Comparison of four different reduction methods for anterior dislocation of the shoulder

Evaluation of the scapulohumeral distraction technique for anterior shoulder dislocation: a randomized controlled trial

BACKGROUND

Shoulder dislocation is a common injury presenting in the emergency department. Numerous methods have been described in the literature for glenohumeral reduction. These methods can be divided into 2 groups: traction maneuvers and the combination of traction with scapula manipulation techniques. In this article, we introduced a new maneuver for shoulder reduction, namely, the combination of traction with handling the scapula (scapulohumeral distraction [SHD]), and compare it to the Hippocratic technique (HT).

MATERIALS AND METHODS

A total of 96 patients with acute anterior shoulder dislocation were enrolled from November 2021 to September 2023. Eighty-seven patients, who met all inclusion criteria, were randomly assigned to one of the 2 groups (SHD or HT). We evaluated each method for success rate, time to relocation, complications over a follow-up of 1 month, and patients' satisfaction and pain level during the procedure.

RESULTS

Both methods had comparable success rates (SHD 95.3% vs. HT 93.2%, P = .833) while no complications where observed. However, SHD method required significantly less procedure time (P = .001). Moreover, patients in SHD group reported significantly less pain (P = .012) and greater satisfaction (P = .003) levels. Furthermore, when we assessed relocation time, pain, and patient satisfaction as a function of recurrence, there were no statistically significant differences between the 2 techniques. Similarly, the evaluation of relocation time for both techniques as a function of body mass index and age did not indicate statistically significant differences.

CONCLUSION

The SHD technique represents a safe, anatomically based and simple method for shoulder reduction. It showed a statistically significant decrease in relocation time and pain, with patients reporting higher satisfaction rates compared with the classical Hippocratic technique. Nonetheless, there were no statistically significant differences between the 2 techniques in regard to their success rates.

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.

First-time traumatic anterior shoulder dislocation: Approach for the primary health care physician

Traumatic anterior shoulder dislocation is a very common injury encountered in emergency rooms as well as in the primary health care physician's office. This injury occurs either in the setting of competitive or recreational sports injuries or as a high-energy injury during a fall or a road traffic accident. Common complications such as a recurrent dislocation can be predicted, monitored and prevented. Early appropriate treatment of associated cuff tears or fractures is associated with improved outcomes. There is a plethora of literature on the assessment and management of the primary anterior shoulder dislocation in specialised fields such as sports medicine, orthopaedic surgery and shoulder surgery. These studies are often highly technical, addressed to a particular subset of readers and often deal with one aspect of the management of the injury. This narrative aims to provide the reader with a simplified, evidence-based assessment and management approach for the first-time acute anterior shoulder dislocation. Emphasis is on closed reduction techniques, position and duration of immobilisation, and return to activities of life or sports. Risk factors for recurrence and other indications for primary referral to the orthopaedic surgeon are discussed. Other forms of shoulder instability such as posterior shoulder dislocation, inferior dislocation and multidirectional instability will not be the focus of this narrative.

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.

Study protocol: hypnosis versus standard care for shoulder dislocation reduction in the emergency department - a multicentre, randomised, controlled study protocol

INTRODUCTION

Anterior shoulder dislocation is a common reason for consultation at the emergency department (ED). Hypnosis could be a safe and effective alternative therapy for pain relief during shoulder dislocation reduction but nowadays, evidence is not sufficient. The main objective of this study is to show that reduction under hypnosis is associated with a decrease in the use of analgesic compared with usual care.

METHODS AND ANALYSIS

We will conduct an interventional, controlled, multicentre, randomised study. A total of 44 patients with shoulder dislocation will be randomised in two groups: the hypnosis group (N=22) and the usual care group (N=22). The primary endpoint will be the comparison of morphine equivalent analgesic consumption during a shoulder dislocation reduction manoeuvre. Secondary endpoints will include haemodynamic parameters monitoring, patient and practitioner satisfaction using a Likert scale, use of coanalgesic or sedative drugs, number of reduction attempts and time spent at ED. Adverse events will be recorded. Statistical analysis will include parametric tests, multivariate linear regression and descriptive statistics.

