Managing Anterior Shoulder Dislocation

Efficacy of supervised self-reduction vs. physician-assisted techniques for anterior shoulder dislocations: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Reduction manipulation using self-reduction procedures such as Stimson, Milch, and Boss-Holtzach should be easy and effective and also require less force, pain medication, and outside assistance. This technique should not cause damage to arteries, nerves, or shoulder joint components. Self-reduction is straightforward and can be done in clinics, making it ideal for people who suffer from shoulder joint dislocation frequently. The goal of this study is to compare the effectiveness of supervised self-reduction procedures vs. physician-assisted treatments in the treatment of anterior shoulder dislocations.

METHOD

We conducted a comprehensive search on PubMed, Scopus, Web of Science, and Cochrane up to March 22, 2023, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Relevant articles were reviewed, with a focus on studies comparing supervised self-reduction techniques to physician-assisted techniques in cases of anterior shoulder dislocation.

RESULTS

Four papers in all were included in the meta-analysis. One prospective trial, one case-control study, one randomized clinical trial, and one retrospective trial made up these studies. The studies involved 283 patients in the physician-assisted group and 180 patients in the supervised self-reduction group. They were carried out in four European countries: Italy, Germany, Portugal, and Spain. The success rate of supervised self-reduction techniques was significantly higher, with an odds ratio of 2.71 (95% CI 1.25-5.58, p-value = 0.01). Based on the Visual Analog Scale (VAS) score, the physician-assisted group reported significantly higher maximum pain, with a mean difference of 1.98 (95% CI 1.24-2.72, p-value < 0.01). The self-reduction approaches exhibit shorter reduction time in comparison to physician-assisted groups. In addition, the self-reduction groups do not document any complications. Based on the GRADE system, the level of assurance in the evidence was high.

CONCLUSION

Supervised self-reduction techniques outperform in terms of success rate and reduction-related maximum pain. These techniques could be used as an effective first-line treatment for anterior shoulder dislocation, potentially reducing the need for analgesics and emergency room visits.

Austere Diagnosis and Reduction of Anterior Shoulder Dislocations: 10-Year Review of a Ski Patrol-Based Program with Emergency Medical Technicians

INTRODUCTION

Glenohumeral dislocations present a challenging management dilemma in austere settings where patient transport time may be prolonged. Expeditious reduction is preferable, but treatment is commonly expected to take place within a hospital or comparable facility. Through a novel shoulder injury program, professional ski patrollers trained as emergency medical technicians (EMTs) have diagnosed and reduced anterior shoulder dislocations using biomechanical techniques without sedation or analgesia for over 20 y. Summary records have been maintained to track the performance and safety of this program.

METHODS

Five hundred forty-six records of winter sports-related shoulder injuries from 2009-10 to 2019-20 were retrospectively analyzed to determine the assessment performance and dislocation reduction efficacy of EMTs, with the intent of ascertaining whether EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations without premedication in a remote and resource-limited setting.

RESULTS

EMTs identified anterior shoulder dislocations with 98% sensitivity and 96% diagnostic accuracy. The overall success rate of reduction attempts was 86%, or 88% when limited to confirmed anterior dislocations. Two fracture-dislocations and 4 misdiagnoses were manipulated. No instances of iatrogenic harm were identified, and no patients who underwent successful reductions required ambulance transportation.

CONCLUSIONS

With appropriate education and within a structured program, EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations using biomechanical techniques without premedication in remote and resource-limited environments. Implementation of similar programs in austere settings has the potential to improve patient care. Further, using biomechanical reduction techniques may reduce reliance on procedural sedation irrespective of care setting.

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.

Successful Glenohumeral Shoulder Reduction With Combined Suprascapular and Axillary Nerve Block

BACKGROUND

Anterior glenohumeral dislocation is a common injury seen in the emergency department (ED) that sometimes requires procedural sedation for manual reduction. When compared with procedural sedation for dislocation reductions, peripheral nerve blocks provide similar patient satisfaction scores but have shorter ED length of stays. In this case report, we describe the first addition of an ultrasound-guided axillary nerve block to a suprascapular nerve block for reduction of an anterior shoulder dislocation in the ED.

