A systematic and technical guide on how to reduce a shoulder dislocation

Effectiveness of the Cunningham technique for shoulder dislocation reduction and its role in providing analgesia and muscle relaxation as an adjunctive method

BACKGROUND

Shoulder dislocation, particularly anterior dislocation, is a common orthopedic injury often presenting in emergency care settings, characterized by significant pain and muscle spasms. Prompt reduction is essential to alleviate symptoms and restore function. The Cunningham technique employs gentle pulling and massage motions targeted at the muscles and has emerged as a promising method for reducing anterior shoulder dislocations. However, its reported success rates vary widely across studies, and questions remain regarding its efficacy, particularly in cases of failure. This study aims to evaluate the effectiveness of the Cunningham technique for reducing anterior shoulder dislocations and its potential role in providing analgesia and muscle relaxation as an adjunctive method.

METHODS

A retrospective study was conducted on patients presenting with acute anterior shoulder dislocation at a single center. Reduction using the Cunningham technique was performed initially, followed by the external rotation technique if unsuccessful. Procedural sedation and analgesia were administered if the reduction was still not achieved, and shoulder dislocation reduction was performed again through the external rotation method. The patients' VAS scores were recorded and evaluated the Cunningham technique's effectiveness in reduction and whether it increases the effectiveness of other techniques applied for reduction by lowering the VAS score, even in cases where it is not effective.

RESULTS

A total of 61 patients were included in the study. The reduction was performed using the Cunningham technique in 34.4% (21/61) patients, the external rotation technique in 47.5% (29/61) patients, and the external rotation technique with PSA in 18% (11/61) patients. Significant differences were observed in the duration of hospital stay among the three techniques, with ER with PSA resulting in the longest stay. VAS scores showed significant improvements from initial presentation to post-reduction in all three groups. A significant decrease in pre-reduction VAS scores was observed during the transition from the Cunningham technique to other techniques.

CONCLUSION

The Cunningham technique showed effectiveness in reducing anterior shoulder dislocations, providing analgesia, and muscle relaxation. It demonstrated favorable outcomes as an initial reduction technique, with the external rotation technique used as a subsequent option. Further studies comparing the success rates and complications of the Cunningham technique with other reduction methods are warranted to establish its role in clinical practice.

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.

Hemodynamic Instability After Axillary Artery Rupture Following Inferior Glenohumeral Joint Dislocation: A Case Report

BACKGROUND Inferior shoulder dislocation is a rare type of glenohumeral joint dislocation. A serious complication to shoulder dislocation is axillary artery injury, which should be taken into consideration early to avoid potentially permanent damage. Literature on artery injury following inferior shoulder dislocation is sparse. CASE REPORT We report the case of a 71-year-old man with a traumatic inferior shoulder dislocation due to a fall. The patient had a medical history of stroke, and thus had a daily intake of 10 mg Warfarin. Previously, he had reported 2 anterior shoulder dislocations. The shoulder reduction was conducted under general anaesthesia after reduction with intravenous morphine sedation. Six hours after reduction, the patient showed signs of hemodynamic instability and a CT scan with contrast showed a suspected axillary artery rupture with a large hematoma in the right axilla. The artery rupture was confirmed with an arteriogram. The patient was successfully treated with an endovascular stent. After 3 months, the patient had normal neurovascular status in the right upper extremity and was continuing rehabilitation of the shoulder. CONCLUSIONS This case emphasizes the importance of proper recognition and awareness of artery injury after inferior shoulder dislocation. The symptoms of artery rupture after inferior shoulder dislocation can be immediate or have a late onset. The diagnostic modalities of CT scan with contrast or arteriogram should be performed with a low threshold of suspicion after reduction. With symptoms such as enlarging hematoma in the axilla, diminished radial and ulnar pulse, sudden pain from the axilla, or signs of hemodynamic instability after reduction, diagnostic modalities should be considered.

Patient perceptions after the operative and nonoperative treatment of shoulder instability: A qualitative focus group study

Background

Little evidence is available regarding patient perceptions of the treatment of shoulder instability. The aim of this study is to investigate patient perceptions regarding the operative and nonoperative treatment of anterior shoulder instability.