ETHICS AND DISSEMINATION

This study has received ethics approval from the Comité de Protection des Personnes of Sud-Est IV on 03/11/2021 (ANSM informed on 19 November 2021). The results will be published in scientific articles and communicated in national and international conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov: NCT04992598; National Clinical trial no ID RCB : 2021-A01382-39.

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.

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.

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.

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.

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 Techniques for Glenohumeral-, Patellofemoral-, and Interphalangeal-Joint Dislocations

Joint dislocations account for a small but important portion of all athletic injuries, with most occurring at the glenohumeral, patellofemoral, and interphalangeal joints. Athletic trainers are responsible for managing acute joint-dislocation injuries, which may include performing closed-reduction techniques when appropriate. To achieve optimal patient outcomes, the clinician should be formally trained and skilled in performing various techniques and familiar with the evidence supporting the selection of each technique. In this clinical review, we outline general reduction procedures and then summarize and synthesize the existing literature on common closed-reduction techniques for glenohumeral-, patellofemoral-, and interphalangeal-joint dislocations. When appropriate, the content has been adapted to be specific to the athletic trainer's scope of practice.

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.

Shoulder Dislocations in the Emergency Department: A Comprehensive Review of Reduction Techniques

BACKGROUND

Shoulder dislocations are a common presentation to the emergency department and one of the most frequent types of joint dislocations. Studies have found that delays from presentation to first reduction attempt and failed attempt at initial reduction are associated with lower rates of overall reduction success.

DISCUSSION

This article reviews 26 total reduction techniques, as well as a variety of modifications to these techniques. Each technique has distinct advantages and limitations associated with its use. While there are limited data comparing specific techniques, the individual success rates of most maneuvers range from 60-100%.

CONCLUSION

It is essential for emergency physicians to be familiar with multiple different reduction techniques in case the initial reduction attempt is unsuccessful or patient-specific characteristics limit the ability to perform certain techniques. This article reviews several reduction maneuvers for shoulder dislocations, variations on these techniques, and advantages and disadvantages for each approach. It is intended to serve as a resource for those interested in expanding their knowledge of shoulder reduction techniques.

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

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.

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.

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

OBJECTIVES

Our objective is to provide a systematic and technical guide on how to reduce a shoulder dislocation, based on techniques that have been described in literature for patients with anterior and posterior shoulder instability.

MATERIALS AND METHODS

A PubMed and EMBASE query was performed, screening all relevant literature on the closed reduction techniques. Studies regarding open reduction techniques and studies with fracture dislocations were excluded.

RESULTS

In this study we give an overview of 23 different techniques for closed reduction and 17 modifications of these techniques.

DISCUSSION

In this review article we present a complete overview of the techniques, that have been described in the literature for closed reduction for shoulder dislocations. This manuscript can be regarded as a clinical guide how to perform a closed reduction maneuver, including several technical tips and tricks to optimize the success rate and to avoid complications.

CONCLUSION

There are 23 different reduction techniques with 17 modifications of these techniques. Knowledge of the different techniques is highly important for a good reduction.

Anterior humeral circumflex artery avulsion with brachial plexus injury following an isolated traumatic anterior shoulder dislocation

A 70-year-old man presented to accident and emergency with an isolated anteriorly dislocated shoulder, in the absence of a concomitant fracture. There was no neurovascular deficit at presentation, and the shoulder was reduced under sedation, using the Kocher's technique. Following this, the patient developed signs of hypovolaemic shock. Clinical examination revealed an expanding fullness in the deltopectoral area, with compromise of the limb neurovascular status. CT imaging confirmed an expanding haematoma from the axillary vessels, restricting left lung expansion. Once resuscitated, the patient was transferred to theatre for exploration of the bleeding vessels. Intraoperative findings included an avulsed anterior circumflex humeral artery that was subsequently ligated. Postoperatively, the patient developed axillary, radial, median and ulnar nerve neuropraxia, which improved clinically prior to discharge. The patient was ultimately discharged home after a lengthy inpatient stay.