Evidence based outcome from a first time dislocation of the shoulder
Peter Brownson
Liverpool Upper Limb Unit
Prevalence
Hovelius 1982 Clinical Orthopaedics
Population study
Random sample of 2092 people
18-70 years
35 reported a dislocation (1.7%)
M:F 3:1
M:F 9:1 21-30 yrs age group
Prevalence Simonet 1984 Clinical Orthopaedics
Cumulative incidence up to 70 years
Male 0.7%
Female 0.3%
Recurrence
The reported rate of redislocation is 17% to 96% with a mean of 67%
Increased rate of recurrence in younger age groups
Primary anterior dislocation of the shoulder in young patients. A 10 year prospective study - Hovelius 1996 JBJS(A)
Multi centre study
10 year follow up
245 patients
Age 12-40 years
57% sporting injury
Non-operative management
52% no additional dislocation
8 shoulders considered unstable but no dislocation
23% operative treatment
In 12 to 22 year age group operation in 34%
Hill -Sachs lesion associated with a worse prognosis
Greater tuberosity fracture associated with a better prognosis
Immobilisation method not relevant
The prognosis following acute primary glenohumeral dislocation - Slaa et al JBJS(B) 2004
105 patients
Mean follow up 5 years
Recurrence of 26% within 4 years overall
Age most significant prognostic factor
Under 20 years recurrence in 64%
Over 40 years recurrence in 6%
Surgical versus non-surgical treatment for acute shoulder dislocations
A prospective, randomised evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations - Bottoni et al AM J Sports Med 2002
24 patients randomised
Non-operative treatment with sling for 4 weeks
Operative arthroscopic repair within 10 days using Suretac
Failure due to redislocation or instability symptoms preventing return to full duty
Average follow up 36 months
3 patients lost to follow up
Non-operative failed in 9/12 (75%)
Operative failed in 1/9 (11%)
Prospective randomised clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder - Kirkley et al 1999 Arthroscopy
Prospective randomised single blind study
40 patients under 30 years of age
Traumatic first time dislocation
Non-operative treatment with shoulder immobilization for 3 weeks
Operative treatment within 4 weeks using arthroscopic transglenoid sutures
Mean age 24 years
All patients except 1 had Bankart lesion
Minimum follow up 24 months
Non-operative 9/19 (47%) redislocation
Operative 3/19 (16%) redislocation
WOSI 16% better in operative group
1 post operative infection treated with antibiotics
Arthroscopic lavage compared with nonoperative treatment for traumatic anterior shoulder dislocation: A two year follow- up of a prospective randomised study. Wintzell JSES 1999
30 consecutive patients
Traumatic primary dislocation
Randomised
Mean age 24 years
Non-operative with immobilization up to 1 week
Operative with arthroscopic lavage within 10 days
2 year follow up
Redislocation in 3/15 (20%) of lavage group
Redislocation in 9/15 (60%) of non-operative group
Primary repair after traumatic anterior dislocation of the shoulder joint Jackobsen 1997 Orthop transactions
Randomised
76 patients
Median age 22 years
Operative open repair within 1 week
Non-operative treatment with sling for 1 week2 year follow up
Primary repair after traumatic anterior dislocation of the shoulder joint Jackobsen 1997 Orthop transactions
Redislocation in 1/37 patients treated operatively
Redislocation in 20/39 treated operatively
Cochrane review Surgical versus non-surgical treatment for acute anterior shoulder dislocation Handoll et al 2004
5 studies included
239 patients
Typically male aged 22 years
Primary traumatic anterior shoulder dislocation
Primary outcomes
Pooled results show subsequent instability, either dislocation or subluxation, was highly statistically significantly less in the surgical group RR 0.2
Secondary outcomes
Objective instability ( positive ant app test) was significantly less common in the surgical group
Only complication was 1 septic joint
No data pertaining to stiffness or muscle strength
Evidence appears reliable but with reservations
Long term prognosis relating to arthritis remains uncertain
Conclusions
"The limited evidence available from randomised controlled trials supports primary surgery in young adults (usually male( engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation.
