1. Management of Acute Shoulder Dislocation
An overview
Heather Campion
Sports Medicine Conference
1/22/08

2. 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

3. 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%

4. 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

5. 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 degrees of lateral or in the plane of the scapula
Axillary: arm is abducted 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

6. Management Pre-Medication Reduction Maneuvers
Post-Reduction Immobilization

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

8. 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

9. 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

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

11. 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%)

12. 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

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

14. 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

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

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

17. 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

18. 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

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

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

21. 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)

22. 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.

23. 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.

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

25. Thanks