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Immobilisation following traumatic anterior glenohumeral joint dislocation
Injury, Int. J. Care Injured (2006) 37, 228—237
www.elsevier.com/locate/injury
REVIEW
Immobilisation following traumatic anterior glenohumeral joint dislocation A literature review Toby O. Smith * Physiotherapy Department - Out-Patients East, Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk, NR4 7UY, UK Accepted 8 June 2005
KEYWORDS Shoulder dislocation; Immobilisation; Literature review
Summary Traumatic anterior dislocations of the shoulder are common and disabling injuries, in young and old alike. For centuries, the means of managing this injury has been to immobilise the affected shoulder after reduction, for up to 8 weeks, in an adducted and internally rotated position. The aim of this literature review is to assess whether traumatic anterior shoulder dislocations should be immobilised; for how long should they be immobilised; and whether the position of immobilisation affects outcomes. An electronic literature search was performed of the databases AMED, Cinahl, Embase, Medline (using Ovid), PEDro and Pubmed, from their inceptions to February 2005. Human clinical trials, written in English, which could assist in answering the research questions, were included. Sixteen (of 168) papers met the inclusion criteria and were reviewed. The review suggests that it remains unclear whether patients with traumatic primary anterior shoulder dislocations should be immobilised, or for how long. Similarly, it remains uncertain whether patients should be immobilised in internal, or external rotation. Much of this uncertainty is due to the limited size of the evidence base, which exhibited numerous methodological weaknesses (e.g. small sample sizes, no control groups, not evaluating findings against statistical tests). Recommendations are made to develop the evidence base. # 2005 Elsevier Ltd. All rights reserved.
Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Should traumatic anterior shoulder dislocations be immobilised?. . . . . Traumatic anterior shoulder dislocations should not be immobilised. * Tel.: +44 1603 286990; fax: +44 1603 287369. E-mail address: [email protected]. 0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.06.005
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Immobilisation following traumatic anterior glenohumeral joint dislocation
Traumatic anterior shoulder dislocations should be immobilised . . . . . . . . . . . . . . . . . . . . . . . How long should traumatic anterior shoulder dislocations be immobilised? . . . . . . . . . . . . . . . . Does the position of immobilisation affect outcomes after traumatic anterior shoulder dislocation? Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction The glenohumeral joint is the most commonly traumatically dislocated joint in the body.17 Although glenohumeral dislocations can occur posterior and inferiorly, in up to 98% of cases, they occur when the humeral head is displaced anteriorly.9 This most frequently occurs when the shoulder is forced into a position of abduction, hyperextension and external rotation, levering the humeral head out of joint.18,32 Trauma remains the main cause of primary shoulder dislocations.9 Common mechanisms of injury include: forceful collision, falling on an outstretched arm or sudden wrenching movements.9 Traumatic shoulder dislocations usually result in damage to the related soft tissues.8 Sequelae of anterior shoulder dislocations include Bankart and Hill-Sachs lesions. In a Bankart lesion, the dislocation tears the anterior glenoid labrum, with detachment of the inferior glenohumeral ligament.23 Dislocation can force the posterolateral margins of the humeral head against the glenoid edge, causing a compression fracture to the posterior aspect of the humeral head.9 This is termed a Hill-Sachs lesion.23 The major long-term sequel of shoulder dislocation is recurrent instability.8 This is generally regarded to be a greater risk in younger patients.32 The conservative management of traumatic anterior shoulder dislocations has not changed significantly since the days of Hippocrates.8 For thousands of years, shoulder dislocations have been treated by immobilising the arm in a sling, in a position of adduction and internal rotation.16,26 The pathophysiological justification for this is to allow the capsule and surrounding soft tissues to heal and ‘scar’, thereby providing some resistance to excessive external rotation, and so preventing re-dislocation.32 However, a number of authors have claimed that there remains little evidence to substantiate whether immobilisation is an appropriate treatment.26,30 In response to this ambiguity, this review was undertaken in order to answer three research questions. Firstly, should traumatic anterior shoulder dislocations be immobilised? If supported, then for how long should they be immobilised? Finally, does the position of immobilisation affect out-
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230 230 234 235 236 236 236
comes? In order for these questions to be answered, a systematic literature search was undertaken.
Methods An electronic literature search was conducted using the databases AMED, Cinahl, Embase, Medline (using Ovid), PEDro and Pubmed, from their inceptions to February 2005. The search terms applied as text words were: ‘‘anterior glenohumeral dislocation’’, ‘‘shoulder dislocation’’, ‘‘immobilisation’’, ‘‘mobilisation’’, and ‘‘conservative treatment’’. Reference lists of the identified studies were scrutinised to identify any additional publications. The British and American editions of the Journal of Bone and Joint Surgery from 1990 to February 2005 were hand-searched for relevant articles. The search initially recovered 168 citations. The titles and abstracts for the identified papers were assessed. The inclusion criteria specified English language, living human subjects, clinical trials, non-specific with regards to subject age group, gender or journal subset. The following publication types were excluded: case reports, abstracts, letters, comments, editorials, and review articles. Review articles were excluded so that a critical appraisal of each paper could be based on the original publication. In total, 22 articles were thought likely to be relevant, and full manuscripts were obtained. Final inclusion or exclusion decisions were made after the full manuscripts had been examined. Finally, 16 papers met the selection criteria and were reviewed.
Results Should traumatic anterior shoulder dislocations be immobilised? Traumatic anterior shoulder dislocations should not be immobilised Four papers were reviewed questioning the efficacy of immobilising traumatic anterior shoulder disloca-
230 tions. Most recently, Kralinger et al.20 reviewed 241 patients, comparing the effects of a 3-week period of shoulder immobilisation versus no immobilisation. The study concluded that statistically, immobilisation did not influence the rate of recurrent dislocations. Probability values validating this statement were not presented. The authors reported that patient age at initial dislocation significantly correlated to recurrent dislocation rates ( p = 0.002), with patients aged 21—30 years reporting the highest rate of recurrent dislocations. Unfortunately, the two study groups were not equally allocated, as 91.1% of the sample were immobilised, whilst the remaining patients were not. Therefore, it is difficult to compare the results from these two groups directly. In a retrospective review, Marans et al.24 investigated the effect of 4 and 6 weeks of immobilisation against no immobilisation, with a childhood population. All patients reported one or more recurrent dislocations during a 15-year follow-up period. Accordingly, the authors suggested that immobilisation had no effect on the rate of recurrence. However, Marans et al.24 did not control the duration of immobilisation or whether patients received physiotherapy when recruiting their cohort, factors which may have influenced outcomes.1 In addition, the evaluation of a larger sample size may further have improved the methodological design of this study. Henry and Genung10 retrospectively compared 62 patients, who were immobilised, against 59 who were not. Their results showed that 85% of the non-immobilised group dislocated a second time, compared to 90% in the immobilised group. Accordingly, Henry and Genung10 concluded that the number of recurrences was not influenced by immobilisation. The study, however, neglected to document the length, or position, of immobilisation, or how subjects were recruited. It is, therefore, not possible to deduce whether significant intra-sample variance in such factors influenced the author’s final conclusions. A detailed analysis of this paper was also limited since the authors did not evaluate their study’s findings against statistical tests. McLaughlin and MacLellan25 evaluated 580 primary and recurrently dislocated shoulders. The authors concluded that in patients over 40 years old, early mobilisation may be essential for a good result. Furthermore, McLaughlin and MacLellan25 suggested that in patients over 60 years old, prolonged immobilisation may be detrimental to recovery. When the cohort was assessed as a whole, prolonged immobilisation did not alter the incidence of recurrence. The patient’s age at primary dislocation had the greatest influence on recurrence rate, with 95% of adolescent primary dislocations recurring, whilst almost all patients aged over 30 years at
