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Management of Management of Acute Shoulder Acute Shoulder
DislocationDislocationAn overview An overview
Heather CampionHeather Campion
Sports Medicine ConferenceSports Medicine Conference
1/22/081/22/08
IncidenceIncidence
Shoulder is the most commonly Shoulder is the most commonly dislocated jointdislocated joint
Traumatic Dislocations Traumatic Dislocations Anterior 96%Anterior 96% Posterior 2-4%Posterior 2-4%
Diverse group of patients experience Diverse group of patients experience dislocations;dislocations;
M and FM and F young and oldyoung and old active and inactiveactive and inactive
Anatomic ConsiderationAnatomic Consideration
Glenohumeral stabilization mechanismsGlenohumeral stabilization mechanisms Passive: joint conformity, vacuum effect, Passive: joint conformity, vacuum effect,
ligamentous and capsular restraints, labrumligamentous and capsular restraints, labrum Active: long head of Biceps and Rotator CuffActive: long head of Biceps and Rotator Cuff
Pathoanatomy of shoulder dislocationsPathoanatomy of shoulder dislocations Bankart Lesion: avulsion of anteroinferior Bankart Lesion: avulsion of anteroinferior
labrumlabrum Hill-Sachs Lesion: posterolateral humeral Hill-Sachs Lesion: posterolateral humeral
head defect head defect Assoc. RCT: more common in older patientsAssoc. RCT: more common in older patients
Clinical EvaluationClinical Evaluation PE:PE:
Prominent acromion, Prominent acromion, sulcus sign, palpable sulcus sign, palpable humeral head anteriorlyhumeral head anteriorly
Neuro integrity of Neuro integrity of axillary and axillary and musculcutaneous nervesmusculcutaneous nerves
Apprehension TestApprehension Test: : reproduces sense of reproduces sense of instability and pain in instability and pain in shoulder reduced prior shoulder reduced prior to examto exam
Radiographic EvaluationRadiographic Evaluation
AP vs true APAP vs true AP Axillary vs Valpeau Axillary vs Valpeau
AxillaryAxillary Special Views:Special Views:
West Point axillary: for West Point axillary: for visualization of glenoid visualization of glenoid rimrim
Hill-Sach view: internal Hill-Sach view: internal rotation viewrotation view
Stryker Notch: view Stryker Notch: view 90% of posterolateral 90% of posterolateral humeral headhumeral head
ManagementManagement
Pre-MedicationPre-Medication
Reduction Reduction ManeuversManeuvers
Post-Reduction Post-Reduction ImmobilizationImmobilization
Pre-MedicationPre-Medication
Methods of Methods of Premedication prior to Premedication prior to ReductionReduction NoneNone Intraarticular Lidocaine Intraarticular Lidocaine
IV SedationIV Sedation Supraclavicular BlockSupraclavicular Block Suprascapular BlockSuprascapular Block
IV Sedation vs IV Sedation vs Intraarticular Lidocaine Intraarticular Lidocaine
InjectionInjection Level 1 RCT: Miller et al JBJS 2002Level 1 RCT: Miller et al JBJS 2002
Prospective Randomized study put Prospective Randomized study put isolated shoulder dislocation patients isolated shoulder dislocation patients (#30) into 2 groups(#30) into 2 groups
Variety of Outcome Measures:Variety of Outcome Measures: Reduction SuccessReduction Success ComplicationsComplications PainPain Time to reduce/Time in the ERTime to reduce/Time in the ER CostCost
IV Sedation vs IV Sedation vs Intraarticular Lidocaine Intraarticular Lidocaine
InjectionInjection No significant difference between:No significant difference between:
Reduction SuccessReduction Success Reduction TimeReduction Time Pain ScorePain Score
Statistical Significance:Statistical Significance: Pts tx with intraarticular LidocainePts tx with intraarticular Lidocaine
left the ER earlierleft the ER earlier Fewer ComplicationsFewer Complications Lower Cost with LidocaineLower Cost with Lidocaine
IV Sedation vs IV Sedation vs Intraarticular Lidocaine Intraarticular Lidocaine
InjectionInjection
Intra-articular Lidocaine
Injection is Preferred over
IV Sedation
Reduction ManeuversReduction Maneuvers
Is there an Ideal Method for Reduction?Is there an Ideal Method for Reduction? Over 24 Techniques DescribedOver 24 Techniques Described
Most Common Techniques Most Common Techniques Kocher (71-100%)Kocher (71-100%) External Rotation (78-90%) External Rotation (78-90%) Milch (70-89%) Milch (70-89%) Stimson (91-96%)Stimson (91-96%) Traction/CountertractionTraction/Countertraction Scapular Manipulation (79-96%)Scapular Manipulation (79-96%)
Kocher ManeuverKocher Maneuver
Arm is adducted Arm is adducted and flexed at the and flexed at the elbowelbow
Externally rotate Externally rotate arm until arm until resistance is feltresistance is felt