Methods

Patients who presented to the emergency department or outpatient clinic between 2016 and 2020 were retrospectively selected using diagnosis and procedure codes. Online focus groups and semistructured interviews were conducted, systematically recorded and subsequently transcribed to MaxQDA 2007 for qualitative analysis. Coded transcripts of all focus groups were subjected to a grounded theory-based analysis.

Results

Six focus groups and two semistructured interviews were hosted with 35 included patients. The mean age of included patients was 34.1 years (±11.5). Eight patients were female (23%), and 27 patients were male (77%). Fear of (recurrent) dislocation, preoperative counseling, communication between surgeon and physiotherapists and need for a consistent postoperative rehab protocol turned out to be important patient perceptions. The most crucial factor for discontent was a lack of communication from the surgeon.

Discussion

This patient-centered focus group study revealed that fear of (recurrent) dislocation, preoperative counseling, communication between surgeons and physiotherapists and the need for a consistent postoperative rehabilitation protocol was the most frequently discussed themes.

Effects of reduction technique for acute anterior shoulder dislocation without sedation or intra-articular pain management: a systematic review and meta-analysis

INTRODUCTION

Anterior shoulder dislocations are commonly seen in the emergency department for which several closed reduction techniques exist. The aim of this systematic review is to identify the most successful principle of closed reduction techniques for an acute anterior shoulder dislocation in the emergency department without the use of sedation or intra-articular lidocaine injection.

METHODS

A literature search was conducted up to 15-08-2022 in the electronic databases of PubMed, Embase and CENTRAL for randomized and observational studies comparing two or more closed reduction techniques for anterior shoulder dislocations. Included techniques were grouped based on their main operating mechanism resulting in a traction-countertraction (TCT), leverage and biomechanical reduction technique (BRT) group. The primary outcome was success rate and secondary outcomes were reduction time and endured pain scores. Meta-analyses were conducted between reduction groups and for the primary outcome a network meta-analysis was performed.

RESULTS

A total of 3118 articles were screened on title and abstract, of which 9 were included, with a total of 987 patients. Success rates were 0.80 (95% CI 0.74; 0.85), 0.81 (95% CI 0.63; 0.92) and 0.80 (95% CI 0.56; 0.93) for BRT, leverage and TCT, respectively. No differences in success rates were observed between the three separate reduction groups. In the network meta-analysis, similar yet more precise effect estimates were found. However, in a post hoc analysis the BRT group was more successful than the combined leverage and TCT group with a relative risk of 1.33 (95% CI 1.19, 1.48).

CONCLUSION

All included techniques showed good results with regard to success of reduction. The BRT might be the preferred technique for the reduction of an anterior shoulder dislocation, as patients experience the least pain and it results in the fastest reduction.

Fourteen years of follow-up after first arthroscopic Bankart repair in athletes: functional outcomes and magnetic resonance imaging findings

BACKGROUND

The arthroscopic Bankart procedure is the most performed surgery for shoulder stabilization. Short-term to midterm results are well studied; however, long-term results over 10 years are rare.

PURPOSE

This study evaluates the long-term results and magnetic resonance imaging (MRI) findings in athletes at a mean follow-up of 14 years after an arthroscopic Bankart stabilization as well as risk factors for osteoarthritis.

METHODS

A total of 63 athletes had an arthroscopic Bankart repair between 2001 and 2008, of whom 46 patients (73.0%) participated in the final follow-up. The Constant, Rowe, and Western Ontario Shoulder Instability Index (WOSI) score and the rate of return to sports were evaluated. Glenohumeral osteoarthritis was assessed using the Samilson-Prieto classification. Known risk factors for osteoarthritis were analyzed. MRI findings (bone marrow edema, cysts, and joint effusion) were analyzed.

RESULTS

The average follow-up was 14 years. Assessment was performed on 46 athletes with an average age of 21.6 at the time of surgery. The overall redislocation rate was 21.7%. The Constant score was 96.7, the Rowe score was 83.4, and the Western Ontario Shoulder Instability Index score was 90.7 out of 100. A total of 84.8% of the athletes returned to their initial sports level. Glenohumeral osteoarthritis occurred in 28.1%. Known risk factors for osteoarthritis were confirmed. Further MRI findings were rare.

