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

Clinical Orthopaedics and Related Research® volume 472, pages 2380–2386 (2014)Cite this article

A CORR Insights to this article was published on 01 February 2014

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.

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Acknowledgments

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

Author information

Authors and Affiliations

  1. Department of Surgery, St Michael’s Hospital and University of Toronto, 55 Queen Street East (800), Toronto, ON, M5C 1R6, Canada

    Daniel B. Whelan MD, MSc

  2. Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, ON, Canada

    Robert Litchfield MD

  3. London Health Sciences Centre, London, ON, Canada

    Elizabeth Wambolt BSc(HK), CCRP

  4. Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON, Canada

    Katie N. Dainty PhD

Authors
  1. Daniel B. Whelan MD, MSc
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  2. Robert Litchfield MD
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  3. Elizabeth Wambolt BSc(HK), CCRP
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  4. Katie N. Dainty PhD
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Consortia

in conjunction with the Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS)

Corresponding author

Correspondence to Daniel B. Whelan MD, MSc.

Additional information

This trial was funded by the Physicians Services Incorporated Foundation and the American Shoulder and Elbow Surgeons Grant.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This study was conducted at the Fowler Kennedy Sport Medicine Clinic in London, Ontario, Canada, in conjunction with JOINTS Canada (Joint Orthopaedic Initiative for National Trials on the Shoulder Canada).

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Whelan, D.B., Litchfield, R., Wambolt, E. et al. External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial. Clin Orthop Relat Res 472, 2380–2386 (2014). https://doi.org/10.1007/s11999-013-3432-6

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  • DOI: https://doi.org/10.1007/s11999-013-3432-6

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