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initial dislocation did not report a second dislocation. The study, unfortunately, did not make reference to which specific immobilisation techniques, or positions, were used, the duration of immobilisation, what follow-up period was used, or how the sample was recruited, limiting the value of this study. Traumatic anterior shoulder dislocations should be immobilised Although the above studies suggest the contrary, 2 early papers concluded that it may be appropriate to immobilise traumatic anterior shoulder dislocations. Rowe and Sakellarides29 evaluated the effects of immobilisation with 324 primary, traumatic, anteriorly dislocated shoulders. The patients who received some form of immobilisation, showed the lowest incidence of recurrence. The authors also acknowledged that the length of immobilisation did not lower the overall recurrence rate. Rowe and Sakellarides,29 however, grouped a traumatic hypermobile joint patients in the ‘no immobilisation’ group. Accordingly, this group’s recurrence rates may have been inflated since such patients may anatomically have a greater risk of recurrent dislocation, irrespective of treatment.28 In an earlier study, Rowe28 reviewed the conservative and surgical management of 275 shoulder dislocations, immobilised, as Table 1 shows, using various techniques, for between 1 and 6 weeks, whilst 63 patients were not immobilised. Rowe28 found that the highest incident of recurrence was in the group who were not immobilised, those in a sling for 1 week, and the group with the arm strapped to the body for 1 week. The incidence of recurrence was lower in patients immobilised for 4 weeks in a sling, 3 weeks in a sling and swathe and 3 weeks with the body strapping techniques, suggesting that 3 weeks may be sufficient time to heal and then begin exercising. However, Rowe28 also concluded that the rate of recurrence was not further lowered by immobilisation longer than 3 weeks. Unfortunately, Rowe’s findings were not evaluated against statistical tests. How long should traumatic anterior shoulder dislocations be immobilised? There is little consensus regarding the duration of immobilisation following traumatic anterior shoulder dislocation.22 Although current textbooks recommend that these injuries be immobilised for between 3 and 8 weeks,2,5,27 the evidence base is obscure. Lill et al.21 examined the effects of age on outcome following primary shoulder dislocations. Patients under 30 years of age were immobilised for 1—3 weeks, whilst patients over 30 were immo-
Study
Study design
Henry and Genung 10
Sample size
Intervention
Outcome measure
Follow-up period
Retrospective 121
Traumatic primary anterior shoulder dislocation. Age range 12-32 (average 19 years)
Frequency of recurrent dislocations and time to first recurrent dislocation. Frequency of surgical intervention
2 years
Hovelius et al. 13
Prospective
257
Primary anterior shoulder dislocation. Subjects less than 40 years of age
Prospective
254
Primary anterior shoulder dislocation. All subjects less than 40 years of age
Hovelius et al. 12
Prospective
245
Primary anterior shoulder dislocation. All subjects less than 40 years of age
Ishikawa et al. 15
Prospective
116
Traumatic anterior shoulder dislocation. Under 29 years old
Shoulder function and recurrent dislocation. Pre-reduction radiography assessment of any fractures. Degree of humeral head displacement Shoulder function and recurrent dislocation. Pre-reduction radiography assessment of any fractures. Degree of humeral head displacement Shoulder function and recurrent dislocation. Pre-reduction radiography assessment of any fractures. Degree of humeral head displacement Recurrent dislocation rate. Complications. Duration of immobilisation
2 years
Hovelius 11
Itoi et al. 17
Prospective
18 (19 shoulders)
6 primary anterior shoulder dislocation. 13 recurrent anterior shoulder dislocations. Average age 23 years old
62 subjects immobilised in adduction and internal rotation. 59 subjects not immobilised post-reduction. Duration of immobilisation not specified Immobilisation of shoulder for 3 weeks.1 week or as long as patient benefited (range 1 day to 2 weeks). Immobilised in adduction and internal rotation Immobilisation of shoulder for 3 weeks. 1 week or as long as patient benefited (range 1 day to 2 weeks). Immobilised in adduction and internal rotation Immobilisation of shoulder for 3 weeks. 1 week or as long as patient benefited (range 1 day to 2 weeks). Immobilised in adduction and internal rotation 75 subjects immobilised on adduction and internal rotation for three weeks. 41 subjects immobilised in modified clavicular harness for more than three weeks, (mean 4.1 weeks) All patients immobilised in either: adduction and internal rotation (mean 298) or adduction and external rotation (mean 358)
MRI analysis measuring: position of labrum relative to the glenoid; coaptation of anterior portion of the capsule to glenoid on opening and closing of the anterior joint cavity
Post MRI assessment
5 years
10 years
1 year
231
Population
Immobilisation following traumatic anterior glenohumeral joint dislocation
Table 1 A summary of the papers reviewed, investigating the effects of immobilisation following traumatic anterior shoulder dislocation
Study
Study design
Sample size
Population
Intervention
Outcome measure
Follow-up period
Itoi et al. 16
Prospective
40
Primary Traumatic Anterior Shoulder Dislocation. Age 17—84 (mean 39 years)
Recurrent dislocation rate. Return to pre-injury sporting activity
Mean 15.5 months
Kiviluoto et al. 19
Prospective
226
Primary shoulder dislocations. 127 older than 50 years, 99 younger than 50
20 immobilised in adduction and full internal rotation. 20 immobilised in adduction and ten degrees external rotation. Immobilised for three weeks 127 over 50 year old subjects immobilised for one week. 53 under 50 year olds immobilised for one week. 46 under 50 year olds immobilised for three weeks. Immobilisation position of adduction and internal rotation
Activity and disability levels. Severity of initial trauma and complications. Duration of non-reduced period. Time to first recurrent dislocation. Recurrent dislocation rate Active range of movement. Clinical assessment using Rowe score. Athletic activity evaluated. Radiological assessment Clinical assessment using the Rowe Score. Recurrent dislocation rate. Bilateral shoulder ultrasound assessment and x-ray evaluation
1 year
Time to first recurrent dislocation. Recurrent dislocation rate, Duration of symptom-free period before first recurrent dislocation Recurrent dislocation rates, time to first recurrent dislocation, frequency of surgical intervention, functional activity and restriction
2 years
Kralinger et al. 20 Retrospective 241
Primary anterior shoulder dislocations. Age 10—86 years old (average 45.69 years)
220 subjects immobilised for three weeks in adduction and internal rotation. 21 patients not immobilised
Lill et al. 21
Retrospective 91
Traumatic primary anterior shoulder dislocation. 45 subjects younger than 30. 46 subjects older than 30
Maeda et al. 22
Survey
Primary traumatic shoulder dislocations. Age 16—23 (average 17.7 years)
All subjects immobilised in adduction and internal rotation. Subjects younger than 30 were immobilised between 7—28 days. Subjects older than 30 were immobilised for between 7—42 days 61 immobilised for 0—3 weeks (average 11.6 days). 18 immobilised for 4—7 weeks (average 34.3 days). Immobilised in adduction and internal rotation
Marans et al. 24
Retrospective 21
79
9 subjects not immobilised. 2 subjects immobilised for four weeks. 10 subjects immobilised for six weeks. Immobilisation position of adduction and internal rotation
13—76 months. Average 43.49 months
6—117 months (average 56 months)
15 years
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Traumatic primary anterior shoulder dislocation. Age range 4—16 (average 13 years)
232
Table 1 (Continued )
Rowe 28
Retrospective 580
265 Recurrent shoulder dislocations. 315 primary shoulder dislocations Retrospective 488 398 primary anterior (500 shoulders) shoulder dislocation. 102 recurrent dislocations. 22 atraumatic. 478 traumatic
Rowe and Sakellarides 29
Retrospective 321 Primary anterior (324 shoulders) shoulder dislocation
Simonet and Cofield 30
Retrospective 124
Primary anterior shoulder dislocation. 33 subjects less than 20 years, 49 were 20—40 years, 42 over 40 years old (Range 14—96 years)
Not specified position, duration or frequency of immobilisation for this cohort
Recurrent dislocation rate. Complications. Functional assessment
Not specified
Details regarding immobilisation for 275 subjects. 63 subjects not immobilised. 46 immobilised for 1 week. 52 immobilised for 2 weeks. 46 immobilised for 3 weeks 33 immobilised for 4 weeks 13 immobilised for 5 weeks 22 immobilised for 6 weeks. Subjects immobilised in either a sling, sling and swathe or strapping to the body, all in adduction and internal rotation 66 subjects not immobilised. 176 subjects immobilised for 1—3 weeks. 82 subjects immobilised for 3—6 weeks. Immobilised in adduction and internal rotation
Recurrent dislocation rate. Mechanism of injury. Complications. Type of dislocation. Ease of reduction. Function following surgical repair
156 subject 1—5 years. 115 subjects 5—10 years. 38 subjects 10—20 years. 4 subjects over 20 years
Recurrent dislocation rate
122 subjects immobilised in adduction and internal rotation. 2 subjects not immobilised. 91 subjects immobilised for 0—3 weeks. 29 subjects for 3—6 weeks. 4 subjects for 6 or more weeks (average 3.32 weeks)