CONCLUSIONS

Arthroscopic Bankart repair in athletes shows good long-term clinical results. However, this is only in patients without osteoarthritis, which was rare, but was confirmed as a risk factor. We assume that resorption of anchors differs in patients. If it does have an impact on developing arthrosis, this should be confirmed in further studies.

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.

Modified chair method: an easy and efficient reduction method without medication for anterior shoulder dislocation

BACKGROUND

Various maneuvers have been introduced to address anterior shoulder dislocations. Chair method allows the patient to sit comfortably and feel less pain during the reduction procedure. However, the rarity of comparative studies led to a lack of evidence to popularize. The present study aimed to introduce a modified chair (MOC) reduction method for anterior shoulder dislocation and explore its effectiveness compared with the traditional Hippocratic approach.

METHODS

This is a single-center retrospective study of 257 patients with anterior shoulder dislocation from September 2020 and July 2021. Patients were divided into two groups according to the reduction method they received (either the Hippocratic method or the MOC method). Success rate, reduction time, visual analog scale (VAS) pain score, satisfaction level, and a new indicator, pain index (reduction time (s)* VAS/ 10), were compared.

RESULTS

One hundred sixteen patients (43 females, 73 males) underwent the Hippocratic method, and 141 (65 females, 76 males) MOC method. A significantly higher success rate was seen in the MOC group (96.5%(136/141) vs. 84.5%(98/116) in the Hippocratic group; OR 5, 95%CI 1.79 ~ 13.91; p = 0.002). Pain index of the patients in the MOC group was much lower than that in the Hippocratic group (3.20 (2.10, 4.53) vs. 36.70 (22.40, 47.25), p <  0.001). The reduction time, VAS pain score, and satisfaction level also favored the MOC method.

CONCLUSIONS

The MOC method is an easy and efficient reduction method with minimum assistance for anterior shoulder dislocations. Physicians can skillfully perform this procedure with the help of their body weight. The MOC method could be attempted for shoulder dislocations in the emergency department.

A Systematic Review of Acute Irreducible Shoulder Dislocations in the 21st Century

Background

Rarely, closed reduction cannot be achieved in patients with acute shoulder dislocation, necessitating open management. A paucity of literature exists regarding these cases.

Purpose

To perform a systematic review on the mechanism, management, and outcome data of acute irreducible shoulder dislocations.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of the literature was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE between 2000 and 2020. Inclusion criteria were as follows: human participants, acute irreducible shoulder dislocation requiring open management, English language, and publication within the past 20 years. We excluded basic science articles, technique articles, reviews, editorials, and studies of chronic shoulder dislocations or dislocations with ipsilateral humeral shaft fractures.

Results

Twelve articles fit the inclusion criteria and were considered for review. All studies were single case reports (level 4 evidence). Ten of the 12 studies were of male patients. The direction of dislocation included 7 anterior/anteroinferior, 2 posterior, 1 inferior, 1 bilateral inferior, and 1 superolateral. Most dislocations were irreducible owing to a mechanical block to reduction. The most common type of block was an incarcerated long head of the biceps tendon, followed by interposition of 1 of the rotator cuff tendons. The axillary and musculocutaneous nerves, displaced fracture fragments, and Hill-Sachs and bony Bankart lesions were other causes of blocks to reduction. Eleven patients were treated with open surgery, while 1 patient was treated arthroscopically. Procedures performed were dependent on concurrent pathology. Final follow-up ranged from 6 weeks to 2 years, with no repeat dislocation episodes reported. Complications after open reduction included 1 case of brachial plexopathy (posterior cord) and 1 case of musculocutaneous nerve palsy.

Conclusion

There is a paucity of literature on the management of irreducible acute shoulder dislocations. The most common irreducible dislocation found in this systematic review was anterior with a mechanical block attributed to interposition of the long head of the biceps tendon. When patients were treated with an open or arthroscopic procedure, recurrence was low, with none reporting recurrent dislocation in limited follow-up.

