposition techniques in anterior shoulder dislocation-a randomized multicenter clinical trial

BACKGROUND

Biomechanical reduction techniques for shoulder dislocations have demonstrated high reduction success rates with a limited pain experience for the patient. We postulated that the combination of biomechanical reduction techniques with the shortest length of stay would also have the lowest pain experience and the highest first reduction success rate.

METHODS

A randomized multicenter clinical trial was performed to compare different biomechanical reduction techniques in treating anterior shoulder dislocations without the use of invasive pain relief. Patients who were able to perform adduction of the arm were randomly assigned to Cunningham, the modified Milch, and the scapular manipulation technique. Those who were not able to do so were randomly assigned to modified Milch and the scapular manipulation technique. Primary outcomes were emergency department length of stay and pain experienced during the reduction process, measured by the numeric pain rating scale. Secondary outcomes were reduction time, reduction success, use of analgesics or sedatives, and complications.

RESULTS

Three hundred eight patients were included, of whom 134 were in the adduction group. In both groups, no differences in emergency department length of stay and experienced pain were observed between the treatment arms. In the adduction group, the modified Milch technique had the highest first reduction success rates 52% (p = 0.016), within protocol 61% (p = 0.94), and with sedation in the ED 100% ( -). In the no-adduction group, the modified Milch was also the most successful primary reduction technique with 51% success (p = 0.040), within protocol 66% (p = 0.90), and with sedation in the ED 98% (p = 0.93). No complications were recorded in any of the techniques.

CONCLUSION

A combination of biomechanical techniques resulted in a similar length of stay in the emergency department and showed similar pain scores with an overall high success rate of reduction. In both groups, the modified Milch had the highest first-reduction success rate.

TRIAL REGISTRATION

Netherlands Trial Register NTR5839-1 April 2016. Ethical committee Noord-Holland with the CCMO-number NL54173.094.15.

Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis

BACKGROUND

We performed a network meta-analysis (NMA) to compare the efficacy and safety of intravenous sedation (IVS), intraarticular anesthetic injection (IAA), and peripheral nerve block (PNB) as sedation or analgesia methods for the reduction of anterior shoulder dislocation.

METHODS

We included randomized controlled trials (RCTs) comparing different sedation or analgesia methods for anterior shoulder dislocation reduction. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar databases were searched in October 2021. We conducted a random-effects NMA within a frequentist framework. We evaluated the confidence in each outcome using the CINeMA tool.

RESULTS

Sixteen RCTs (957 patients) were included. Regarding the primary outcomes, the three methods might result in little to no difference in the immediate success rate of reduction and patient satisfaction. The IAA method had a shorter emergency department length of stay than that of the IVS method (mean difference [MD] -107.88 min, 95% confidence interval [CI] -202.58 to -13.18). In the secondary outcomes, the IAA method had a lower pain score than that of the PNB method (standardized MD -1.83, 95% CI -3.64 to -0.02). The IAA and PNB methods might require a longer time for reduction than that of the IVS method (MD 5.3 min, 95% CI 2.4 to 10.36; MD 15.25, 95% CI 5.49 to 25.01). The three methods might result in little to no difference in the number of reduction attempts and total success rate of reduction. However, the confidence ratings for all treatment comparisons were very low. IAA and PNB had no adverse respiratory events.

CONCLUSIONS

The results of our NMA indicated that three sedation or analgesia methods (IVS, IAA, and PNB) might result in little to no difference in the success rate of reduction and patient satisfaction. IAA and PNB had no adverse respiratory events.

Han's technique: a new reduction technique for acute anterior shoulder dislocation

INTRODUCTION

Acute anterior shoulder dislocation (AASD) is the most common joint dislocation. Here, we introduced a new reduction technique for AASD, named "Han's technique" (or "Touch overhead technique").

METHODS

Patients diagnosed with AASD were treated with "Han's technique" in the orthopaedic department of our hospital from October 2018 to November 2020. An orthopedic surgeon performed the reduction maneuver without any anesthesia or sedation throughout the reduction process. The fundamental information and related data were recorded, including patients' age, sex, dislocation side, previous dislocations history, reduction time, number of attempts at reduction, success rate of the reduction, intensity of pain during reduction using the 10-point visual analogue scale score (VAS), any complications, with or without the fracture and neurovascular examination results.