Recurrent dislocation rates, time to first recurrent dislocation, surgical intervention, shoulder function and restriction
160 subjects from 1—5 years. 120 from 6—10 years. 44 subjects over 10 years 2—11 years (average 4.63 years)
Immobilisation following traumatic anterior glenohumeral joint dislocation
McLaughlin and MacLellan 25
233
234
bilised for between 1 and 6 weeks. This study found no difference in re-dislocation rate between patients who were immobilised for up to 2 weeks compared to patients immobilised for 3—4 weeks, irrespective of age ( p = 0.8). However, younger age and higher sporting activities correlated with higher incidences of recurrent dislocation. Unfortunately, the paper neglected to note whether abduction, or lateral rotation, was limited by the sling immobilisation. This is a factor which may have influenced outcomes.16 Similarly, Simonet and Cofield30 evaluated 124 patients who were immobilised for between 1 and 6 weeks. The authors reported that the duration of immobilisation had no influence on the result. Aside from immobilisation, they reported that 56% of patients refrained from resuming sports participation, or full activity, for 6 weeks or greater, had satisfactory results, compared with only 15% of patients who were restricted for less than 6 weeks. This was a significant difference ( p < 0.001). Furthermore, they found that there was a significant difference in recurrence rate depending on age ( p < 0.001); 66% of patients under 20 years of age dislocated one or more times, compared to no recurrences in patients over 40 years. In a prospective study, Hovelius et al.13 randomly allocated 257 patients following a primary anterior shoulder dislocation, to be immobilised in a sling for either 1 day to 2 weeks or for 3—4 weeks. This study found no difference in recurrent dislocation rates between the 2 groups, but concluded that recurrent dislocations were dependent on age at first dislocation. This is justified, because of their patients aged 22 years or younger, nearly 50% had one or more recurrences, whereas in patients aged 22—40, the incidence of recurrence was 25%. Interestingly, the presence of a greater tuberosity fracture, in addition to an anterior dislocation, was shown to be a good prognostic indicator for recurrent dislocation, a finding also observed by Kralinger et al.,20 McLaughlin and MacLellan,25 Rowe and Sakellarides29 and Rowe.28 Two hundred and fifty-six shoulders of 254 patients in this sample were evaluated 3 years later.11 The duration of immobilisation still did not influence outcomes. A further 5 years later, 245 of this cohort were again assessed.12 Yet again, the duration of immobilisation did not appear to have influenced outcomes. Age continued to be a significant prognostic indicator for recurrent dislocations. Since Hovelius et al.12 only studied patients under the age of 40 years, further long-term prospective trials investigating older patients could be a suitable addition to this series of papers. Kiviluoto et al.19 evaluated 1 week of immobilisation in a triangular sling (mitella) versus 3 weeks
T.O. Smith
immobilisation in a stockinette-Gilchrist bandage, in a sample of 226 primary shoulder dislocations. After 1 year, recurrent dislocations rates were shown to be better in subjects who were immobilised for 3 weeks rather than one. Fifty-six percent of patients under 30 years of age, who were immobilised for 1 week, reported a recurrent dislocation, compared to 22% who were immobilised for 3 weeks. Age also appeared to indicate re-dislocation risk with a significantly higher recurrent dislocation rate in patients under 30 years compared to those older than 30 ( p < 0.001). There was a difference in the median number of days off work on sick leave, between the groups. Of the patients who were immobilised for 1 week, those aged under 50 years needed 2.8 weeks off work, whilst those over 50, required 3.9 weeks; a statistically significant difference ( p < 0.01). In addition, of the patients aged under 50 years, those who were immobilised for 1 week, needed 2.8 weeks off work, whilst those immobilised for 3 weeks took off 3.8 weeks; again, a significant difference ( p < 0.01). However, since Henry and Genung10 found that the time to a first recurrent dislocation may be as long as 18 months, Kiviluoto et al.’s19 follow up after 12 months appears a little premature to evaluate, comprehensively, the effects of their different immobilisation protocols for this cohort. As noted, some authors recommend that the age of the patient on initial dislocation should be taken into account when clinically reasoning the duration of immobilisation.12,21 It has also been acknowledged that ‘sporty’ patients may be at greater risk of recurrent dislocation.21,30 Such a high-risk group was studied by Maeda et al.22 They surveyed 79 young rugby players, who sustained primary traumatic shoulder dislocations. Similarly to Kiviluoto et al.’s19 findings, after 2 years, 85% of subjects immobilised for 0—3 weeks at the time of initial dislocation, suffered a recurrent dislocation, compared to 69% who were immobilised for 4—7 weeks. This was a significant difference ( p = 0.019). The symptom-free period after primary dislocation was longer in subjects who were immobilised for 4—7 weeks (14 months) compared to subjects immobilised for the shorter period (4 months). Due to the disparities between these studies’ findings and design weaknesses, if traumatic anterior shoulder dislocations are immobilised, it is presently unclear how long they should be immobilised. Does the position of immobilisation affect outcomes after traumatic anterior shoulder dislocation? Historically, the position of immobilisation following traumatic anterior shoulder dislocation has been
Immobilisation following traumatic anterior glenohumeral joint dislocation
with the arm slightly anterior, adducted and internally rotated.2,4,6,14 However, the literature suggests that the efficacy of immobilising in such a position is unproven. Two studies have questioned this position of immobilisation, investigating the effects of immobilisation in external rotation, specifically to aid the healing of Bankart lesions.16,17 The pathoanatomical justification for this is to improve the approximation of torn capsular fibres by placing subscapularis on greater tension, closing the anterior joint cavity, so bringing the labrum back to the gleniod rim.17 Firstly, in Itoi et al.’s17 study, 6 primary and 13 recurrent anterior shoulder dislocations underwent magnetic resonance imaging, with their shoulders in adduction combined with either internal, or external, rotation. On assessment, there was significantly less separation and significantly less displacement of the labrum when the arm was externally rotated, than when internally rotated ( p = 0.0047 and 0.0017). Both the detached area of capsule and the opening angle of the lesion were significantly smaller ( p = 0.0003 and <0.0001) and the detached length significantly shorter ( p < 0.0001) when the arm was externally, compared with internally, rotated. There was no significant difference in these measurements between primary and recurrent dislocations. The authors concluded that shoulders may best be immobilised in external rotation, to approximate Bankart lesions better, than the conventional position of internal rotation. Following these results, Itoi et al.16 undertook a prospective trial, randomly allocating 40 subjects with primary traumatic anterior shoulder dislocations to receive 3 weeks of either conventional immobilisation in adduction and internal rotation, or in adduction and external rotation. When followed up, 30% of the study population immobilised in internal rotation reported a recurrent dislocation, compared to no recurrences in the external rotation group; this was a significant difference ( p = 0.008). When only patients under 30 years old were evaluated, 45% reported recurrent dislocations, compared to none in the external rotation group; this remained a significant difference ( p = 0.011). Fifty-eight percent of the internal rotation group returned to pre-injury sporting activity, compared to 82% in the external rotation group. However, the relatively short follow-up period and small sample size limit the significance of these encouraging findings. Employing a different immobilisation procedure, Ishikawa et al.15 compared the effects of a modified clavicular harness after anterior shoulder
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dislocation, against conventional shoulder immobilisation. All subjects were instructed to wear their ‘immobilisers’ for more than 3 weeks. The harness comprised 2 pads, one over the anterior aspect of the shoulder joint, and the second over the lower anterior part of the joint, covering the anteroinferior part of the glenoid. This seemed to restrict the outer ranges of glenohumeral movement, without limiting any particular direction in inner and mid-ranges. After 1 year, the conventional treatment group reported a recurrence rate of 29%, compared to no reported recurrent dislocations in the harness group. However, the authors acknowledged that 64% of the conventional treatment group failed to wear their bandage for 3 weeks, a factor which may limit the value of this study when comparing the groups. No functional outcomes were measured in this study. Finally, as in Kiviluoto et al.’s19 study, the 1-year follow-up period may have been insufficient to evaluate the rates of recurrent dislocations for these two immobilisation techniques.