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.

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.

Success rate of anterior shoulder dislocation reduction by emergency physicians: a retrospective cohort study

Aim

Methods

Results

Conclusion

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.

[Anterior-superior dislocation of the shoulder: case report and review of the literature]

Traumatic dislocations of the shoulder joint are generally described as an antero-inferior dislocations. Anterior-superior dislocations are extremely rare. We report a rare case of traumatic dislocation of the anterior-superior shoulder in a 45-year-old patient whose physical examination showed an anterior-superior subcutaneous protrusion of the head filling the subacromial space. The diagnosis was radiologically confirmed. MRI showed total rupture of the supraspinatus and subscapularis tendons. Shoulder instability occurred after reduction of the dislocation. Temporary glenohumeral arthrodesis was subsequently performed with good functional results.

Practice Patterns of Athletic Trainers Regarding the On-Site Management of Patients With Joint Dislocations

CONTEXT

As part of clinical practice, athletic trainers (ATs) provide immediate management of patients with acute joint dislocations. Management techniques may include on-site closed joint reduction of the dislocated joint. Although joint reduction is part of the 2020 educational standards, currently practicing ATs may have various levels of exposure, knowledge, and skills.

OBJECTIVE

To capture AT self-reported knowledge and practice patterns concerning closed joint reductions.

DESIGN

Cohort study.

SETTING

Online survey (Qualtrics).

PATIENTS OR OTHER PARTICIPANTS

The survey link was emailed to 5000 certified ATs. A total of 772 responses were completed by certified ATs with clinical practice experience (15.4% response rate).

MAIN OUTCOME MEASURE(S)

Participants were asked to complete a survey about their practice patterns concerning patients with closed joint reductions, which included questions about the types of closed reductions ATs performed most commonly, the frequency of on-site reduction by ATs, and participants' demographic information. Additionally, the survey addressed the ATs' training and comfort level in performing closed reductions and knowledge of standing orders and the state practice act.

RESULTS

Ninety percent (n = 694) of ATs reported ever performing a closed reduction (either with or without a physician present), with 10% (n = 78) stating they had never performed a joint reduction. The interphalangeal joint of the finger (73.2% of ATs), shoulder (63.3%), and patella (48.2%) were cited as the 3 most common reductions performed without a physician present. Only 46.5% (n = 359) of ATs indicated receiving training in joint-reduction techniques as part of their precertification athletic training curriculum or program; a greater percentage (64%) said they learned directly from a physician. Fewer than 60% of ATs reported having standing orders related to joint reductions.

CONCLUSIONS

Considering the high percentage of ATs who reported performing closed joint reductions and the low percentage with formal training, further development of joint-reduction training and standing orders is warranted.

Promising Mid-Term Outcomes after Humeral Head Preserving Surgery of Posterior Fracture Dislocations of the Proximal Humerus

Background: The aim of this study was to evaluate the clinical outcome after humeral head preserving surgical treatment of posterior fracture dislocations of the proximal humerus. Methods: Patients with a posterior fracture dislocation of the proximal humerus that were operatively treated in two level-1 trauma centers within a timeframe of 8 years were identified. With a minimum follow-up of 2 years, patients with humeral head preserving surgical treatment were invited for examination. Results: 19/24 fractures (79.2%; mean age 43 years) were examined with a mean follow-up of 4.1 ± 2.1 years. Of these, 12 fractures were categorized as posteriorly dislocated impression type fractures, and 7 fractures as posteriorly dislocated surgical neck fractures. Most impression type fractures were treated by open reduction, allo- or autograft impaction and screw fixation (n = 11), while most surgical neck fractures were treated with locked plating (n = 6). Patients with impression type fractures showed significantly better ASES scores (p = 0.041), Simple Shoulder Test scores (p = 0.003), Rowe scores (p = 0.013) and WOSI scores (p = 0.023), when compared to posteriorly dislocated surgical neck fractures. Range of motion was good to excellent for both groups with no significant difference. Conclusions: This mid-term follow-up study reports good to very good clinical results for humeral head preserving treatment.