CASE REPORT

A 34-year-old man presented to the ED with an acute left shoulder dislocation. The patient was a fit rock climber with developed muscular build and tone. An attempt to reduce the shoulder with peripheral analgesia was unsuccessful. A combined suprascapular and axillary nerve block was performed with 0.5% bupivacaine, allowing appropriate relaxation of the patient's musculature while providing excellent pain control. The shoulder was then successfully reduced without procedural sedation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Procedural sedation for reduction of anterior shoulder dislocations is time consuming, resource intensive, and can be risky in some populations. The addition of an axillary nerve block to a suprascapular nerve block allows for more complete muscle relaxation to successfully reduce a shoulder dislocation without procedural sedation.

Epidemiological and Clinical Characteristics of Shoulder Dislocations in Emergency Care Settings in Turkey: A Single-Center Experience

Objective: This study evaluated the general epidemiological and clinical characteristics of patients admitted to the emergency department with shoulder dislocations. Methods: This is a retrospective cross-sectional study, conducted as a chart review at the Emergency Department of the *** State Hospital between 01 January 2018 to 31 December 2019. Results: A total of 165 patients (median age 50 years and 60% of males) with anterior shoulder dislocations were included. The most common mechanism was traumatic dislocation (65.5%), the primary maneuver of treatment was traction/countertraction (80.6%), and 22.4% were recurrent dislocations. Males were younger and had more spontaneous dislocations. Also, patients with spontaneous dislocations were younger and predominantly males, and tended to be recurrent dislocations than traumatic ones. Conclusions: Epidemiological characteristics of our patients were similar to a previous study conducted in Turkey, but slightly different from the studies in other populations. Further studies evaluating the incidence and long-term follow-up data are also needed to better elucidate the epidemiological features of shoulder dislocations.

Which factors influence the ED length-of-stay after anterior shoulder dislocations: a retrospective chart review in 716 cases

Background

Anterior shoulder dislocations (ASD) are commonly seen in Emergency Departments (ED). ED overcrowding is increasingly burdening many healthcare systems. Little is known about factors influencing ED length-of-stay (LOS) for ASD. This study defines the factors influencing ED LOS for ASD patients.

Methods

Retrospective chart reviews were performed on all patients ≥12 years admitted with an anterior shoulder dislocation at two regional hospitals in the Netherlands between 2010 and 2016. The electronic patient records were reviewed for baseline patient characteristics, trauma mechanism, reduction methods, medication used, complications and the LOS at the ED. The main objective was determining factors influencing the LOS in patients with an anterior shoulder dislocation at the ED.

Results

During the study period, 716 ASD occurred in 574 patients, 374 (65.2%) in males. There were 389 (54.3%) primary ASD; the remainder (327, 45.7%) were recurrent. Median LOS was 92 min (IQR 66 min), with a significantly shorter LOS in those with recurrent dislocations (p < 0.001), younger age group (p < 0.03) and in patients who received no medications in the ED (p < 0.001). Traction-countertraction and leverage techniques were associated with a significant more use of ED medication compared to other techniques. Although the use of more medication might suggest the LOS would be longer for these techniques, we did not find a significant difference between different reduction techniques and LOS.

Conclusion

To our knowledge this study is the largest of its kind, demonstrating ED LOS in ASD patients is influenced by age, the need for medication and dislocation history, primary versus recurrent. Notably, we found that biomechanical reduction techniques, which are not primarily traction-countertraction or leverage techniques, e.g. scapular manipulation and Cunningham, were associated with less ED medication use. Further research is needed to define how reduction methods influence ED medication use, patient satisfaction and ED throughput times.

Three-week joint immobilization increases anterior-posterior laxity without alterations in mechanical properties of the anterior cruciate ligament in the rat knee

BACKGROUND

Although knee immobilization may deteriorate the mechanical parameters of the anterior cruciate ligament, such as stiffness and failure strength, it is unknown whether it induces laxity in the whole joint. We examined the effects of immobilization on anterior-posterior joint laxity and mechanical properties of the anterior cruciate ligament, as well as histological and gene expression profiles of the joint capsule in rat knee joints.

METHODS

Unilateral rat knees were immobilized using an external fixator. Non-immobilized contralateral knees were used as controls. After 3 weeks, anterior-posterior laxity in the whole joint (i.e., a complex of bones, ligaments, and capsule) and stiffness and failure strength in the anterior cruciate ligament were examined using a universal testing machine. Moreover, the knee joint capsule was histologically analyzed, and the expression levels of genes related to collagen turnover in the posterior joint capsule were examined.