Discussion The aim of this literature review was to determine whether traumatic anterior shoulder dislocations should be immobilised; if they should be, then for what period of time; and in what position? This review has presented a number of studies, which suggest that immobilising primary traumatic anterior shoulder dislocations may not be an effective means of preventing recurrent dislocations. It has also been suggested that age may be a greater prognostic factor for the rate of recurrent dislocation than immobilisation. Conversely, papers were identified that found that immobilisation did reduce the rate of recurrent dislocations. However, no consensus could be gleaned on the optimal duration of immobilisation. The majority of the reviewed literature investigated subjects who were immobilised in adduction and internal rotation. Although limited in size, the research assessing the efficacy of immobilising subjects in adduction and external rotation appears promising.16,17 A number of repeated methodological limitations plagued the evidence base. These included: not documenting the duration, position, or compliance of immobilisation; recruiting heterogeneous samples with regard to age and sporting activity; neglecting to document how subjects were selected and not assessing findings against statistical tests. Future research is recommended, employing large, well-controlled, randomised trials.
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Further study is proposed to investigate the efficacy of immobilising shoulder dislocations in external rotation, following the initially favourable findings of Itoi et al.’s.16,17 Their studies should be repeated, recruiting a larger sample size to be assessed over a longer follow-up period. In a similar vein, investigating the effects of immobilising the shoulder in external rotation over different durations may be an area for future study, as well as using functional outcome instruments. The literature suggests that it may be detrimental to immobilise patients over the age of 30 or 40 years following primary traumatic shoulder dislocation.6,19,25 In practice, however, patients over the age of 50 are routinely immobilised in most Orthopaedic and Accident & Emergency departments.7,31 It seems reasonable to encourage early mobilisation in this age-group, since the risk of recurrent dislocation is very low in patients over 50 years of age.25,30 Furthermore, the early restoration of movement could prevent joint stiffness and unnecessary functional constraint.2 Accordingly, it is recommended that clinical practice be reviewed in response to these findings. Patients who engage in physically demanding sporting activities appear to be more susceptible to recurrent shoulder dislocations than sedentary patients.21 The age of the patient on initial dislocation may significantly influence the prognosis for future recurrent dislocations.12,19,21 In response, future investigations, recruiting specific age groups from individual sporting backgrounds, may be particularly pertinent in order to compare the effectiveness of different immobilisation regimens in patients with similar risks, before and after anterior shoulder dislocations. It may be wise to consider a number of factors, which may have influenced the results of this literature review. The sole author selected the identified papers. Although the inclusion and exclusion criteria were strictly adhered to, this process was, to some extent, subjective, potentially introducing selection bias. The methodological design of this review would probably have been improved through the recruitment of additional reviewers, independently assessing the inclusion, or exclusion, of each study. The author was not blinded against the outcomes of the reviewed papers. Consequently, reviewer bias cannot be completely excluded. Similarly, since no attempt was made to identify unpublished studies, this review may have been influenced by publication bias. The majority of the literature search was undertaken using computerised databases. As computer searches may not necessarily be comprehensive,3 it is conceivable that some relevant papers may have been missed by the search strategy.
T.O. Smith
Conclusion This review suggests that, at present, there appears little clarity on whether patients with traumatic primary anterior shoulder dislocations should be immobilised, or, if so, for how long. Similarly, it remains uncertain whether patients should be immobilised in internal, or external, rotation. Much of this uncertainty exists because the present literature is limited by both sample size and by methodological weaknesses. Further study is required to improve the quality of the findings and to develop the evidence base. Following this, the effectiveness of immobilising primary traumatic anterior shoulder dislocation could then be determined with greater conviction.
Conflict of interest statement None.
References 1. Aronen JG, Regan K. Decreasing the incidence of recurrence of first time anterior shoulder dislocations with rehabilitation. Am J Sports Med 1984;12(4):283—91. 2. Buschbacher R. Shoulder girdle and arm. In: Buschbacher RM, editor. Musculoskeletal disorders. Diagnosis and rehabilitation. Oxford: Andover Medical Publishers, 2002. Chapter 8. p. 113—39. 3. Colville-Stewart S. How to do a literature search. In: Tarling M, Croft L, editors. The essential researcher’s handbook. For nurses and healthcare professionals. 2nd ed., London: Baillie `re Tindall; 2002. p. 35—53. 4. Dandy DJ, Edwards DJ. Essential orthopaedics and trauma, 3rd ed., London: Churchill Livingstone, 1999. 5. Duckworth T. Lecture notes on orthopaedics and fractures, 3rd ed., Oxford: Blackwell Science, 1995. 6. Goldie BS. Orthopaedic diagnosis and management. A guide to the care of orthopaedics patients, 2nd ed., Oxford: ISIS Medical Media, 1998. 7. Gumina S, Postacchini F. Anterior dislocation of the shoulder in elderly patients. J Bone Jt Surg 1997;79(4):540—3. 8. Handoll HHG, Almaiyah MA, Rangan A. Surgical versus nonsurgical treatment for acute anterior shoulder dislocations. The Cochrane Database of Systematic Reviews 2005; Issue 1. Art No.: CD004325. DOI: 10.1002/14651858.CD004325.pub2 9. Hayes K, Callanan M, Walton J, et al. Shoulder instability: management and rehabilitation. J Orth Sports Phys Ther 2002;32(10):497—509. 10. Henry JH, Genung JA. Natural history of glenohumeral dislocation-revisited. Am J Sports Med 1982;10(3):135—7. 11. Hovelius L. Anterior dislocation of the shoulder in teen-agers and young adults. Five-year prognosis. J Bone Jt Surg 1987;69-A(3):393—9. 12. Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Jt Surg 1996;78-A(11):1677—84.