Evaluating the results of Bankart repair in recurrent traumatic anterior shoulder dislocation

INTRODUCTION

Bankart procedure is considered a safe and effective technique in the management of traumatic shoulder dislocation. Various studies have evaluated the results of Bankart Repair in different populations. The aim of the current study is to evaluate and report the outcomes of Bankart capsulorrhaphy in patients with recurrent shoulder dislocation in Iran.

METHODS

This is a clinical trial without a control group that was performed in 2021. The study population consisted of all patients diagnosed with recurrent anterior shoulder dislocation and Bankart lesion that were candidates for Bankart capsulorrhaphy in 2012-2020. All patients that met the inclusion criteria entered the study using census method. We assessed variables including shoulder range of motion (ROM), shoulder joint symptoms using Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Rowe score, Constant Shoulder Score and patient's quality of life using 36-Item Short Form Survey Instrument (SF-36) before surgeries and within 2 months, 6 months and 1 year after surgeries.

RESULTS

Data of 300 patients were analyzed. All patients underwent Bankart capsulorrhaphy. Patients were followed up for minimum of 1 year after surgery. These data showed improvements in external rotation, abduction, DASH score, Rowe score and SF-36 in patients (P < 0.05 for all items). No significant changes were observed within 1 year in forward elevation (P = 0.07), internal rotation (P = 0.125) and Constant Shoulder Score (P = 0.082).

CONCLUSION

Bankart surgery is an effective method for reducing pain and recurrence of shoulder dislocation. Based on our results, using Bankart surgery led to significantly increased shoulder functions among patients.

[Shoulder instability: review of current concepts of diagnosis and treatment]

OBJECTIVE

To conduct a systematic review of modern literature data on the modern approaches in diagnosis and treatment of shoulder instability.

MATERIAL AND METHODS

Searching for literature data was performed using the Pubmed and Google Scholar databases.

RESULTS

The authors analyzed the results of conservative treatment of patients with shoulder instability and emphasized higher risk of instability recurrence, degeneration of anatomical structures and functional impairment in these patients. Surgery is advisable to restore shoulder stability and normalize its function. Several methods for stabilizing the shoulder have been proposed.

The approaches to diagnosis and treatment of shoulder instability have been updated.

CONCLUSION

Successful treatment of shoulder instability is based on qualitative and complete assessment of soft tissues and bone structures. An individual approach considering bone tissue deficiency and individual needs of the patient is required.

[Emergency treatment of dislocation of large joints]

Joint dislocations are always accompanied by rupture of the joint capsule. Depending on the forces exerted on the joint as well as individual bone quality, fractures (dislocation fractures) and injuries to ligaments occur. As blood vessels and nerves can also be damaged, reduction is an urgent measure. Only impaired peripheral perfusion, loss of motor function or sensation justify reduction without radiological documentation. As reduction can be a painful procedure, analgosedation is nearly always necessary. Evidence for superiority of individual maneuvers is weak. Reduction is followed by immobilization and documented by another control X‑ray. Follow-up treatment depends on concomitant injuries, age and individual demands on joint function. Even with correct follow-up treatment, deficits often persist. This article deals with the diagnostics and treatment of dislocations of the shoulder, elbow, hip, patella and knee.

The use of denosumab in the setting of acute pathological fracture through giant cell tumour of bone

Background

Denosumab (Xgeva^TM) is a fully human antibody to RANK-Ligand, an important signal mediator in the pathogenesis of giant cell tumour of bone (GCTB). The use of denosumab in the treatment of GCTB has changed the way in which these tumours are managed over the past years.

Case presentation

Described is the case of an acute fracture through a GCTB of the distal radius of a fit and well 32-year-old, non-smoking, female patient following a simple fall onto her outstretched, dominant hand. The aim was to enable joint sparing management for the patient, as opposed to an acute fusion procedure of the carpus. The patient underwent percutaneous k-wire fixation with application of plaster and immediate commencement with denosumab to halt the activity of the GCTB. Bone healing was rapid; plaster and k-wires were removed after 6 weeks. At 6 months denosumab, was ceased and an open curettage and grafting procedure of the tumour bed was undertaken (using MIIG X3, Wright Medical, aqueous calcium sulphate as graft material).

