Presentation is loading. Please wait.

Presentation is loading. Please wait.

Management of Acute Shoulder Dislocation An overview Heather Campion Sports Medicine Conference 1/22/08.

Similar presentations


Presentation on theme: "Management of Acute Shoulder Dislocation An overview Heather Campion Sports Medicine Conference 1/22/08."— Presentation transcript:

1 Management of Acute Shoulder Dislocation An overview Heather Campion Sports Medicine Conference 1/22/08

2 Incidence Shoulder is the most commonly dislocated joint Shoulder is the most commonly dislocated joint Traumatic Dislocations Traumatic Dislocations Anterior 96% Anterior 96% Posterior 2-4% Posterior 2-4% Diverse group of patients experience dislocations; Diverse group of patients experience dislocations; M and F M and F young and old young and old active and inactive active and inactive

3 Anatomic Consideration Glenohumeral stabilization mechanisms Glenohumeral stabilization mechanisms Passive: joint conformity, vacuum effect, ligamentous and capsular restraints, labrum Passive: joint conformity, vacuum effect, ligamentous and capsular restraints, labrum Active: long head of Biceps and Rotator Cuff Active: long head of Biceps and Rotator Cuff Pathoanatomy of shoulder dislocations Pathoanatomy of shoulder dislocations Bankart Lesion: avulsion of anteroinferior labrum Bankart Lesion: avulsion of anteroinferior labrum Hill-Sachs Lesion: posterolateral humeral head defect Hill-Sachs Lesion: posterolateral humeral head defect Assoc. RCT: more common in older patients Assoc. RCT: more common in older patients

4 Clinical Evaluation PE: PE: Prominent acromion, sulcus sign, palpable humeral head anteriorly Prominent acromion, sulcus sign, palpable humeral head anteriorly Neuro integrity of axillary and musculcutaneous nerves Neuro integrity of axillary and musculcutaneous nerves Apprehension Test: reproduces sense of instability and pain in shoulder reduced prior to exam Apprehension Test: reproduces sense of instability and pain in shoulder reduced prior to exam

5 Radiographic Evaluation AP vs true AP AP vs true AP Axillary vs Valpeau Axillary Axillary vs Valpeau Axillary Special Views: Special Views: West Point axillary: for visualization of glenoid rim West Point axillary: for visualization of glenoid rim Hill-Sach view: internal rotation view Hill-Sach view: internal rotation view Stryker Notch: view 90% of posterolateral humeral head Stryker Notch: view 90% of posterolateral humeral head

6 Management Pre-Medication Pre-Medication Reduction Maneuvers Reduction Maneuvers Post-Reduction Immobilization Post-Reduction Immobilization

7 Pre-Medication Methods of Premedication prior to Reduction Methods of Premedication prior to Reduction None None Intraarticular Lidocaine Intraarticular Lidocaine IV Sedation IV Sedation Supraclavicular Block Supraclavicular Block Suprascapular Block Suprascapular Block

8 IV Sedation vs Intraarticular Lidocaine Injection Level 1 RCT: Miller et al JBJS 2002 Level 1 RCT: Miller et al JBJS 2002 Prospective Randomized study put isolated shoulder dislocation patients (#30) into 2 groups Prospective Randomized study put isolated shoulder dislocation patients (#30) into 2 groups Variety of Outcome Measures: Variety of Outcome Measures: Reduction Success Reduction Success Complications Complications Pain Pain Time to reduce/Time in the ER Time to reduce/Time in the ER Cost Cost

9 IV Sedation vs Intraarticular Lidocaine Injection No significant difference between: No significant difference between: Reduction Success Reduction Success Reduction Time Reduction Time Pain Score Pain Score Statistical Significance: Statistical Significance: Pts tx with intraarticular Lidocaine Pts tx with intraarticular Lidocaine left the ER earlier left the ER earlier Fewer Complications Fewer Complications Lower Cost with Lidocaine Lower Cost with Lidocaine

10 IV Sedation vs Intraarticular Lidocaine Injection Intra-articular Lidocaine Injection is Preferred over IV Sedation

11 Reduction Maneuvers Is there an Ideal Method for Reduction? Is there an Ideal Method for Reduction? Over 24 Techniques Described Over 24 Techniques Described Most Common Techniques Most Common Techniques Kocher (71-100%) Kocher (71-100%) External Rotation (78-90%) External Rotation (78-90%) Milch (70-89%) Milch (70-89%) Stimson (91-96%) Stimson (91-96%) Traction/Countertraction Traction/Countertraction Scapular Manipulation (79-96%) Scapular Manipulation (79-96%)

