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Recurrence of shoulder dislocation reduced by immobilization in external rotation with abduction

Clinical Question:
Does immobilization of the shoulder in external rotation with abduction decrease recurrence after a primary anterior shoulder dislocation?

Bottom Line:
Immobilization in external rotation with abduction significantly decreases recurrence of primary anterior shoulder dislocation compared with immobilization with a conventional sling in adduction with internal rotation. Noncompliance, however, is significantly increased among patients using this new method: approximately 1 in 5 will inappropriately remove the brace at least once during a 3-week treatment period. (LOE = 1b-)

Reference:
Heidari K, Asadollahi S, Vafaee R, et al. Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation. J Shoulder Elbow Surg 2014:23(6):759-766.  [PMID:24725898]

Study Design:
Randomized controlled trial (single-blinded)

Funding:
Foundation

Allocation:
Uncertain

Setting:
Emergency department

Synopsis:
Recurrent dislocation rates following conventional nonsurgical methods of sling stabilization for primary anterior shoulder dislocation are 33% to 83%. These investigators enrolled consecutive patients (N = 102), aged 15 years to 55 years, who presented to the emergency department of a university-affiliated hospital with primary anterior shoulder dislocation within 6 hours of an injury. After manual reduction of the dislocation, eligible patients randomly received assignment (uncertain allocation) to 3 weeks of immobilization in either abduction and external rotation (AbER) or traditional adduction and internal rotation (AdIR). Patients in the traditional AdIR group were immobilized with sling and swathe bandage. A complex stabilizer brace was used for the AbER group, which immobilized the arm at 15? abduction and 10? external rotation. All patients underwent radiographic and neurovascular examination before and after manual reduction. After 3 weeks both groups underwent identical physical therapy rehabilitation. The authors do not state whether interviewers who assessed functional outcomes remained masked to treatment group assignment. Complete follow-up occurred for 95% of patients at 33 months. Using both intention-to-treat and per-protocol analyses yielded similar results: Recurrent dislocation occurred significantly more often in the traditional AdIR group than in the AbER group (33.3% vs 3.9%, respectively; number needed to treat = 3.4; 95% CI, 2.3-6.8). Improvement in physical functioning—including sports, recreation, and work—was measured using a valid scoring tool, which demonstrated a significant improvement difference between the AbER group and the traditional AdIR group (mean = 187.72 vs 230.92, respectively, where 0 represents no deficit and 2100 represents the worst deficit). Compliance was defined as wearing the brace at all times, except when showering, for 3 weeks. Noncompliance was significantly higher in the experimental AbER group (19.6%) than in the traditional AdIR group (5.8%), with the main complaint being that the brace made it difficult to sleep and awkward to maneuver through doors. Gabrielle Johnson, MD; Faculty Development Fellow, Department of Family Medicine, University of Virginia, Charlottesville, VA.

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