Conclusions

The use of denosumab in the acute setting of pathological fracture through giant cell tumour of bone allowing joint salvage has not been previously described. The treatment was well tolerated and functional outcomes are excellent, with very promising 4-year follow-up.

This novel approach may allow for more joint sparing strategies in the future for other patients in this difficult situation. Further cases will need to be gathered to establish this technique as a suitable treatment pathway.

Simultaneous bilateral anterior shoulder dislocation as a result of minimal trauma

Simultaneous bilateral anterior shoulder dislocation is rare, it often occurs after high energy trauma, we report a case of a 43-years-old male presented with bilateral anterior shoulder dislocation when he tries to stand up from the floor, shoulders in extension, abduction and external rotation. A closed reduction was performed without complications, and one month later the right shoulder was stabilized by open Laterjet technique. The evolution was favorable for both shoulders with no pain, recuperation of the range motion and no recurrence of dislocation. Through this case we underline the value of early diagnosis and appropriate treatment of bilateral anterior shoulder dislocation, to avoid complications and obtain good result.

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.

Management of primary anterior shoulder dislocations: a narrative review

Abstract

The recurrence rate following acute anterior shoulder dislocations is high, particularly in young, active individuals. The purpose of this paper is to provide a narrative overview of the best available evidence and results with regards to diagnostic considerations, comorbidities, position of immobilization, surgical versus conservative management, and time to return to play for the management of primary anterior shoulder dislocations. Three independent reviewers performed literature searches using PubMed, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials and systematic reviews meeting inclusion criteria from 1930 to April 2019 were appraised and discussed with the intent to consolidate the best available evidence with regards to lowering recurrence rates. A majority of studies support early surgical intervention for individuals between 21 and 30 years of age following primary shoulder dislocations, as this group is particularly susceptible to recurrence. Conservative treatment plans favor 1–3 weeks of immobilization in internal rotation, followed by rehabilitation. Surgical methods are associated with longer time to return to play, but lower recurrence rates. Return to play time is best determined on an individualized basis, when subjective and objective function of both shoulders is determined to be symmetric. This paper broadly summarizes the best available evidence for the management of primary anterior shoulder dislocations. There remains a need for randomized studies to determine ideal long-term treatment following conservative or surgical management, as general timelines for returning to play following injury remain vague.

Level of evidence

IV, Narrative Review

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.

A systematic comparison of the closed shoulder reduction techniques

PURPOSE

To identify the optimal technique for closed reduction for shoulder instability, based on success rates, reduction time, complication risks, and pain level.

METHODS

A PubMed and EMBASE query was performed, screening all relevant literature of closed reduction techniques mentioning the success rate written in English, Dutch, German, and Arabic. Studies with a fracture dislocation or lacking information on success rates for closed reduction techniques were excluded. We used the modified Coleman Methodology Score (CMS) to assess the quality of included studies and excluded studies with a poor methodological quality (CMS < 50). Finally, a meta-analysis was performed on the data from all studies combined.

RESULTS

2099 studies were screened for their title and abstract, of which 217 studies were screened full-text and finally 13 studies were included. These studies included 9 randomized controlled trials, 2 retrospective comparative studies, and 2 prospective non-randomized comparative studies. A combined analysis revealed that the scapular manipulation is the most successful (97%), fastest (1.75 min), and least painful reduction technique (VAS 1,47); the "Fast, Reliable, and Safe" (FARES) method also scores high in terms of successful reduction (92%), reduction time (2.24 min), and intra-reduction pain (VAS 1.59); the traction-countertraction technique is highly successful (95%), but slower (6.05 min) and more painful (VAS 4.75).

CONCLUSION

For closed reduction of anterior shoulder dislocations, the combined data from the selected studies indicate that scapular manipulation is the most successful and fastest technique, with the shortest mean hospital stay and least pain during reduction. The FARES method seems the best alternative.