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 young and old active and inactive Shoulder dislocations make upto 45% of all dislocations Mechanism of Injury: -Indirect trauma to the upper extremity with the shoulder abducted, extended, and in external rotation -Direct anteriorly directed trauma to the posterior shoulder

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 The anteroinferior capsule limits anterior subluxation of the abducted shoulder. The inferior glenohumeral ligament is of primary importance to prevent anterior dislocation. Bony Bankart includes anteroinferior labrum avulsion with a glenoid rim fracture Hill-Sachs Lesions are see in 27% acute anterior dislocations, 74% recurrent dislocations Associated RCT in pts >40yo 35-40%, >60yo ~80%

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 Neuro exam: Test axillary sensation over deltoid and musculcutaneous sensation over anterolateral forearm Axillary nerve injury in 9-18% of anterior dislocations Apprehension Test: placement of shoulder into abduction, extension, and ER

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 True AP xray taken at 30-40 degrees of lateral or in the plane of the scapula Axillary: arm is abducted 70-90 degrees with beam pointed into axilla with cassette superior to shoulder (can try technique of having pt grab IV pole with ipsilateral hand and roll IV poll laterally to obtain xray Valpeau Axillary: If standard axillary cannot be obtained, patient is left in a sling and leaned obliquely backward 45 degrees over a cassette, beam is directed caudally West Point: Pt is prone with beam directed to the axilla 25 D downward and on the horizontal 25 D medial. Helps to identify Bankart Lesion. Hill-Sach View: Place shoulder in maximal internal rotation to visualize a posterolateral defect Stryker Notch:Pt is supine with the ipsilateral palm on the crown of the head and the elbow pointed upward. The xray beam is pointed 10 D off the vertical at the coracoid. This can visualize 90% of the posterolateral head defects (Hill-Sach lesion) CT scan: once reduction is complete for surgical preoperative planning if nec -->concern for fraccture/comminution/bony Bankart

Management Pre-Medication Reduction Maneuvers Post-Reduction Immobilization

Pre-Medication Methods of Premedication prior to Reduction None Intraarticular Lidocaine IV Sedation Supraclavicular Block Suprascapular Block Intraarticular Lidocaine Injection with 15-20 cc of Lidocaine through a posterior approach (aspirate obtains hemarthrosis= in the joint)

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 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 Reduction Success: Stimson technique reduction in 14/16 w/ lido, 11/14 w/ IV Sed. All 5 that could not be reduced initially were reduced with scapular manipulation Reduction Time: 11.4 w/ Lidocaine, 8.5 w/ IV Sedation Pain Score: 7.0 +/- 2.6 w/ Lidocaine, 7.4 +/- 2.5 for IV Sedation ER time: 75 min +/- 48 minutes w/ Lido, 185 min +/- 26 min for IV Sed (p<0.01) Other studies have shown incidence of respiratory depression with IV Sedation Use Cost: Lidocaine: $0.52, IV Sedation: $97.64

IV Sedation vs Intraarticular Lidocaine Injection Injection is Preferred over IV Sedation

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 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 Arm aducted to body Forearm flexed to 90 degrees Traction on forearm Gentle and gradual external rotation until reduction

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 Patient is supine Affected arm hanging down over the edge 10 lbs weight applied to wrist Wait for relaxation and auto-reduction

Traction/Countertraction Arm in some abduction Traction applied to arm Assistant applies firm counter-traction with sheet across the body

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 RCT (Beattie 1986) Randomization by date 111 patients No premedication Outcome: Successful Reduction Results: No difference in manuever for successful reduction Greater success with Milch’s technique in pts <40yo Greater success with Kocher approach, especially in people with a heavier build

Is there a best Reduction Maneuver? Unknown: More Research Needed Recommend learning three techniques and gaining experience with them each

Post-Reduction Immobilization Is immobilization necessary? What Method is Best?

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 Immobilization: Arm tied to torso (internal 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 ER: with wire-mesh splint, held arm in 10 D of ER IR: sling and swathe Compliance 40% for IR pts, 68% for ER pts Miller et al, Journal of Shoulder Elbow Surgery 2004, measured contact forces between the Bankart lesion and the glenoid in cadaveric shoulders. Showed that the greater the external rotation, the greater the amount of contact force. Itoi et al placed patient’s in 10 D of ER because of concerns of patient comfort with increased ER.

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 Questions yet to be answered: The best position for immobilization -- > how much ER? 2. The optimum duration of immobilization has not bee determined.

Conclusion Premedicate with Intraarticular Lidocaine Learn multiple reduction maneuvers If you decide to immobilize, immobilize in ER

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