RESULTS

Forty-one patients with AASD were involved in our study. Thirty-nine cases (95%) were primary dislocation. Eleven patients (27%) were complicated with large tubercle fracture and one patient (2%) complicated with inferior glenoid fractures. All patients were successfully reduced by Han's technique with mean reduction time was 138 s. The pain score during the reduction operation is only1.83 ± 0.83 points. No neurovascular injury or iatrogenic fracture was found after reduction in all patients.

CONCLUSIONS

Han's technique (or Touch overhead technique) is a simple, safe, effective, mild and easy to master which can be operated by one surgeon without anesthesia or sedation for AASD.

Glenohumeral Joint Dislocation Classification: Literature Review and Suggestion for a New Subtype

ABSTRACT

Glenohumeral joint (GHJ) dislocation is a relatively common injury. Anterior GHJ dislocations are divided into subcoracoid, subglenoid, subclavicular, and intrathoracic subtypes. The aim of this article is to review current GHJ dislocation classification and briefly discuss management of each type. Discrepancies and inaccuracies exist in regard to GHJ dislocation classification. We suggest adding a new subtype, "paraglenoid," to improve the current GHJ dislocation classification system. The paraglenoid subtype describes a portion of the subcoracoid anterior GHJ dislocation. GHJ dislocation is most often caused by force applied to the arm during a fall but also can be due to direct impact to the shoulder. Physical examination often reveals classic deformities, and thorough neurovascular examination is crucial. Radiographs should be used to confirm the diagnosis and assess for associated bony injuries. Numerous reduction techniques are described in the literature, with chosen method dependent on patient factors, provider experience, and GHJ dislocation type.

Aortic Injury After Shoulder Reduction in a Patient with Multiple Rib Fractures: A Case Report

CASE

A 74-year-old woman presented with multiple rib fractures, hemothorax, spleen rupture, and right shoulder dislocation. Shoulder joint reduction was performed using the traction-countertraction method. An injury to the descending aorta, caused by the seventh rib, was confirmed.

CONCLUSION

The authors encountered an aortic injury, a rare complication of shoulder joint reduction, in a patient with a posterior rib fracture. When managing patients with posterior fractures of the fourth to ninth ribs on the left side, the reduction method should be carefully selected depending on the status of the patient to avoid aortic injuries.

Evaluation of Davos self-assisted technique for reduction of anterior glenohumeral dislocations: a comparative study with traction/counter-traction technique

Background

Few studies have compared conventional and self-assisted shoulder reduction maneuvers. The goal of this study was to evaluate the results of self-assisted Davos vs. traction/countertraction (T/Ct) techniques in the treatment of acute anterior shoulder dislocations.

Methods

This was a single-center, prospective study carried out at a tertiary hospital emergency department. Patients aged 18-69 years old, with radiographic confirmation of anterior glenohumeral dislocations, were consecutively allocated to treatment groups. Recorded data included pain at admission (visual analog scale [VAS] score at admission), analgesia before reduction, maximum pain during reduction (maximum VAS score), demographic characteristics, lesion mechanism, laterality, prior dislocation, and immediate complications. The primary outcomes were reduction success rate and pain.

Results

Eighty individuals were included (40/group). Regarding the success rate, no statistically significant differences were found between Davos or T/Ct (87.5% vs. 85%; P = .058). The maximum VAS score was significantly lower in Davos than that in T/Ct (4.18 ± 2.00 vs. 6.30 ± 2.13; P < .001). The effect of analgesia in the maximum VAS score was more evident among Davos patients, with significantly lower pain in the subgroup who were provided analgesia (3.63 ± 2.02 vs. 5.31 ± 2.01; P = .01).

Discussion

Davos was as effective as T/Ct for reduction of acute anterior shoulder dislocations (highest reported success rate: 87.5%) and conditioned a less traumatic experience, with significantly lower pain during reduction (the maximum VAS score was more than 2 points lower in the Davos group; P < .001). Analgesia had a synergistic effect among patients submitted to the Davos technique, suggesting that T/Ct is inherently more painful.

Conclusion

The Davos is a patient-controlled, atraumatic, and safe technique, allowing successful, gentle, and less painful glenohumeral reduction. These findings favor Davos as an easy-to-teach and effective first-line treatment for first-time and recurrent shoulder dislocations.

Closed Reduction of Anterior Shoulder Dislocations Performed by Ski Patrollers in the Alpine Prehospital Environment: A Retrospective Review Demonstrating Efficacy in a Canadian Ski Resort

INTRODUCTION

Shoulder dislocations are common ski hill injuries. Rapid reduction is known to improve outcomes; however, advanced providers are not always available to provide care to these patients. In 2017, nonmedical ski patrollers at Sunshine Village ski resort in Alberta, Canada, were trained to perform anterior shoulder dislocation (ASD) reductions. Program success was determined by a chart review after the 2020 ski season.

