Transcript Management of Acute Shoulder Dislocation

Management of Acute
Shoulder Dislocation
An overview
Heather Campion
Sports Medicine Conference
1/22/08
Incidence
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Shoulder is the most commonly dislocated joint
Traumatic Dislocations
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Anterior 96%
Posterior 2-4%
Diverse group of patients experience dislocations;
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M and F
young and old
active and inactive
Anatomic Consideration
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Glenohumeral stabilization mechanisms
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Passive: joint conformity, vacuum effect, ligamentous and
capsular restraints, labrum
Active: long head of Biceps and Rotator Cuff
Pathoanatomy of shoulder dislocations
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Bankart Lesion: avulsion of anteroinferior labrum
Hill-Sachs Lesion: posterolateral humeral head defect
Assoc. RCT: more common in older patients
Clinical Evaluation
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PE:
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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
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AP vs true AP
Axillary vs Valpeau
Axillary
Special Views:
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West Point axillary: for
visualization of glenoid rim
Hill-Sach view: internal
rotation view
Stryker Notch: view 90% of
posterolateral humeral head
Management
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Pre-Medication
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Reduction Maneuvers
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Post-Reduction
Immobilization
Pre-Medication
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Methods of Premedication
prior to Reduction
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None
Intraarticular Lidocaine
IV Sedation
Supraclavicular Block
Suprascapular Block
IV Sedation vs Intraarticular
Lidocaine Injection
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Level 1 RCT: Miller et al JBJS 2002
Prospective Randomized study put isolated shoulder
dislocation patients (#30) into 2 groups
 Variety of Outcome Measures:
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Reduction Success
 Complications
 Pain
 Time to reduce/Time in the ER
 Cost
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IV Sedation vs Intraarticular
Lidocaine Injection
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No significant difference between:
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Reduction Success
Reduction Time
Pain Score
Statistical Significance:
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Pts tx with intraarticular Lidocaine
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left the ER earlier
Fewer Complications
Lower Cost with Lidocaine
IV Sedation vs Intraarticular
Lidocaine Injection
Intra-articular Lidocaine
Injection is Preferred over
IV Sedation
Reduction Maneuvers
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Is there an Ideal Method for Reduction?
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Over 24 Techniques Described
Most Common Techniques
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Kocher (71-100%)
External Rotation (78-90%)
Milch (70-89%)
Stimson (91-96%)
Traction/Countertraction
Scapular Manipulation (79-96%)
Kocher Maneuver
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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
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Arm aducted to body
Forearm flexed to 90
degrees
Traction on forearm
Gentle and gradual
external rotation until
reduction
Milcher Technique
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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
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Patient is supine
Affected arm hanging
down over the edge
10 lbs weight applied to
wrist
Wait for relaxation and
auto-reduction
Traction/Countertraction
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Arm in some abduction
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Traction applied to arm
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Assistant applies firm
counter-traction with
sheet across the body
Scapular Manipulation
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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
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RCT (Beattie 1986)
Randomization by date
 111 patients
 No premedication
 Outcome: Successful Reduction
 Results: No difference in manuever for successful
reduction
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Is there a best Reduction Maneuver?
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Unknown: More Research Needed
Recommend learning three techniques and gaining
experience with them each
Post-Reduction Immobilization
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Is immobilization
necessary?
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What Method
is Best?
Does immobilization
reduce recurrence?
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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
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Internal vs External Rotation
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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
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Internal vs External Rotation
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Level II RCT: Itoi JBJS 2007
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ER for 3 weeks
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IR for 3 weeks
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Recurrence rate: 32%
Recurrence rate: 60%
P = 0.007
Conclusion
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Premedicate with Intraarticular Lidocaine
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Learn multiple reduction maneuvers
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If you decide to immobilize, immobilize in ER
Thanks