Immobilisation following traumatic anterior glenohumeral joint dislocation
13. Hovelius L, Eriksson K, Fredin H, et al. Recurrences after initial dislocation of the shoulder. J Bone Jt Surg 1983;65A(3):343—9. 14. Hughes SPF, Porter RW. Textbook of orthopaedics and fractures. London: Arnold, 1997. 15. Ishikawa M, Fujimaki E, Kobayashi N, et al. Anterior dislocation of the shoulder. Experience with a modified clavicular harness. Int Orthop 1986;10:127—30. 16. Itoi E, Hatakeyama Y, Kido T, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg 2003;12(5):413—5. 17. Itoi E, Sashi R, Minagawa H, et al. Position of immobilisation after dislocation of the glenohumeral joint. J Bone Jt Surg 2001;83-A(5):661—7. 18. Kirkley A, Werstine R, Ratjek A, Griffin S. Prospective randomised clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilisation and rehabilitation in first traumatic anterior dislocations of the shoulder: long-term evaluation. Arthroscopy 2005;21(1):55—63. 19. Kiviluoto O, Pasila M, Jaroma H, Sundholm A. Immobilisation after primary dislocation of the shoulder. Acta Orthop Scand 1980;51:915—9. 20. Kralinger FS, Golser K, Wischatta R, et al. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med 2002;30(1):116—20. 21. Lill H, Korner J, Hepp P, et al. Age-dependent prognosis following conservative treatment of traumatic anterior shoulder dislocation. Euro J Trauma 2001;27(1):29—33.
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22. Maeda A, Yoneda M, Horibe S, et al. Longer immobilization extends the ‘‘symptom-free’’ period following primary shoulder dislocation in young rugby players. J Orthop Sci 2002;7:43—7. 23. Mahaffey BL, Smith PA. Shoulder instability in young athletes. Am Fam Physician 1999;59(10):2773—82. 24. Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Jt Surg 1992;74-A(8):1242—4. 25. McLaughlin HL, MacLellan DI. Recurrent anterior dislocation of the shoulder. II. A comparative study. J Trauma 1967; 7(2):191—201. 26. Murrell GAC. Treatment of shoulder dislocation: is a sling appropriate? Med J Australia 2003;179:370—1. 27. Richardson JK, Iglarsh ZA. Clinical orthopaedic physical therapy. London: WB Saunders Company, 1994. 28. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Jt Surg 1956;38-A(5):957—77. 29. Rowe CR, Sakellarides HT. Factors related to recurrences of anterior dislocations of the shoulder. Clin Orthop 1961; 20:40—8. 30. Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med 1984;12(1):19—23. 31. Sonnabend DH. Treatment of primary anterior shoulder dislocation in patients older than forty years of age. Clin Orthop Related Res 1994;304:74—7. 32. Wen DY. Current concepts in the treatment of anterior shoulder dislocations. Am J Emerg Med 1999;17(4):401—7.
www.elsevier.com/locate/injury
REVIEW
Immobilisation following traumatic anterior glenohumeral joint dislocation A literature review Toby O. Smith * Physiotherapy Department - Out-Patients East, Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk, NR4 7UY, UK Accepted 8 June 2005
KEYWORDS Shoulder dislocation; Immobilisation; Literature review
Summary Traumatic anterior dislocations of the shoulder are common and disabling injuries, in young and old alike. For centuries, the means of managing this injury has been to immobilise the affected shoulder after reduction, for up to 8 weeks, in an adducted and internally rotated position. The aim of this literature review is to assess whether traumatic anterior shoulder dislocations should be immobilised; for how long should they be immobilised; and whether the position of immobilisation affects outcomes. An electronic literature search was performed of the databases AMED, Cinahl, Embase, Medline (using Ovid), PEDro and Pubmed, from their inceptions to February 2005. Human clinical trials, written in English, which could assist in answering the research questions, were included. Sixteen (of 168) papers met the inclusion criteria and were reviewed. The review suggests that it remains unclear whether patients with traumatic primary anterior shoulder dislocations should be immobilised, or for how long. Similarly, it remains uncertain whether patients should be immobilised in internal, or external rotation. Much of this uncertainty is due to the limited size of the evidence base, which exhibited numerous methodological weaknesses (e.g. small sample sizes, no control groups, not evaluating findings against statistical tests). Recommendations are made to develop the evidence base. # 2005 Elsevier Ltd. All rights reserved.
Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Should traumatic anterior shoulder dislocations be immobilised?. . . . . Traumatic anterior shoulder dislocations should not be immobilised. * Tel.: +44 1603 286990; fax: +44 1603 287369. E-mail address: [email protected]. 0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.06.005
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Immobilisation following traumatic anterior glenohumeral joint dislocation
Traumatic anterior shoulder dislocations should be immobilised . . . . . . . . . . . . . . . . . . . . . . . How long should traumatic anterior shoulder dislocations be immobilised? . . . . . . . . . . . . . . . . Does the position of immobilisation affect outcomes after traumatic anterior shoulder dislocation? Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction The glenohumeral joint is the most commonly traumatically dislocated joint in the body.17 Although glenohumeral dislocations can occur posterior and inferiorly, in up to 98% of cases, they occur when the humeral head is displaced anteriorly.9 This most frequently occurs when the shoulder is forced into a position of abduction, hyperextension and external rotation, levering the humeral head out of joint.18,32 Trauma remains the main cause of primary shoulder dislocations.9 Common mechanisms of injury include: forceful collision, falling on an outstretched arm or sudden wrenching movements.9 Traumatic shoulder dislocations usually result in damage to the related soft tissues.8 Sequelae of anterior shoulder dislocations include Bankart and Hill-Sachs lesions. In a Bankart lesion, the dislocation tears the anterior glenoid labrum, with detachment of the inferior glenohumeral ligament.23 Dislocation can force the posterolateral margins of the humeral head against the glenoid edge, causing a compression fracture to the posterior aspect of the humeral head.9 This is termed a Hill-Sachs lesion.23 The major long-term sequel of shoulder dislocation is recurrent instability.8 This is generally regarded to be a greater risk in younger patients.32 The conservative management of traumatic anterior shoulder dislocations has not changed significantly since the days of Hippocrates.8 For thousands of years, shoulder dislocations have been treated by immobilising the arm in a sling, in a position of adduction and internal rotation.16,26 The pathophysiological justification for this is to allow the capsule and surrounding soft tissues to heal and ‘scar’, thereby providing some resistance to excessive external rotation, and so preventing re-dislocation.32 However, a number of authors have claimed that there remains little evidence to substantiate whether immobilisation is an appropriate treatment.26,30 In response to this ambiguity, this review was undertaken in order to answer three research questions. Firstly, should traumatic anterior shoulder dislocations be immobilised? If supported, then for how long should they be immobilised? Finally, does the position of immobilisation affect out-
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230 230 234 235 236 236 236
comes? In order for these questions to be answered, a systematic literature search was undertaken.
Methods An electronic literature search was conducted using the databases AMED, Cinahl, Embase, Medline (using Ovid), PEDro and Pubmed, from their inceptions to February 2005. The search terms applied as text words were: ‘‘anterior glenohumeral dislocation’’, ‘‘shoulder dislocation’’, ‘‘immobilisation’’, ‘‘mobilisation’’, and ‘‘conservative treatment’’. Reference lists of the identified studies were scrutinised to identify any additional publications. The British and American editions of the Journal of Bone and Joint Surgery from 1990 to February 2005 were hand-searched for relevant articles. The search initially recovered 168 citations. The titles and abstracts for the identified papers were assessed. The inclusion criteria specified English language, living human subjects, clinical trials, non-specific with regards to subject age group, gender or journal subset. The following publication types were excluded: case reports, abstracts, letters, comments, editorials, and review articles. Review articles were excluded so that a critical appraisal of each paper could be based on the original publication. In total, 22 articles were thought likely to be relevant, and full manuscripts were obtained. Final inclusion or exclusion decisions were made after the full manuscripts had been examined. Finally, 16 papers met the selection criteria and were reviewed.