METHODS

This study retrospectively reviewed data on patients who presented to Sunshine Village ski patrol with a suspected ASD and who met the study inclusion criteria from November 2017 through March 2020. Data were collected from ski patrol electronic patient care records regarding general demographics, reduction technique used, analgesia administration, and reduction success rates.

RESULTS

Ninety-six cases were available for review after exclusions. Trained nonmedical ski patrollers successfully reduced 82 of these cases, resulting in an overall reduction success rate of 89%. Sixty-three (66%) of these patients had experienced first-time dislocations. Eighty-two (87%) patients were male, with a median age of 25 y. The most used technique was the Cunningham method (75%), and analgesia was administered to 70% of patients.

CONCLUSIONS

This retrospective study documents the results of a quality assurance review of the treatment of ASD at Sunshine Village ski resort. With a success rate of 89%, the evidence supports the conclusion that nonmedical ski patrollers can successfully perform ASD reductions. We believe training ski patrollers to reduce ASD improved patient care in our austere environment by providing early definitive treatment with a high success rate.

Closed reduction techniques for acute anterior shoulder dislocation: a systematic review and meta-analysis

BACKGROUND

Anterior shoulder dislocations are the most common type of joint dislocation with the majority treated with closed reduction. Reduction methods can be grouped into their principle mode of action: traction-countertraction, leverage and scapular manipulation. The best method has yet to be identified and our aim was to find the most effective, safe and least painful method of closed reduction for acute anterior shoulder dislocations.

METHODS

A search of the online databases of CENTRAL, MEDLINE and Embase was performed to identify randomised control trials (RCTs) comparing closed reduction methods for anterior shoulder dislocations. A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twelve eligible RCTs were included with a total of 1055 patients. Our meta-analysis showed traction-countertraction methods are marginally less painful than leverage methods by 0.86 points on the VAS scale but leverage methods are quicker by 20 s. Amongst traction-countertraction methods, the Spaso technique was the least painful and quickest, albeit with no difference in overall success rate. A meta-analysis was not possible for comparisons involving scapular manipulation due to the paucity of studies, but within two studies, scapular manipulation was significantly less painful than both leverage and traction-countertraction methods by 1.5 and 2.3 points (VAS), respectively.

CONCLUSION

Traction-countertraction methods are less painful but slower than leverage methods with no difference in complication rates. However, there was no difference in overall reduction success rate between any of the groups.

LEVEL OF EVIDENCE

I.

"Can patients learn how to reduce their shoulder dislocation?" A one-year follow-up of the randomized clinical trial between the Boss-Holzach-Matter self-assisted technique and the Spaso method

OBJECTIVE

The aim of this study was to assess the effectiveness and reproducibility of self-assisted Boss-Holzach-Matter (BHM) technique compared with the Spaso (Sp) method for shoulder dislocation.

METHODS

We conducted a follow-up at 1 year from the randomization of 60 patients with shoulder dislocation enrolled in the study "Teaching patients to reduce a shoulder dislocation." Half of these patients had been taught the self-assisted technique, whereas the other half had been treated by a physician's manipulative maneuver for reduction. We surveyed all the enrolled patients to describe recurrence rates and reproducibility for both the techniques without supervision as well as the number of emergency visits.

RESULTS

In total, 52 patients (age range: 18-44 years) answered the survey from the 60 patients enrolled in the study. The total rate of recurrence was 38.5% (20 patients). For the Sp group, 4 of the 30 patients were lost. There were 9 recurrent patients (30%), and 7 were treated in the emergency department (ED). For the BHM group, 4 of the 30 patients were lost. There were 11 recurrent patients (37%), and 2 were treated in the ED. The difference in self-reduction rates and ED visits for both the groups was statistically significant (p=0.025).

CONCLUSION

Teaching the BHM technique to the patients is effective and reproducible without direct supervision. It can decrease the number of visits to the ED and is a valid option to teach the patients at risk of recurrence when not being able to get immediate help.

LEVEL OF EVIDENCE

Level I, Therapeutic study.

No Sedation, No Traction, and No Need for Assistance: Analysis of New Prakash's Method of Shoulder Reduction

Materials and Methods

A total of 19 patients who were admitted to the emergency department with the diagnosis of anterior shoulder dislocation participated in this study. The diagnosis of shoulder dislocation was established in the emergency department with physical examination and anteroposterior shoulder radiography. The method was applied only once to the patients in the sitting position by the same physician without using any help, traction, anesthesia, analgesia, and myorelaxant.

