External rotation immobilization reduces risk of recurrence after shoulder dislocation .
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2013;1(11):232 J Bone Joint Surg Am. 2007 Oct;89(10):2124-31198 patients with an initial anterior shoulder dislocation were randomized to receive one of two immobilization treatments for a period of 3 weeks. One group had their arm immobilized in the conventional internal rotation position while the other group had their arm immobilized in the external rotation position. The primary outcomes examined were recurrence of dislocation or subluxation. Results indicated that external rotation immobilization at 10 degrees had a lower risk of recurrence compared to internal rotation immobilization. Patients under 30 years old also showed particularly more benefit.
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
3/4
Randomization
3/4
Outcome Measurements
2/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
The shoulder is one of the most common locations for dislocations and higher rates of recurrence seem to appear in younger patients. A high percentage of individuals with an initial anterior shoulder dislocation face recurrence of injury when the arm is immobilized in an internal rotation position. Cadaver studies and MRI imaging has shown that anterior shoulder dislocation (particularly the Bankart lesion) may heal better when immobilized in an external rotation position. This study examines the outcomes of shoulder immobilization in external rotation compared to internal rotation as part of anterior shoulder dislocation treatment.
What was the principal research question?
What are the risks of recurrence when external rotation immobilization of the shoulder is applied compared to internal rotation immobilization in the treatment of an initial anterior shoulder dislocation?
- The external rotation group had a recurrence rate of 26% (22/85) which was significantly lower than the internal rotation group which had a recurrence rate of 42% (31/74). (p=0.033)
- The external rotation group had a relative risk reduction of 38.2% and an absolute risk reduction of 16.0%.
- The group of patients under 30 years old had a relative risk reduction of 46.1%.
- The internal rotation group had a compliance rate of 53% (39/74) compared to the external rotation group which had a compliance rate of 72% (61/85). (p=0.013)
- 7% (6/85) patients had a minor complication of temporary stiffness that was resolved with self-directed range of motion exercises. No other complications were reported.
- The external rotation group had a significantly lower rate of recurrence when immobilization was started on the day of dislocation.
What should I remember most?
Patients who had their arm immobilized in an external rotation (10 degrees) position for 3 weeks had a lower risk of recurrence compared to those who were immobilized in the internal rotation position. Patients under 30 years old appeared to have particularly more benefit from this treatment. The author also suggests that earlier mobilization may lead to better results.
How will this affect the care of my patients?
Patients undergoing an external rotation immobilization treatment for an initial anterior shoulder dislocation may have lower risks of recurrence compared to undergoing internal rotation immobilization - particularly in patients under 30 years old. Further studies are required to determine the optimal position and duration for external rotation immobilization.
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