1、Management of Acute Shoulder Dislocation,An overview Heather Campion Sports Medicine Conference 1/22/08,Incidence,Shoulder is the most commonly dislocated joint Traumatic Dislocations Anterior 96% Posterior 2-4% Diverse group of patients experience dislocations; M and F young and old active and inac
2、tive,Anatomic Consideration,Glenohumeral stabilization mechanisms Passive: joint conformity, vacuum effect, ligamentous and capsular restraints, labrum Active: long head of Biceps and Rotator Cuff Pathoanatomy of shoulder dislocations Bankart Lesion: avulsion of anteroinferior labrum Hill-Sachs Lesi
3、on: posterolateral humeral head defect Assoc. RCT: more common in older patients,Clinical Evaluation,PE: Prominent acromion, sulcus sign, palpable humeral head anteriorly Neuro integrity of axillary and musculcutaneous nerves Apprehension Test: reproduces sense of instability and pain in shoulder re
4、duced prior to exam,Radiographic Evaluation,AP vs true AP Axillary vs Valpeau Axillary Special Views: West Point axillary: for visualization of glenoid rim Hill-Sach view: internal rotation view Stryker Notch: view 90% of posterolateral humeral head,Management,Pre-MedicationReduction ManeuversPost-R
5、eduction Immobilization,Pre-Medication,Methods of Premedication prior to Reduction None Intraarticular Lidocaine IV Sedation Supraclavicular Block Suprascapular Block,IV Sedation vs Intraarticular Lidocaine Injection,Level 1 RCT: Miller et al JBJS 2002 Prospective Randomized study put isolated shoul
6、der dislocation patients (#30) into 2 groups Variety of Outcome Measures: Reduction Success Complications Pain Time to reduce/Time in the ER Cost,IV Sedation vs Intraarticular Lidocaine Injection,No significant difference between: Reduction Success Reduction Time Pain Score Statistical Significance:
7、 Pts tx with intraarticular Lidocaineleft the ER earlier Fewer Complications Lower Cost with Lidocaine,IV Sedation vs Intraarticular Lidocaine Injection,Intra-articular Lidocaine Injection is Preferred over IV Sedation,Reduction Maneuvers,Is there an Ideal Method for Reduction? Over 24 Techniques De
8、scribed Most Common Techniques Kocher (71-100%) External Rotation (78-90%) Milch (70-89%) Stimson (91-96%) Traction/Countertraction Scapular Manipulation (79-96%),Kocher Maneuver,Arm is adducted and flexed at the elbow Externally rotate arm until resistance is felt The ER arm is flexed forward as fa
9、r as possible The arm is internally rotated,External Rotation,Arm aducted to body Forearm flexed to 90 degrees Traction on forearm Gentle and gradual external rotation until reduction,Milcher Technique,Patient is supine One hand on shoulder, with thumb on dislocated humeral head Other arm slowly abd
10、ucts shoulder to overhead position Head is gently pushed over glenoid rim to reduce dislocated shoulder,Stimson Technique,Patient is supine Affected arm hanging down over the edge 10 lbs weight applied to wrist Wait for relaxation and auto-reduction,Traction/Countertraction,Arm in some abductionTrac
11、tion applied to armAssistant applies firm counter-traction with sheet across the body,Scapular Manipulation,Patient is prone Shoulder flexed to 90 degrees hanging with elbow flexed and humerus in external rotation 5-15lbs of traction on arm One hand on superior scapula pushing laterally Other hand o
12、n inferior angle pushing medially,Milch vs Kocher,RCT (Beattie 1986) Randomization by date 111 patients No premedication Outcome: Successful Reduction Results: No difference in manuever for successful reduction,Is there a best Reduction Maneuver?,Unknown: More Research Needed Recommend learning thre
13、e techniques and gaining experience with them each,Post-Reduction Immobilization,Is immobilization necessary? What Method is Best?,Does immobilization reduce recurrence?,Level I RCT: Hovelius JBJS 2008 Prospective multi-center study 257 primary anterior shoulder dislocations 25 year follow up Result
14、s:Immobilization for 3-4 weeks after shoulder dislocation does NOT change the prognosis compared with immediate mobilization,Internal vs External Rotation,Level II RCT: Itoi JBJS 2007 Basis: MRI has shown that coaptation of the Bankart lesion is better with the arm in ER than in IR Thought: If the B
15、ankart heals recurrence is less likely 198 primary shoulder dislocations randomized to ER or IR immobilization for 3 weeks Followed for a minimum of 2 years Level 2: low compliance, instructional bias, short f/u,Internal vs External Rotation,Level II RCT: Itoi JBJS 2007 ER for 3 weeks Recurrence rate: 32% IR for 3 weeks Recurrence rate: 60% P = 0.007,Conclusion,Premedicate with Intraarticular LidocaineLearn multiple reduction maneuversIf you decide to immobilize, immobilize in ER,Thanks,