There is no evidence available to determine whether surgical or non-surgical treatment is better for other categories of patient or injury.
In particular there is no evidence available to determine whether non-surgical treatment should not remain the prime treatment option after primary dislocation in those patients who are at a much lower risk of redislocation."
External Rotation Brace Evidence
Lennard Funk
Consultant Shoulder & Upper Limb Surgeon, Manchester, UK
For several thousand years, even before Hippocrates used his hot poker, dislocated shoulders have been treated in a sling with the arm internally rotated. In spite of, and perhaps because of, using the same treatment for so long, there is little information that it does any good.
The labrum acts as a Chuck Block, increasing the concavity of the glenoid and preventing translation of the Humeral Head. Thus it stops the head sliding or rolling off the glenoid.
Itoi felt that following an anterior dislocation of the shoulder the labrum would lie medially in internal rotation and reduce on external rotation. This theory was based on previous studies already in the literature.
Bonutti, J Comput Assist Tomogr. 1993
the tense subscapularis kept the capsule in contact with the underlying bone structures in external rotation, whereas in internal rotation the subscapularis became redundant and the labrum and the capsule folded into the joint
Ten thawed fresh-frozen cadaveric shoulders with all of the muscles removed.
A simulated Bankart lesion was created.
Linear transducers attached to the anteroinferior and inferior portions of the Bankart lesion
The opening and closing of the lesion were recorded with the arm in:
0, 30, 45, and 60 degrees of elevation in the coronal and sagittal planes
as well as with the arm in rotation from full internal to full external rotation in 10-degree increments.
The best coapted positions were:
Adduction + full internal rotation to 30 degrees of external rotation.
30 degrees of flexion or abduction, neutral and internal rotation
Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I Sato K (2001) - Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging - Journal of Bone & Joint Surgery 83A: 661-7
19 patients with shoulder dislocations.
MRI
Arm held at the side of the trunk and positioned
internal rotation (mean, 29 degrees)
external rotation (mean, 35 degrees)
The effect of an external rotation position (Itoi et al 2001)
Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I, Kobayashi M (2003) - A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. - Journal of Shoulder & Elbow Surgery 12: 413-5 2003
40 patients with initial shoulder dislocations.
Randomised into:
internal rotation (IR) sling
external rotation (ER) splint (10 degrees)
15.5 month Follow-up
Recurrence rate:
30% in the IR group
0% in the ER group
Latest Unpublished Results form Itoi - October 2004
Prospective multicenter randomised study from January 2000
110 patients
Age range 17-80 (mean 40 yrs )
Anterior dislocation of the shoulder without fractures
Randomised to immobilization in either internal rotation (IR group, 51 shoulders) or external rotation (ER group, 59 shoulders) for 3 weeks.
Mean follow-up = 20 months.
Average immobilization period = 15.9 ± 8.1 days in the IR group and 16.9 ± 7.1 days in the ER group.
Recurrence rate = 18/51 (35%) in the IR group and 11/59 (19%) in the ER group.
For those less than 29 years of age, recurrence rate was 48% in the IR group and 24% in the ER group.
In the IR group no significant difference between those immobilized for 3 weeks and those immobilized for less than 3 weeks (29% vs 45%, p=0.24)
In the ER group, there was a significant difference (8.7% vs 54%, p=0.0002).
For all patients splinted for at least 3 weeks, there was a significant difference in the recurrence rate between the IR and ER groups (p=0.0196).
Conclusion: Immobilization in external rotation after shoulder dislocation is better than the conventional immobilization in internal rotation in terms of reducing recurrent dislocations.
Rehab after Dislocation
Kathleen Roney (Manchester) & Jo Gibson (Liverpool) Shoulder Physiotherapists November 2004
Physiotherapy
Explanation of injury and the splint - Need to look at compliance with wearing the sling and advice.