Results Should traumatic anterior shoulder dislocations be immobilised? Traumatic anterior shoulder dislocations should not be immobilised Four papers were reviewed questioning the efficacy of immobilising traumatic anterior shoulder disloca-
230 tions. Most recently, Kralinger et al.20 reviewed 241 patients, comparing the effects of a 3-week period of shoulder immobilisation versus no immobilisation. The study concluded that statistically, immobilisation did not influence the rate of recurrent dislocations. Probability values validating this statement were not presented. The authors reported that patient age at initial dislocation significantly correlated to recurrent dislocation rates ( p = 0.002), with patients aged 21—30 years reporting the highest rate of recurrent dislocations. Unfortunately, the two study groups were not equally allocated, as 91.1% of the sample were immobilised, whilst the remaining patients were not. Therefore, it is difficult to compare the results from these two groups directly. In a retrospective review, Marans et al.24 investigated the effect of 4 and 6 weeks of immobilisation against no immobilisation, with a childhood population. All patients reported one or more recurrent dislocations during a 15-year follow-up period. Accordingly, the authors suggested that immobilisation had no effect on the rate of recurrence. However, Marans et al.24 did not control the duration of immobilisation or whether patients received physiotherapy when recruiting their cohort, factors which may have influenced outcomes.1 In addition, the evaluation of a larger sample size may further have improved the methodological design of this study. Henry and Genung10 retrospectively compared 62 patients, who were immobilised, against 59 who were not. Their results showed that 85% of the non-immobilised group dislocated a second time, compared to 90% in the immobilised group. Accordingly, Henry and Genung10 concluded that the number of recurrences was not influenced by immobilisation. The study, however, neglected to document the length, or position, of immobilisation, or how subjects were recruited. It is, therefore, not possible to deduce whether significant intra-sample variance in such factors influenced the author’s final conclusions. A detailed analysis of this paper was also limited since the authors did not evaluate their study’s findings against statistical tests. McLaughlin and MacLellan25 evaluated 580 primary and recurrently dislocated shoulders. The authors concluded that in patients over 40 years old, early mobilisation may be essential for a good result. Furthermore, McLaughlin and MacLellan25 suggested that in patients over 60 years old, prolonged immobilisation may be detrimental to recovery. When the cohort was assessed as a whole, prolonged immobilisation did not alter the incidence of recurrence. The patient’s age at primary dislocation had the greatest influence on recurrence rate, with 95% of adolescent primary dislocations recurring, whilst almost all patients aged over 30 years at
T.O. Smith
initial dislocation did not report a second dislocation. The study, unfortunately, did not make reference to which specific immobilisation techniques, or positions, were used, the duration of immobilisation, what follow-up period was used, or how the sample was recruited, limiting the value of this study. Traumatic anterior shoulder dislocations should be immobilised Although the above studies suggest the contrary, 2 early papers concluded that it may be appropriate to immobilise traumatic anterior shoulder dislocations. Rowe and Sakellarides29 evaluated the effects of immobilisation with 324 primary, traumatic, anteriorly dislocated shoulders. The patients who received some form of immobilisation, showed the lowest incidence of recurrence. The authors also acknowledged that the length of immobilisation did not lower the overall recurrence rate. Rowe and Sakellarides,29 however, grouped a traumatic hypermobile joint patients in the ‘no immobilisation’ group. Accordingly, this group’s recurrence rates may have been inflated since such patients may anatomically have a greater risk of recurrent dislocation, irrespective of treatment.28 In an earlier study, Rowe28 reviewed the conservative and surgical management of 275 shoulder dislocations, immobilised, as Table 1 shows, using various techniques, for between 1 and 6 weeks, whilst 63 patients were not immobilised. Rowe28 found that the highest incident of recurrence was in the group who were not immobilised, those in a sling for 1 week, and the group with the arm strapped to the body for 1 week. The incidence of recurrence was lower in patients immobilised for 4 weeks in a sling, 3 weeks in a sling and swathe and 3 weeks with the body strapping techniques, suggesting that 3 weeks may be sufficient time to heal and then begin exercising. However, Rowe28 also concluded that the rate of recurrence was not further lowered by immobilisation longer than 3 weeks. Unfortunately, Rowe’s findings were not evaluated against statistical tests. How long should traumatic anterior shoulder dislocations be immobilised? There is little consensus regarding the duration of immobilisation following traumatic anterior shoulder dislocation.22 Although current textbooks recommend that these injuries be immobilised for between 3 and 8 weeks,2,5,27 the evidence base is obscure. Lill et al.21 examined the effects of age on outcome following primary shoulder dislocations. Patients under 30 years of age were immobilised for 1—3 weeks, whilst patients over 30 were immo-
Study
Study design
Henry and Genung 10
Sample size
Intervention
Outcome measure
Follow-up period
Retrospective 121
Traumatic primary anterior shoulder dislocation. Age range 12-32 (average 19 years)
Frequency of recurrent dislocations and time to first recurrent dislocation. Frequency of surgical intervention
2 years
Hovelius et al. 13
Prospective
257
Primary anterior shoulder dislocation. Subjects less than 40 years of age
Prospective
254
Primary anterior shoulder dislocation. All subjects less than 40 years of age
Hovelius et al. 12
Prospective
245
Primary anterior shoulder dislocation. All subjects less than 40 years of age
Ishikawa et al. 15
Prospective
116
Traumatic anterior shoulder dislocation. Under 29 years old
Shoulder function and recurrent dislocation. Pre-reduction radiography assessment of any fractures. Degree of humeral head displacement Shoulder function and recurrent dislocation. Pre-reduction radiography assessment of any fractures. Degree of humeral head displacement Shoulder function and recurrent dislocation. Pre-reduction radiography assessment of any fractures. Degree of humeral head displacement Recurrent dislocation rate. Complications. Duration of immobilisation
2 years
Hovelius 11
Itoi et al. 17
Prospective
18 (19 shoulders)
6 primary anterior shoulder dislocation. 13 recurrent anterior shoulder dislocations. Average age 23 years old
62 subjects immobilised in adduction and internal rotation. 59 subjects not immobilised post-reduction. Duration of immobilisation not specified Immobilisation of shoulder for 3 weeks.1 week or as long as patient benefited (range 1 day to 2 weeks). Immobilised in adduction and internal rotation Immobilisation of shoulder for 3 weeks. 1 week or as long as patient benefited (range 1 day to 2 weeks). Immobilised in adduction and internal rotation Immobilisation of shoulder for 3 weeks. 1 week or as long as patient benefited (range 1 day to 2 weeks). Immobilised in adduction and internal rotation 75 subjects immobilised on adduction and internal rotation for three weeks. 41 subjects immobilised in modified clavicular harness for more than three weeks, (mean 4.1 weeks) All patients immobilised in either: adduction and internal rotation (mean 298) or adduction and external rotation (mean 358)
MRI analysis measuring: position of labrum relative to the glenoid; coaptation of anterior portion of the capsule to glenoid on opening and closing of the anterior joint cavity
Post MRI assessment
5 years
10 years
1 year
231
Population
Immobilisation following traumatic anterior glenohumeral joint dislocation
Table 1 A summary of the papers reviewed, investigating the effects of immobilisation following traumatic anterior shoulder dislocation
Study
Study design
Sample size
Population
Intervention
Outcome measure
Follow-up period
Itoi et al. 16
Prospective
40
Primary Traumatic Anterior Shoulder Dislocation. Age 17—84 (mean 39 years)
Recurrent dislocation rate. Return to pre-injury sporting activity
Mean 15.5 months
Kiviluoto et al. 19
Prospective
226
Primary shoulder dislocations. 127 older than 50 years, 99 younger than 50
20 immobilised in adduction and full internal rotation. 20 immobilised in adduction and ten degrees external rotation. Immobilised for three weeks 127 over 50 year old subjects immobilised for one week. 53 under 50 year olds immobilised for one week. 46 under 50 year olds immobilised for three weeks. Immobilisation position of adduction and internal rotation
