Management of Primary Anterior Shoulder Dislocations Using Immobilization

Abstract

Clinical Question: Does an optimum duration and position of immobilization after primary anterior shoulder dislocation exist for reducing recurrence rates?Data Sources: MEDLINE/PubMed, EMBASE, and Cochrane databases were searched up to December 2009 without limitations. The search terms for all databases used were shoulder AND dislocation and shoulder AND immobilization.Study Selection: Criteria used to include articles were (1) English language, (2) prospective level I or level II studies (according to Journal of Bone & Joint Surgery guidelines), (3) nonoperative management of initial anterior shoulder dislocation, (4) minimum follow-up of 1 year, and (5) rate of recurrent dislocation as a reported outcome.Data Extraction: A standardized evaluation method was used to extract data to allow assessment of methods issues and statistical analysis to determine sources of bias. The primary outcome was the recurrence rate after nonoperative management of anterior shoulder dislocation. Additional data extracted and used in subanalyses included duration and position of immobilization and age at the time of initial dislocation. Data were analyzed to determine associations among groups using 2-tailed Fisher exact tests. For pooled categorical data, relative risk of recurrent dislocation, 95% confidence intervals, and heterogeneity using the I 2 statistic and v 2 tests were calculated for individual studies. The Mantel-Haenszel method was used to combine studies and estimate overall relative risk of recurrent dislocation and 95% confidence intervals. The statistical difference between duration of immobilization and position was determined using z tests for overall effect. Pooled results were presented as forest plots.Main Results: In the initial search of the databases, the authors identified 2083 articles. A total of 9 studies met all of the criteria and were included in this review. In most of the studies, age was a risk factor for recurrence. Patients less than 30 years of age were more likely to sustain a recurrent dislocation than patients more than 30 years of age. In 5 studies (n ¼ 1215), researchers found no difference in recurrence of shoulder dislocation when immobilized in internal rotation (IR) for less than 1 week (41%, 40 of 97) compared with more than 3 weeks (37%, 34 of 93) in patients less than 30 years of age (P ¼ .52). Authors of 3 studies (n ¼ 289) compared the effect of immobilization in IR versus external rotation (ER), and whereas they found no statistical difference, a trend appeared toward reduced recurrence rates in ER but not IR (P ¼ .07). The rate of recurrent dislocation was 40% (25 of 63) in patients treated with IR sling immobilization and 25% (22 of 88) in patients immobilized in ER.Conclusions: Overall, the investigators found that younger age (,30 years) was a predictor of recurrent dislocations, immobilization for more than 1 week did not improve recurrence rates, and an apparent trend existed toward decreased recurrence rates with ER rather than IR. According to the review and meta-analys...

Management of primary anterior shoulder dislocations: a narrative review

“…A meta-analysis found immobilization for longer than 1 week following anterior shoulder dislocation does not improve the risk of recurrence. The same study also demonstrates slightly decreased rates of dislocation recurrence with external rotation immobilization over internal rotation [38]. A 2018 study of 50 patients found that external rotation showed a significant improvement over internal rotation for recurrent dislocations in the 20–40 age subgroup [39].…”

Immobilization in External Rotation Reduces the Risk of Recurrence After Primary Anterior Shoulder Dislocation: A Meta-analysis

“…Several meta-analyses regarding arm immobilization for patients with primary anterior shoulder dislocation have been reported; however, the efficacy of immobilization in ER compared with IR remains controversial. Some meta-analyses demonstrated significant effects of ER immobilization in reducing the recurrence rate, 18,24,32 whereas others demonstrated no significant effect. 3,13,17,36,38 We adopted the literature search method used in a recent meta-analysis.…”

“…Accordingly, several meta-analyses have also been reported, but the conclusions are controversial. Some meta-analyses showed that immobilization in ER was effective in reducing the recurrence rate, 19,24,32 but others reported otherwise. 3,13,17,36,38 Recently, a new RCT was added to the literature.…”

Managing Anterior Shoulder Dislocation

“…However, it is unclear whether 3 weeks is superior to 1 week with respect to the rate of recurrent dislocation. 17,18 Some authors have reported a significantly lower rate of recurrence after the shoulder was immobilized in external rotation, although others found no advantage to external rotation. [17][18][19][20][21] It remains unclear whether this form of immobilization should be routinely recommended because its benefit may be partially offset by the inconvenience to the patient.…”