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Management of Acute Shoulder Dislocation. An overview Heather Campion Sports Medicine Conference 1/22/08. Incidence. Shoulder is the most commonly dislocated joint Traumatic Dislocations Anterior 96% Posterior 2-4% Diverse group of patients experience dislocations; M and F

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management of acute shoulder dislocation

Management of Acute Shoulder Dislocation

An overview

Heather Campion

Sports Medicine Conference

1/22/08

incidence
Incidence
  • Shoulder is the most commonly dislocated joint
  • Traumatic Dislocations
    • Anterior 96%
    • Posterior 2-4%
  • Diverse group of patients experience dislocations;
    • M and F
    • young and old
    • active and inactive
anatomic consideration
Anatomic Consideration
  • Glenohumeral stabilization mechanisms
    • Passive: joint conformity, vacuum effect, ligamentous and capsular restraints, labrum
    • Active: long head of Biceps and Rotator Cuff
  • Pathoanatomy of shoulder dislocations
    • Bankart Lesion: avulsion of anteroinferior labrum
    • Hill-Sachs Lesion: posterolateral humeral head defect
    • Assoc. RCT: more common in older patients
clinical evaluation
Clinical Evaluation
  • PE:
    • Prominent acromion, sulcus sign, palpable humeral head anteriorly
    • Neuro integrity of axillary and musculcutaneous nerves
    • Apprehension Test: reproduces sense of instability and pain in shoulder reduced prior to exam
radiographic evaluation
Radiographic Evaluation
  • AP vs true AP
  • Axillary vs Valpeau Axillary
  • Special Views:
    • West Point axillary: for visualization of glenoid rim
    • Hill-Sach view: internal rotation view
    • Stryker Notch: view 90% of posterolateral humeral head
management
Management
  • Pre-Medication
  • Reduction Maneuvers
  • Post-Reduction Immobilization
pre medication
Pre-Medication
  • Methods of Premedication prior to Reduction
    • None
    • Intraarticular Lidocaine
    • IV Sedation
    • Supraclavicular Block
    • Suprascapular Block
iv sedation vs intraarticular lidocaine injection
IV Sedation vs Intraarticular Lidocaine Injection
  • Level 1 RCT: Miller et al JBJS 2002
    • Prospective Randomized study put isolated shoulder dislocation patients (#30) into 2 groups
    • Variety of Outcome Measures:
      • Reduction Success
      • Complications
      • Pain
      • Time to reduce/Time in the ER
      • Cost
iv sedation vs intraarticular lidocaine injection1
IV Sedation vs Intraarticular Lidocaine Injection
  • No significant difference between:
    • Reduction Success
    • Reduction Time
    • Pain Score
  • Statistical Significance:
    • Pts tx with intraarticular Lidocaine
      • left the ER earlier
      • Fewer Complications
      • Lower Cost with Lidocaine
iv sedation vs intraarticular lidocaine injection2
IV Sedation vs Intraarticular Lidocaine Injection

Intra-articular Lidocaine

Injection is Preferred over

IV Sedation

reduction maneuvers
Reduction Maneuvers
  • Is there an Ideal Method for Reduction?
    • Over 24 Techniques Described
  • Most Common Techniques
    • Kocher (71-100%)
    • External Rotation (78-90%)
    • Milch (70-89%)
    • Stimson (91-96%)
    • Traction/Countertraction
    • Scapular Manipulation (79-96%)
kocher maneuver
Kocher Maneuver
  • Arm is adducted and flexed at the elbow
  • Externally rotate arm until resistance is felt
  • The ER arm is flexed forward as far as possible
  • The arm is internally rotated
external rotation
External Rotation
  • Arm aducted to body
  • Forearm flexed to 90 degrees
  • Traction on forearm
  • Gentle and gradual external rotation until reduction
milcher technique
Milcher Technique
  • Patient is supine
  • One hand on shoulder, with thumb on dislocated humeral head
  • Other arm slowly abducts shoulder to overhead position
  • Head is gently pushed over glenoid rim to reduce dislocated shoulder
stimson technique
Stimson Technique
  • Patient is supine
  • Affected arm hanging down over the edge
  • 10 lbs weight applied to wrist
  • Wait for relaxation and auto-reduction
traction countertraction
Traction/Countertraction
  • Arm in some abduction
  • Traction applied to arm
  • Assistant applies firm counter-traction with sheet across the body
scapular manipulation
Scapular Manipulation
  • Patient is prone
  • Shoulder flexed to 90 degrees hanging with elbow flexed and humerus in external rotation
  • 5-15lbs of traction on arm
  • One hand on superior scapula pushing laterally
  • Other hand on inferior angle pushing medially
milch vs kocher
Milch vs Kocher
  • RCT (Beattie 1986)
    • Randomization by date
    • 111 patients
    • No premedication
    • Outcome: Successful Reduction
    • Results: No difference in manuever for successful reduction
is there a best reduction maneuver
Is there a best Reduction Maneuver?
  • Unknown: More Research Needed
  • Recommend learning three techniques and gaining experience with them each
post reduction immobilization
Post-Reduction Immobilization
  • Is immobilization necessary?
  • What Method

is Best?

does immobilization reduce recurrence
Does immobilization reduce recurrence?
  • Level I RCT: Hovelius JBJS 2008
    • Prospective multi-center study
    • 257 primary anterior shoulder dislocations
    • 25 year follow up
    • Results:

Immobilization for 3-4 weeks after shoulder dislocation does NOT change the prognosis compared with immediate mobilization

internal vs external rotation
Internal vs External Rotation
  • Level II RCT: Itoi JBJS 2007
    • Basis: MRI has shown that coaptation of the Bankart lesion is better with the arm in ER than in IR
    • Thought: If the Bankart heals recurrence is less likely
    • 198 primary shoulder dislocations randomized to ER or IR immobilization for 3 weeks
    • Followed for a minimum of 2 years
    • Level 2: low compliance, instructional bias, short f/u
internal vs external rotation1
Internal vs External Rotation
  • Level II RCT: Itoi JBJS 2007
    • ER for 3 weeks
      • Recurrence rate: 32%
    • IR for 3 weeks
      • Recurrence rate: 60%
    • P = 0.007
conclusion
Conclusion
  • Premedicate with Intraarticular Lidocaine
  • Learn multiple reduction maneuvers
  • If you decide to immobilize, immobilize in ER