Activity and disability levels. Severity of initial trauma and complications. Duration of non-reduced period. Time to first recurrent dislocation. Recurrent dislocation rate Active range of movement. Clinical assessment using Rowe score. Athletic activity evaluated. Radiological assessment Clinical assessment using the Rowe Score. Recurrent dislocation rate. Bilateral shoulder ultrasound assessment and x-ray evaluation
1 year
Time to first recurrent dislocation. Recurrent dislocation rate, Duration of symptom-free period before first recurrent dislocation Recurrent dislocation rates, time to first recurrent dislocation, frequency of surgical intervention, functional activity and restriction
2 years
Kralinger et al. 20 Retrospective 241
Primary anterior shoulder dislocations. Age 10—86 years old (average 45.69 years)
220 subjects immobilised for three weeks in adduction and internal rotation. 21 patients not immobilised
Lill et al. 21
Retrospective 91
Traumatic primary anterior shoulder dislocation. 45 subjects younger than 30. 46 subjects older than 30
Maeda et al. 22
Survey
Primary traumatic shoulder dislocations. Age 16—23 (average 17.7 years)
All subjects immobilised in adduction and internal rotation. Subjects younger than 30 were immobilised between 7—28 days. Subjects older than 30 were immobilised for between 7—42 days 61 immobilised for 0—3 weeks (average 11.6 days). 18 immobilised for 4—7 weeks (average 34.3 days). Immobilised in adduction and internal rotation
Marans et al. 24
Retrospective 21
79
9 subjects not immobilised. 2 subjects immobilised for four weeks. 10 subjects immobilised for six weeks. Immobilisation position of adduction and internal rotation
13—76 months. Average 43.49 months
6—117 months (average 56 months)
15 years
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Traumatic primary anterior shoulder dislocation. Age range 4—16 (average 13 years)
232
Table 1 (Continued )
Rowe 28
Retrospective 580
265 Recurrent shoulder dislocations. 315 primary shoulder dislocations Retrospective 488 398 primary anterior (500 shoulders) shoulder dislocation. 102 recurrent dislocations. 22 atraumatic. 478 traumatic
Rowe and Sakellarides 29
Retrospective 321 Primary anterior (324 shoulders) shoulder dislocation
Simonet and Cofield 30
Retrospective 124
Primary anterior shoulder dislocation. 33 subjects less than 20 years, 49 were 20—40 years, 42 over 40 years old (Range 14—96 years)
Not specified position, duration or frequency of immobilisation for this cohort
Recurrent dislocation rate. Complications. Functional assessment
Not specified
Details regarding immobilisation for 275 subjects. 63 subjects not immobilised. 46 immobilised for 1 week. 52 immobilised for 2 weeks. 46 immobilised for 3 weeks 33 immobilised for 4 weeks 13 immobilised for 5 weeks 22 immobilised for 6 weeks. Subjects immobilised in either a sling, sling and swathe or strapping to the body, all in adduction and internal rotation 66 subjects not immobilised. 176 subjects immobilised for 1—3 weeks. 82 subjects immobilised for 3—6 weeks. Immobilised in adduction and internal rotation
Recurrent dislocation rate. Mechanism of injury. Complications. Type of dislocation. Ease of reduction. Function following surgical repair
156 subject 1—5 years. 115 subjects 5—10 years. 38 subjects 10—20 years. 4 subjects over 20 years
Recurrent dislocation rate
122 subjects immobilised in adduction and internal rotation. 2 subjects not immobilised. 91 subjects immobilised for 0—3 weeks. 29 subjects for 3—6 weeks. 4 subjects for 6 or more weeks (average 3.32 weeks)
Recurrent dislocation rates, time to first recurrent dislocation, surgical intervention, shoulder function and restriction
160 subjects from 1—5 years. 120 from 6—10 years. 44 subjects over 10 years 2—11 years (average 4.63 years)
Immobilisation following traumatic anterior glenohumeral joint dislocation
McLaughlin and MacLellan 25
233
234
bilised for between 1 and 6 weeks. This study found no difference in re-dislocation rate between patients who were immobilised for up to 2 weeks compared to patients immobilised for 3—4 weeks, irrespective of age ( p = 0.8). However, younger age and higher sporting activities correlated with higher incidences of recurrent dislocation. Unfortunately, the paper neglected to note whether abduction, or lateral rotation, was limited by the sling immobilisation. This is a factor which may have influenced outcomes.16 Similarly, Simonet and Cofield30 evaluated 124 patients who were immobilised for between 1 and 6 weeks. The authors reported that the duration of immobilisation had no influence on the result. Aside from immobilisation, they reported that 56% of patients refrained from resuming sports participation, or full activity, for 6 weeks or greater, had satisfactory results, compared with only 15% of patients who were restricted for less than 6 weeks. This was a significant difference ( p < 0.001). Furthermore, they found that there was a significant difference in recurrence rate depending on age ( p < 0.001); 66% of patients under 20 years of age dislocated one or more times, compared to no recurrences in patients over 40 years. In a prospective study, Hovelius et al.13 randomly allocated 257 patients following a primary anterior shoulder dislocation, to be immobilised in a sling for either 1 day to 2 weeks or for 3—4 weeks. This study found no difference in recurrent dislocation rates between the 2 groups, but concluded that recurrent dislocations were dependent on age at first dislocation. This is justified, because of their patients aged 22 years or younger, nearly 50% had one or more recurrences, whereas in patients aged 22—40, the incidence of recurrence was 25%. Interestingly, the presence of a greater tuberosity fracture, in addition to an anterior dislocation, was shown to be a good prognostic indicator for recurrent dislocation, a finding also observed by Kralinger et al.,20 McLaughlin and MacLellan,25 Rowe and Sakellarides29 and Rowe.28 Two hundred and fifty-six shoulders of 254 patients in this sample were evaluated 3 years later.11 The duration of immobilisation still did not influence outcomes. A further 5 years later, 245 of this cohort were again assessed.12 Yet again, the duration of immobilisation did not appear to have influenced outcomes. Age continued to be a significant prognostic indicator for recurrent dislocations. Since Hovelius et al.12 only studied patients under the age of 40 years, further long-term prospective trials investigating older patients could be a suitable addition to this series of papers. Kiviluoto et al.19 evaluated 1 week of immobilisation in a triangular sling (mitella) versus 3 weeks
T.O. Smith
immobilisation in a stockinette-Gilchrist bandage, in a sample of 226 primary shoulder dislocations. After 1 year, recurrent dislocations rates were shown to be better in subjects who were immobilised for 3 weeks rather than one. Fifty-six percent of patients under 30 years of age, who were immobilised for 1 week, reported a recurrent dislocation, compared to 22% who were immobilised for 3 weeks. Age also appeared to indicate re-dislocation risk with a significantly higher recurrent dislocation rate in patients under 30 years compared to those older than 30 ( p < 0.001). There was a difference in the median number of days off work on sick leave, between the groups. Of the patients who were immobilised for 1 week, those aged under 50 years needed 2.8 weeks off work, whilst those over 50, required 3.9 weeks; a statistically significant difference ( p < 0.01). In addition, of the patients aged under 50 years, those who were immobilised for 1 week, needed 2.8 weeks off work, whilst those immobilised for 3 weeks took off 3.8 weeks; again, a significant difference ( p < 0.01). However, since Henry and Genung10 found that the time to a first recurrent dislocation may be as long as 18 months, Kiviluoto et al.’s19 follow up after 12 months appears a little premature to evaluate, comprehensively, the effects of their different immobilisation protocols for this cohort. As noted, some authors recommend that the age of the patient on initial dislocation should be taken into account when clinically reasoning the duration of immobilisation.12,21 It has also been acknowledged that ‘sporty’ patients may be at greater risk of recurrent dislocation.21,30 Such a high-risk group was studied by Maeda et al.22 They surveyed 79 young rugby players, who sustained primary traumatic shoulder dislocations. Similarly to Kiviluoto et al.’s19 findings, after 2 years, 85% of subjects immobilised for 0—3 weeks at the time of initial dislocation, suffered a recurrent dislocation, compared to 69% who were immobilised for 4—7 weeks. This was a significant difference ( p = 0.019). The symptom-free period after primary dislocation was longer in subjects who were immobilised for 4—7 weeks (14 months) compared to subjects immobilised for the shorter period (4 months). Due to the disparities between these studies’ findings and design weaknesses, if traumatic anterior shoulder dislocations are immobilised, it is presently unclear how long they should be immobilised. Does the position of immobilisation affect outcomes after traumatic anterior shoulder dislocation? Historically, the position of immobilisation following traumatic anterior shoulder dislocation has been
