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Clinical Orthopaedics and Related Research®

, Volume 472, Issue 8, pp 2380–2386 | Cite as

External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial

  • Daniel B. Whelan
  • Robert Litchfield
  • Elizabeth Wambolt
  • Katie N. Dainty
  • in conjunction with the Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS)
Symposium: Complex Issues in Glenohumeral Instability

Abstract

Background

The traditional treatment for primary anterior shoulder dislocations has been immobilization in a sling with the arm in a position of adduction and internal rotation. However, recent basic science and clinical data have suggested recurrent instability may be reduced with immobilization in external rotation after primary shoulder dislocation.

Questions/purposes

We performed a randomized controlled trial to compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients.

Methods

Sixty patients younger than 35 years of age with primary, traumatic, anterior shoulder dislocations were randomized (concealed, computer-generated) to immobilization with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean of 4 days after closed reduction (range, 1–7 days). Patients with large bony lesions or polytrauma were excluded. The two groups were similar at baseline. Both groups were immobilized for 4 weeks with identical therapy protocols thereafter. Blinded assessments were completed by independent observers for a minimum of 12 months (mean, 25 months; range, 12–43 months). Recurrent instability was defined as a second documented anterior dislocation or multiple episodes of shoulder subluxation severe enough for the patient to request surgical stabilization. Validated disease-specific quality-of-life data (Western Ontario Shoulder Instability index [WOSI], American Shoulder and Elbow Surgeons evaluation [ASES]) were also collected. Ten patients (17%, five from each group) were lost to followup. Reported compliance with immobilization in both groups was excellent (80%).

Results

With the numbers available, there was no difference in the rate of recurrent instability between groups: 10 of 27 patients (37%) with the external rotation brace versus 10 of 25 patients (40%) with the sling redislocated or developed symptomatic recurrent instability (p = 0.41). WOSI scores were not different between groups (p = 0.74) and, although the difference in ASES scores approached statistical significance (p = 0.05), the magnitude of this difference was small and of uncertain clinical importance.

Conclusions

Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Further studies with larger numbers may elucidate whether functional outcomes, compliance, or comfort with immobilization can be improved with this device.

Level of Evidence

Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Keywords

Internal Rotation External Rotation Shoulder Dislocation Recurrent Dislocation Recurrent Instability 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

We would like to acknowledge the contributions of Professor Michael McKee FRCS(C), in obtaining funding for this research.

References

  1. 1.
    Bulbena A, Duro JC, Porta M, Faus S, Vallescar R, Martin-Santos R. Clinical assessment of hypermobility of joints: assembling criteria. J Rheum. 1992;19:115–122.PubMedGoogle Scholar
  2. 2.
    Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I, Kobayashi M. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg. 2003;12:413–416.PubMedCrossRefGoogle Scholar
  3. 3.
    Itoi E, Hatakeyama Y, Sato T, Kido T, Minagawa H, Yamamoto N, Wakabayashi I, Nozaka K. Immobilization in external rotation after shoulder dislocation reduces risk of recurrence: a randomized controlled trial. J Bone Joint Surg Am. 2007;89:2124–2131.PubMedCrossRefGoogle Scholar
  4. 4.
    Kirkley A, Griffin S, Dainty K. Scoring systems for the functional assessment of the shoulder. Arthroscopy. 2003;19:1109–1120.PubMedCrossRefGoogle Scholar
  5. 5.
    Kirkley A, Griffin S, McLintock H, Ng L. The development and evaluation of a disease specific quality of life measurement tool for shoulder instability: the Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med. 1998;26:764–772.PubMedGoogle Scholar
  6. 6.
    Kirkley A, Griffin S, Richards C, Miniaci A, Mohtadi N. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocation of the shoulder. Arthroscopy. 1999;15:507–514.PubMedCrossRefGoogle Scholar
  7. 7.
    Liavaag S, Brox JI, Pripp AH, Enger M, Soldal LA, Svenningsen S. Immobilization in external rotation after primary dislocation did not reduce the risk of recurrence. J Bone Joint Surg Am. 2011;93:897–904.PubMedCrossRefGoogle Scholar
  8. 8.
    Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11:587–594.PubMedCrossRefGoogle Scholar
  9. 9.
    Rowe C. Prognosis in dislocations of the shoulder. J Shoulder Elbow Surg. 1956;38:957–977.Google Scholar
  10. 10.
    Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med. 1984;12:19–21.PubMedCrossRefGoogle Scholar
  11. 11.
    Zachilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010;92:542–549.CrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Daniel B. Whelan
    • 1
  • Robert Litchfield
    • 2
  • Elizabeth Wambolt
    • 3
  • Katie N. Dainty
    • 4
  • in conjunction with the Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS)
  1. 1.Department of SurgerySt Michael’s Hospital and University of TorontoTorontoCanada
  2. 2.Fowler Kennedy Sport Medicine ClinicUniversity of Western OntarioLondonCanada
  3. 3.London Health Sciences CentreLondonCanada
  4. 4.Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada

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