Results

The mean age of the patients was 37.3 ± 13.1 years. Among them, 36.8% (n=7) were female and 63.2% (n=12) were male. Recurrent dislocations were observed in 21.1% (n=4) of the patients. The success rate of the method was 94.7% (n=18). No complication was noted in the patients. The mean procedure time was 243 ± 38 seconds.

Conclusion

Prakash's method is a safe method for anterior shoulder dislocations that can be quickly performed with no need for sedation, assistance, and traction and has a high success rate.

Comparison between new modified external rotation method and external rotation method for reduction of ASD

INTRODUCTION

Dislocation of the shoulder joint is common and is mainly anterior. Several reduction methods have been described and the external reduction method (ERM) is one of the newest. We modified the ERM by making some additions in hopes to develop a less painful, quick and simple method. The aim of this study was to compare the new modified external rotation reduction method (MERM) with ERM in acute anterior shoulder dislocations (ASD).

METHODS

A total of 62 patients with ASD were classified randomly into 2 groups. The reduction was performed with MERM in one group and with ERM in the other group and the results were compared. Patients' pain scores, reduction time, success rate of the reduction methods, age, sex, dislocation side, dislocation time, previous dislocations history, injury mechanism, any complications, reduction time and neurovascular examination were collected. Parametric and nonparametric analyses were used to compare MERM and ERM.

RESULTS

The study cohort consisted of 62 patients (52 males, 10 females; mean age, 35 years; age range, 18-73 years) who were randomly assigned to treatment with the MERM (n = 32) or the ERM (n = 30). There was a statistically significant difference between the two methods in terms of time, and the MERM can be applied much faster than ERM (1.34 ± 1.41 min vs 3.05 ± 1.93 min; p < 0.001). The intra-reduction VAS pain score was not significantly in patients who were treated with MERM (85.31 ± 10.39 vs. 78.33 ± 16.54; p = 0.122).

CONCLUSION

MERM can be an alternate method compared to the ERM for the reduction of ASD.

Shoulder Reduction Bench Project: improving care for patients with shoulder dislocations

This paper presents the background, methodology and results of a quality improvement project undertaken at a district general hospital. The project was launched in response to the concerning results from audit data which showed significant delays in the treatment of patients with shoulder dislocations and a high percentage of patients receiving procedural sedation. Using ‘Plan-Do-Study-Act’ cycles involving training sessions, written protocols and an online video, we were able to train a large cohort of nurse practitioners in the use of the Shoulder Reduction Bench. This is a relatively novel, evidence-based technique for reducing shoulder dislocations without the need for sedation. The new shoulder dislocation protocol was successful in reducing the average time from presentation to shoulder relocation by 31 min and the average time from presentation to discharge by 52 min. It also resulted in a 68% reduction in the number of patients receiving procedural sedation over a 6-month period. This project inspired the practitioners, most of whom had never reduced a shoulder dislocation before. The success of the new shoulder reduction bench protocol prompted interest from the trust’s innovation department and has been publicised both within the trust and regionally. This publicity and the satisfaction gained by the staff from this effective new skill have helped to anchor the change in departmental culture. Link to training video: https://www.youtube.com/watch?v=40aCqhfQXD4&feature=youtu.be

Ring versus non-ring plate for the treatment of displaced scapular body fractures: a retrospective study with a mean follow-up of 5 years

Objective

To compare surgical complications and functional outcomes of the ring plate versus the non-ring plate approach to the surgical repair of scapular body fractures (SBFs; AO/OTA classification: 14-A2.2).

Methods

This retrospective study reviewed data from adults with SBFs who underwent a modified Judet approach combined with non-ring or ring plates between November 2006 and June 2013. The primary outcomes were the Constant and Murley score and the Disabilities of the Arm, Shoulder and Hand (DASH) score. The secondary outcomes were radiographic findings.

Results

A total of 318 patients had a non-ring or ring plate internal fixation, of which 147 patients (ring-treated, n = 72; non-ring-treated, n = 75) were evaluated with a mean follow-up period of 60 months. At the 3-month follow-up, the complication rate was 2.8% and 13.3% for the ring-treated and non-ring-treated groups, respectively. The difference persisted over time, with significantly different rates of 8.3% and 20.0% at the final follow-up for the ring and non-ring groups, respectively. The ring-treated group had significantly higher postoperative Constant and Murley scores and lower DASH scores compared with the non-ring-treated group.

