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