Surrounding joints eg wrist, elbow, fingers and hand. Not forgetting the cervical spine.
Scapula setting as preparation for active rehab and ensuring that the arm is actually resting on the splint.
Even with the sling in situ the arm will be subject to the effects of gravity pulling the shoulder girdle into a position of protraction add this to the bodies natural reaction to injury which is to curl up and protect promotion of scapula position and posture will help to maintain postural muscles such as lower traps etc
Proprioception
Shoulder depends on the intact feedback system due to the inherent unstable nature of the joint. Proprioception transmitted to the brain via the mechanoreceptors within the capsuloligamentous structures. The rotator cuff shares an intimate link with the capsule and therefore disruption in proprioception will have a knock on affect in the recruitment of the cuff muscles therefore further reducing the stability of the joint.
Proprioception disrupted with injury to the shoulder.
Tension created within the muscles will have a direct effect on the proprioceptive information. Muscles that are kept in one position for a period of time the sensitivity to joint position reduces.
Weight bearing through joint will result in the co –contraction of the muscles thereby having a facilitatory effect on the neuro-receptors.
Aim too bring an approximation of the surfaces together to increase the joint awareness.
Examples of Exercises
Isometric contractions
Weight bearing through the limb. For example: pushing hand/ fist against wall
Scapula setting
Balance exercises.
Looking to produce approximation of joint facilitation of proprioception.
Preparation for final rehab.
Depends on patients treating level of expectations etc. Can incorporate gym ball balance work, standing on one leg and encourage facilitation of entire neural system.
The neural system is linked throughout the body and due to the nature of its transmission of its messages influence one part of the system and you will cause a resultant effect somewhere else in the system.
Mobilisation of the shoulder after splint removal
Aims of Rehab
Regain ROM - ROM at GH joint with good humeral scapula rhythm
Start progressive strengthening
Facilitate specific muscle groups
Practice activity related movements.
Move between lying/ sitting and standing. Looking for control and pain free success
Incorporating proprioceptive rehab
For example sitting on a ball, standing on one leg, four point kneeling.
Infraspinatus during flexion/ abduction. Serratus anterior in four point kneeling.
Altering the speed / repetition / resistance according to point in rehab.
Range Of Motion Exercises
Active assisted / active
Specific mobilisation techniques
Normal movement patterns
Related patterns to job / sport
Progressive Resisted exercises
Starting position
Speed and control of exercises
Increase resistance
Facilitation of Specific Muscles groups
Infraspinatus
Lower traps, middle traps
Trans abds
Activity related Activities
Manual workers
Sports person
Sedentary workers
Physiotherapy should allow full return to work and try not to encourage an avoidance culture.
Applying External Rotation Sling
The External Rotation braces can be difficult to apply. The most popular current brace is the Donjoy Ultrasling ER
a) Unfasten the Velcro straps at the forearm and wrist positions on the outside of the sling.
b) Insert arm into the sling resting the cusion on your hip. Place your arm as far back as possible in the sling and the thumb strap between the thumb and first finger.
c) Reattach both the forearm and wrist straps on top of the sling to secure the arm.
Step 2
Align cushion on the injured side at waist level with the ball (front) away from your body. Place the cushion so the line on top of the cushion is parallel to the front of your body (If you stand at a table, the line should be parallel to the table).
Step 3
a) Bring waist strap around from the back of the cushion around your waist, inserting into and attaching to the front buckle.
b) Adjust waist strap for proper fit.
Step 4
Unfasten the shoulder strap buckle at the front of the cushion. Using your free arm, reach behind your body and slip your arm through the shoulder strap. This motion will be similar to putting on a backpack, with the wide strap on the collarbone and the thin pad in the underarm area.
Step 5
Reattach the shoulder strap to the buckle at the front of the cushion.
Step 6
Adjust all straps for adequate stabilisation of the injured shoulder
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