FINDINGS

Joint immobilization slightly but significantly increased anterior-posterior laxity compared with the contralateral side. Unexpectedly, the stiffness and failure strength of the anterior cruciate ligament were not altered by immobilization. There was no correlation found between anterior cruciate ligament stiffness and anterior-posterior joint laxity. In the posterior joint capsule, thinning of the collagen fiber bundles accompanied by a decrease in COL3A1 gene expression was observed after immobilization.

INTERPRETATION

These results suggest that 3 weeks of joint immobilization alters the biomechanical integrity in the knee joint without altering the mechanical properties of the anterior cruciate ligament. Changes in the joint capsule may contribute to the immobilization-induced increase in anterior-posterior laxity.

Luxations aiguës d'épaule : évaluation rétrospective aux urgences et proposition d'un protocole de sédation procédurale

Introduction : Les luxations d'épaule sont des pathologies fréquentes aux urgences, parmi les plus douloureuses et pour lesquelles il n'existe pas de recommandations spécifiques. Elles représentent 45 % de l'ensemble des luxations. L'objectif principal de cette étude était d'analyser la gestion de la douleur dans cette pathologie.

Matériel et méthodes : Nous avons conduit une étude observationnelle, monocentrique et rétrospective colligeant 238 patients ayant consulté aux urgences pour une luxation aiguë d'épaule (01/01/2012-30/04/2015). Les luxations réduites spontanément, les luxations sur prothèse et les luxations chroniques étaient exclues de l'étude.

Résultats : Les luxations aiguës d'épaule étaient majoritairement réduites aux urgences (90 %, IC95 % : [86-94]). Il s'agissait d'une pathologie hyperalgique (Echelle numérique médiane : 8/10, [EIC : 6-9]) touchant plutôt les sujets jeunes (âge médian : 48 ans, EIC : 28-73). Il existait une grande hétérogénéité dans la répartition des antalgiques utilisés, le mélange équimolaire d'oxygène et de protoxyde d'azote (MEOPA) était l'antalgique le plus prescrit (50 % (IC95 % : [42-55])), suivi par le paracétamol (25 %) et le néfopam (15 %). Dans le sous-groupe des luxations compliquées d'une fracture, le MEOPA était également le plus prescrit. La répartition des autres antalgiques était par ailleurs similaire. Enfin, la comparaison entre les deux équipes médicales (urgentiste vs orthopédiste) ne retrouvait aucune différence de prescription en dehors du midazolam davantage utilisé par les urgentistes (16 % vs 4 %, p=0,001).

Conclusion : Il existait une grande hétérogénéité des pratiques et une sous-utilisation d'antalgiques et d'hypnotiques malgré des douleurs importantes dès l'admission. Un chemin clinique visant à améliorer cette prise en charge est proposé afin d'homogénéiser les pratiques.

Irreducible Anterior Shoulder Dislocation with Interposition of the Long Head of the Biceps and Greater Tuberosity Fracture: A Case Report and Review of the Literature

Background:

Failure of closed manipulative reduction of an acute anterior shoulder dislocation is seldom reported in the literature and is usually due to structural blocks such as soft tissue entrapment (biceps, subscapularis, labrum), bony fragments (glenoid, greater tuberosity) and severe head impaction (Hill-Sachs lesion).

Case report:

We present a case of an irreducible anterior shoulder dislocation in a 57-year-old male patient after a road-traffic accident. He had severe impaction of the head underneath glenoid rim and associated fracture of the greater tuberosity. Closed reduction performed in the emergency room under sedation and later at the theatre under general anaesthesia was unsuccessful. Open reduction using the dectopectoral approach revealed that the reason for obstruction was the posterolateral entrapment of the biceps tendon between the humeral head and the tuberosity fragment. Reduction was achieved after subscapularis tenotomy and opening of the joint; the tuberosity fragment was fixed with transosseous sutures and the long head of the biceps tendon was tenodesized. The patient had an uneventful postoperative recovery and at his last follow up, 12 months postoperatively, he had a stable joint, full range of motion and a Constant score of 90.

Conclusion:

A comprehensive literature review revealed 22 similar reports affecting a total of 30 patients. Interposition of the LHBT alone or in combination with greater tuberosity fracture was the most common obstacle to reduction, followed by subscapularis tendon interposition and other less common reasons. Early surgical intervention with open reduction and confrontation of associated injuries is mandatory for a successful outcome.