Immobilisation following traumatic anterior glenohumeral joint dislocation
with the arm slightly anterior, adducted and internally rotated.2,4,6,14 However, the literature suggests that the efficacy of immobilising in such a position is unproven. Two studies have questioned this position of immobilisation, investigating the effects of immobilisation in external rotation, specifically to aid the healing of Bankart lesions.16,17 The pathoanatomical justification for this is to improve the approximation of torn capsular fibres by placing subscapularis on greater tension, closing the anterior joint cavity, so bringing the labrum back to the gleniod rim.17 Firstly, in Itoi et al.’s17 study, 6 primary and 13 recurrent anterior shoulder dislocations underwent magnetic resonance imaging, with their shoulders in adduction combined with either internal, or external, rotation. On assessment, there was significantly less separation and significantly less displacement of the labrum when the arm was externally rotated, than when internally rotated ( p = 0.0047 and 0.0017). Both the detached area of capsule and the opening angle of the lesion were significantly smaller ( p = 0.0003 and <0.0001) and the detached length significantly shorter ( p < 0.0001) when the arm was externally, compared with internally, rotated. There was no significant difference in these measurements between primary and recurrent dislocations. The authors concluded that shoulders may best be immobilised in external rotation, to approximate Bankart lesions better, than the conventional position of internal rotation. Following these results, Itoi et al.16 undertook a prospective trial, randomly allocating 40 subjects with primary traumatic anterior shoulder dislocations to receive 3 weeks of either conventional immobilisation in adduction and internal rotation, or in adduction and external rotation. When followed up, 30% of the study population immobilised in internal rotation reported a recurrent dislocation, compared to no recurrences in the external rotation group; this was a significant difference ( p = 0.008). When only patients under 30 years old were evaluated, 45% reported recurrent dislocations, compared to none in the external rotation group; this remained a significant difference ( p = 0.011). Fifty-eight percent of the internal rotation group returned to pre-injury sporting activity, compared to 82% in the external rotation group. However, the relatively short follow-up period and small sample size limit the significance of these encouraging findings. Employing a different immobilisation procedure, Ishikawa et al.15 compared the effects of a modified clavicular harness after anterior shoulder
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dislocation, against conventional shoulder immobilisation. All subjects were instructed to wear their ‘immobilisers’ for more than 3 weeks. The harness comprised 2 pads, one over the anterior aspect of the shoulder joint, and the second over the lower anterior part of the joint, covering the anteroinferior part of the glenoid. This seemed to restrict the outer ranges of glenohumeral movement, without limiting any particular direction in inner and mid-ranges. After 1 year, the conventional treatment group reported a recurrence rate of 29%, compared to no reported recurrent dislocations in the harness group. However, the authors acknowledged that 64% of the conventional treatment group failed to wear their bandage for 3 weeks, a factor which may limit the value of this study when comparing the groups. No functional outcomes were measured in this study. Finally, as in Kiviluoto et al.’s19 study, the 1-year follow-up period may have been insufficient to evaluate the rates of recurrent dislocations for these two immobilisation techniques.
Discussion The aim of this literature review was to determine whether traumatic anterior shoulder dislocations should be immobilised; if they should be, then for what period of time; and in what position? This review has presented a number of studies, which suggest that immobilising primary traumatic anterior shoulder dislocations may not be an effective means of preventing recurrent dislocations. It has also been suggested that age may be a greater prognostic factor for the rate of recurrent dislocation than immobilisation. Conversely, papers were identified that found that immobilisation did reduce the rate of recurrent dislocations. However, no consensus could be gleaned on the optimal duration of immobilisation. The majority of the reviewed literature investigated subjects who were immobilised in adduction and internal rotation. Although limited in size, the research assessing the efficacy of immobilising subjects in adduction and external rotation appears promising.16,17 A number of repeated methodological limitations plagued the evidence base. These included: not documenting the duration, position, or compliance of immobilisation; recruiting heterogeneous samples with regard to age and sporting activity; neglecting to document how subjects were selected and not assessing findings against statistical tests. Future research is recommended, employing large, well-controlled, randomised trials.
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Further study is proposed to investigate the efficacy of immobilising shoulder dislocations in external rotation, following the initially favourable findings of Itoi et al.’s.16,17 Their studies should be repeated, recruiting a larger sample size to be assessed over a longer follow-up period. In a similar vein, investigating the effects of immobilising the shoulder in external rotation over different durations may be an area for future study, as well as using functional outcome instruments. The literature suggests that it may be detrimental to immobilise patients over the age of 30 or 40 years following primary traumatic shoulder dislocation.6,19,25 In practice, however, patients over the age of 50 are routinely immobilised in most Orthopaedic and Accident & Emergency departments.7,31 It seems reasonable to encourage early mobilisation in this age-group, since the risk of recurrent dislocation is very low in patients over 50 years of age.25,30 Furthermore, the early restoration of movement could prevent joint stiffness and unnecessary functional constraint.2 Accordingly, it is recommended that clinical practice be reviewed in response to these findings. Patients who engage in physically demanding sporting activities appear to be more susceptible to recurrent shoulder dislocations than sedentary patients.21 The age of the patient on initial dislocation may significantly influence the prognosis for future recurrent dislocations.12,19,21 In response, future investigations, recruiting specific age groups from individual sporting backgrounds, may be particularly pertinent in order to compare the effectiveness of different immobilisation regimens in patients with similar risks, before and after anterior shoulder dislocations. It may be wise to consider a number of factors, which may have influenced the results of this literature review. The sole author selected the identified papers. Although the inclusion and exclusion criteria were strictly adhered to, this process was, to some extent, subjective, potentially introducing selection bias. The methodological design of this review would probably have been improved through the recruitment of additional reviewers, independently assessing the inclusion, or exclusion, of each study. The author was not blinded against the outcomes of the reviewed papers. Consequently, reviewer bias cannot be completely excluded. Similarly, since no attempt was made to identify unpublished studies, this review may have been influenced by publication bias. The majority of the literature search was undertaken using computerised databases. As computer searches may not necessarily be comprehensive,3 it is conceivable that some relevant papers may have been missed by the search strategy.
T.O. Smith
Conclusion This review suggests that, at present, there appears little clarity on whether patients with traumatic primary anterior shoulder dislocations should be immobilised, or, if so, for how long. Similarly, it remains uncertain whether patients should be immobilised in internal, or external, rotation. Much of this uncertainty exists because the present literature is limited by both sample size and by methodological weaknesses. Further study is required to improve the quality of the findings and to develop the evidence base. Following this, the effectiveness of immobilising primary traumatic anterior shoulder dislocation could then be determined with greater conviction.
Conflict of interest statement None.
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