Conclusion

Application of a modified Judet approach combined with ring plate internal fixation for the treatment of SBFs may be the preferred treatment option.

Current Approach to the Diagnosis and Management of Shoulder Dislocation in Children

Shoulder dislocations are a common presentation to the emergency department. Although many cases may be diagnosed by history and clinical examination alone, imaging may help diagnose more challenging cases. Three-view radiographs are important for identifying subtle posterior dislocations, and ultrasonography has been gaining evidence as an alternate diagnostic modality. Intra-articular lidocaine and nerve blocks may improve pain control and reduce the need for procedural sedation. Multiple, evidence-based reduction techniques are described including tips for improving success. Immobilization strategies and follow-up are also discussed.

Medical speciality, medication or skills: key factors of prehospital joint reduction. A prospective, multicenter cohort study

PURPOSE

Joint dislocations occur frequently in prehospital settings. The medical specialities of emergency physicians are heterogeneous. Decision making and the success rates of reduction attempt can vary greatly. The aim of this prospective multicentre study was to identify the factors most crucial for achieving successful prehospital reduction.

METHODS

Study was conducted from 05/2012-05/2015 investigating cases of shoulder, patella and ankle joint dislocations in 16 emergency physician rescue stations. Parameters included: affected joint, type and use of medication, incidence and circumstances of reduction or reduction attempt and medical specialty as well as subjective skill status.

RESULTS

In total 118 patients could be included. Mean age was 40.1 ± 21.3 years. Medical specialties were: n = 61 (51.7%) anaesthesiologists (A), n = 41 (34.5%) surgeons (S), and n = 16 (13.5%) internal medicine/others (I/O). Reduction attempt was performed in n = 97 (82.2%). With taking into account the complexity of the reduction (S) had significantly the highest success rates followed by (A) and (I/O). Regarding the applied medication there was neither a significant correlation between pain (p = 0.161) nor success of reduction (p = 0.09). A higher number of attempts does not improve the success rate (p ≤ 0.001), the pain level was no predictor for success of reduction attempt (p = 0.88).

CONCLUSION

A successful reduction is determined by the trias of affected joint, skill level and medical specialty of the physician. In each case this trias should be considered by the physician in charge and he must evaluate limitations and circumstances.

Teaching Patients How to Reduce a Shoulder Dislocation: A Randomized Clinical Trial Comparing the Boss-Holzach-Matter Self-Assisted Technique and the Spaso Method

BACKGROUND

There are many different techniques for reducing acute anterior dislocations of the shoulder, and their use depends on surgeon preference. The objective of this study was to compare the pain experienced by a patient performing a self-reduction technique with the pain felt during a reduction performed by a trained physician.

METHODS

The study was carried out at the emergency department of a tertiary referral center. Patients between 18 and 60 years of age with an acute anterior shoulder dislocation were randomly allocated into 2 groups. In 1 group the emergency doctor actively guided the reduction process with the Spaso technique (Sp group), and in the other group the patient used the Boss-Holzach-Matter (also known as Davos or Aronen) self-reduction technique (BHM group). The pain experienced by the patient during the reduction was recorded by means of a visual analogue scale (VAS) ranging from 0 to 10. Other recorded data included demographic characteristics, reduction time, and success rate.

RESULTS

Of 378 patients assessed for eligibility from May 2015 until February 2017, 197 did not meet the inclusion criteria, 58 met exclusion criteria, 22 declined to participate, and 41 withdrew before randomization. Sixty acute anterior shoulder dislocations were randomized into the Sp group (n = 30) or the BHM group (n = 30). The BHM group experienced significantly less pain during reduction than the Sp group (p = 0.047), with mean pain scores of 3.57 (standard deviation [SD] = 2.1]) and 5.26 (SD = 2.9), respectively. No significant difference between groups was found with respect to reduction time (105 seconds [range, 10 to 660 seconds] in the Sp group and 90 seconds [range, 5 to 600 seconds] in the BHM group; p = 0.6) or success rate (67% and 77%, respectively; p = 0.39).

CONCLUSIONS

The self-reduction technique results in less pain than, and is as efficient in achieving reduction of anterior shoulder dislocations as, the Spaso technique. These findings favor the use of the self-assisted method as an effective first-line treatment for shoulder dislocations seen in the emergency department as well as its use by patients with recurrent dislocation.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.