The ER arm is The ER arm is flexed forward as flexed forward as far as possiblefar as possible
The arm is The arm is internally rotatedinternally rotated
External RotationExternal Rotation
Arm aducted to Arm aducted to bodybody
Forearm flexed to Forearm flexed to 90 degrees90 degrees
Traction on Traction on forearmforearm
Gentle and gradual Gentle and gradual external rotation external rotation until reductionuntil reduction
Milcher TechniqueMilcher Technique Patient is supinePatient is supine One hand on One hand on
shoulder, with shoulder, with thumb on dislocated thumb on dislocated humeral headhumeral head
Other arm slowly Other arm slowly abducts shoulder to abducts shoulder to overhead positionoverhead position
Head is gently Head is gently pushed over glenoid pushed over glenoid rim to reduce rim to reduce dislocated shoulderdislocated shoulder
Stimson TechniqueStimson Technique
Patient is supinePatient is supine Affected arm Affected arm
hanging down over hanging down over the edgethe edge
10 lbs weight 10 lbs weight applied to wristapplied to wrist
Wait for relaxation Wait for relaxation and auto-reductionand auto-reduction
Traction/CountertractionTraction/Countertraction
Arm in some Arm in some abductionabduction
Traction applied to Traction applied to armarm
Assistant applies Assistant applies firm counter-firm counter-traction with sheet traction with sheet across the bodyacross the body
Scapular ManipulationScapular Manipulation Patient is pronePatient is prone Shoulder flexed to 90 Shoulder flexed to 90
degrees hanging with degrees hanging with elbow flexed and elbow flexed and humerus in external humerus in external rotationrotation
5-15lbs of traction on 5-15lbs of traction on armarm
One hand on superior One hand on superior scapula pushing scapula pushing laterallylaterally
Other hand on inferior Other hand on inferior angle pushing mediallyangle pushing medially
Milch vs KocherMilch vs Kocher RCT (Beattie 1986)RCT (Beattie 1986)
Randomization by dateRandomization by date 111 patients111 patients No premedicationNo premedication Outcome: Successful ReductionOutcome: Successful Reduction Results: No difference in manuever for Results: No difference in manuever for
successful reductionsuccessful reduction
Is there a best Reduction Is there a best Reduction Maneuver?Maneuver?
Unknown: More Research NeededUnknown: More Research Needed Recommend learning three techniques and Recommend learning three techniques and
gaining experience with them eachgaining experience with them each
Post-Reduction Post-Reduction ImmobilizationImmobilization
Is Is immobilization immobilization necessary? necessary?
What Method What Method
is Best?is Best?
Does immobilization Does immobilization reduce recurrence?reduce recurrence?
Level I RCT: Hovelius JBJS 2008Level I RCT: Hovelius JBJS 2008 Prospective multi-center studyProspective multi-center study 257 primary anterior shoulder 257 primary anterior shoulder
dislocationsdislocations 25 year follow up25 year follow up Results:Results:
Immobilization for 3-4 weeks after Immobilization for 3-4 weeks after shoulder dislocation does NOT change shoulder dislocation does NOT change the prognosis compared with the prognosis compared with immediate mobilizationimmediate mobilization
Internal vs External Internal vs External RotationRotation
Level II RCT: Itoi JBJS 2007Level II RCT: Itoi JBJS 2007 Basis: MRI has shown that coaptation of the Basis: MRI has shown that coaptation of the
Bankart lesion is better with the arm in ER Bankart lesion is better with the arm in ER than in IRthan in IR
Thought: If the Bankart heals recurrence is less Thought: If the Bankart heals recurrence is less likelylikely
198 primary shoulder dislocations randomized 198 primary shoulder dislocations randomized to ER or IR immobilization for 3 weeks to ER or IR immobilization for 3 weeks
Followed for a minimum of 2 yearsFollowed for a minimum of 2 years Level 2: low compliance, instructional bias, Level 2: low compliance, instructional bias,
short f/ushort f/u
Internal vs External Internal vs External RotationRotation
Level II RCT: Itoi JBJS 2007Level II RCT: Itoi JBJS 2007 ER for 3 weeksER for 3 weeks
Recurrence rate: 32%Recurrence rate: 32% IR for 3 weeksIR for 3 weeks
Recurrence rate: 60%Recurrence rate: 60% P = 0.007P = 0.007
Conclusion Conclusion
Premedicate with Intraarticular Premedicate with Intraarticular LidocaineLidocaine
Learn multiple reduction maneuversLearn multiple reduction maneuvers
If you decide to immobilize, If you decide to immobilize, immobilize in ERimmobilize in ER
ThanksThanks