12 Kocher Maneuver Arm is adducted and flexed at the elbow Arm is adducted and flexed at the elbow Externally rotate arm until resistance is felt Externally rotate arm until resistance is felt The ER arm is flexed forward as far as possible The ER arm is flexed forward as far as possible The arm is internally rotated The arm is internally rotated

13 External Rotation Arm aducted to body Arm aducted to body Forearm flexed to 90 degrees Forearm flexed to 90 degrees Traction on forearm Traction on forearm Gentle and gradual external rotation until reduction Gentle and gradual external rotation until reduction

14 Milcher Technique Patient is supine Patient is supine One hand on shoulder, with thumb on dislocated humeral head One hand on shoulder, with thumb on dislocated humeral head Other arm slowly abducts shoulder to overhead position Other arm slowly abducts shoulder to overhead position Head is gently pushed over glenoid rim to reduce dislocated shoulder Head is gently pushed over glenoid rim to reduce dislocated shoulder

15 Stimson Technique Patient is supine Patient is supine Affected arm hanging down over the edge Affected arm hanging down over the edge 10 lbs weight applied to wrist 10 lbs weight applied to wrist Wait for relaxation and auto-reduction Wait for relaxation and auto-reduction

16 Traction/Countertraction Arm in some abduction Arm in some abduction Traction applied to arm Traction applied to arm Assistant applies firm counter-traction with sheet across the body Assistant applies firm counter-traction with sheet across the body

17 Scapular Manipulation Patient is prone Patient is prone Shoulder flexed to 90 degrees hanging with elbow flexed and humerus in external rotation Shoulder flexed to 90 degrees hanging with elbow flexed and humerus in external rotation 5-15lbs of traction on arm 5-15lbs of traction on arm One hand on superior scapula pushing laterally One hand on superior scapula pushing laterally Other hand on inferior angle pushing medially Other hand on inferior angle pushing medially

18 Milch vs Kocher RCT (Beattie 1986) RCT (Beattie 1986) Randomization by date Randomization by date 111 patients 111 patients No premedication No premedication Outcome: Successful Reduction Outcome: Successful Reduction Results: No difference in manuever for successful reduction Results: No difference in manuever for successful reduction

19 Is there a best Reduction Maneuver? Unknown: More Research Needed Unknown: More Research Needed Recommend learning three techniques and gaining experience with them each Recommend learning three techniques and gaining experience with them each

20 Post-Reduction Immobilization Is immobilization necessary? Is immobilization necessary? What Method What Method is Best? is Best?

21 Does immobilization reduce recurrence? Level I RCT: Hovelius JBJS 2008 Level I RCT: Hovelius JBJS 2008 Prospective multi-center study Prospective multi-center study 257 primary anterior shoulder dislocations 257 primary anterior shoulder dislocations 25 year follow up 25 year follow up Results: Results: Immobilization for 3-4 weeks after shoulder dislocation does NOT change the prognosis compared with immediate mobilization Immobilization for 3-4 weeks after shoulder dislocation does NOT change the prognosis compared with immediate mobilization

22 Internal vs External Rotation Level II RCT: Itoi JBJS 2007 Level II RCT: Itoi JBJS 2007 Basis: MRI has shown that coaptation of the Bankart lesion is better with the arm in ER than in IR Basis: MRI has shown that coaptation of the Bankart lesion is better with the arm in ER than in IR Thought: If the Bankart heals recurrence is less likely Thought: If the Bankart heals recurrence is less likely 198 primary shoulder dislocations randomized to ER or IR immobilization for 3 weeks 198 primary shoulder dislocations randomized to ER or IR immobilization for 3 weeks Followed for a minimum of 2 years Followed for a minimum of 2 years Level 2: low compliance, instructional bias, short f/u Level 2: low compliance, instructional bias, short f/u

23 Internal vs External Rotation Level II RCT: Itoi JBJS 2007 Level II RCT: Itoi JBJS 2007 ER for 3 weeks ER for 3 weeks Recurrence rate: 32% Recurrence rate: 32% IR for 3 weeks IR for 3 weeks Recurrence rate: 60% Recurrence rate: 60% P = P = 0.007

24 Conclusion Premedicate with Intraarticular Lidocaine Premedicate with Intraarticular Lidocaine Learn multiple reduction maneuvers Learn multiple reduction maneuvers If you decide to immobilize, immobilize in ER If you decide to immobilize, immobilize in ER

25 Thanks


Download ppt "Management of Acute Shoulder Dislocation An overview Heather Campion Sports Medicine Conference 1/22/08."

Similar presentations


Ads by Google