1. Acute Traumatic First-time Anterior Shoulder Dislocation : Post-reduction and Rehabilitation (EBM Appraisal)
Nadhaporn Saengpetch
Division of Sports Medicine,
Department of Orthopaedics,
Faculty of Medicine Ramathibodi Hospital
Mahidol University

2. Strong (1) recommendation/ Weak (2) recommendation/
Grade
Strong (1) recommendation/
Quality evidence
Weak (2) recommendation/
High (A)
Moderate (B)
Low (C)
Very-low (D)

3. The Points of View Immobilization techniques
Duration of immobilization
Post-reduction rehabilitation
Functional outcomes and risk factors

4. …Like other surgeons, we love to operate and feel that we can “fix” almost anyone. It takes restraint to allow the natural history of shoulder instability to play out….
Raymond A. Sachs, MD, Southern California Permanente Medical Group, El Cajon, CA

5. Immobilization Techniques

6. Sling VS No-sling questionable benefit
no difference in the recurrence rate and did not change the prognosis

7. N=257
Sling immobilization (the torso bandage) 3-4 weeks VS early motion
25-year follow-up
DASH questionnaire + x-ray both shoulders
Recurrence, GT fracture, age, activity, gender, contralateral dislocation

8. Recurrence occurred in the first 15 years
Become stable overtime (stabilized spontaneously) in the last 10 years
Immobilization after the primary dislocation did not change the prognosis
Prognostic Level 1
Weak recommendation, high-quality evidence
(Hovelius L J Bone Joint Surg Am 2008;90:945-52)

9. Types of Sling
Better coaptation of the Bankart lesion with the shoulder in external rotation than internal rotation
(Itoi E JBJS Am 2001;83(5): 661-7)

10. Evaluation 4 commercial braces which maintain in external rotation
Healthy subjects
Initial external rotation measurement, simulated ADL, reapplication of brace, rate of the comfort

11. (Sullivan LG Arthroscopy 2007;23(2):129-34)
Rigid orthoses were most successful
dj Ultrasling ER: the most comfortable
No brace was successful in achieving its anticipated degree of external rotation
Therapeutic Level IV
Weak recommendation, moderate quality evidence
$82
$52
$405
$284
(Sullivan LG Arthroscopy 2007;23(2):129-34)

12. Position: cadaver 10 human cadaveric shoulders
Measuring contact force between the labrum and the glenoid
Humeral arc of rotation from IR 60º-neutral-ER 45º

13. No contact force with the arm in IR
Forces increased as the arm passed to neutral and reached a maximum at ER 45º (83.5g)
ER significantly increased the labrum-glenoid contact force and may influence the healing of a Bankart lesion
Prognostic Level IV
Weak recommendation, low quality of evidence
(Miller BS J Shoulder Elbow Surg 2004;13:589-92)

14. Position: MRI 19 shoulders (first time=6, recur=13)
Plain MRI: fast-spin-echo T2 weighted axial images
MR arthrography: spin-echo T1 weighted axial images
Assessed the coaptation by measurement of the detached area, opening angle and detached length

15. D and S were both lesser with ER than IR
A detached area, angle and length were significantly lesser with ER
Displacement & separation
Detached area, angle & length

16. (Itoi E J Bone Joint Surg Am 2001; 83(5):661-7)
ER immobilization better approximates the Bankart lesion to the glenoid neck than does the conventional
Prognostic Level I
Weak recommendation, high quality of evidence
(Itoi E J Bone Joint Surg Am 2001; 83(5):661-7)

17. Position 159 shoulders (ER=85, IR=74)
Immobilized for 3 weeks, F/U >2 yrs
Recurrent rate, compliance, return to sports, complication
Subgroup analysis: younger pts (<30 yrs) with early immobilization had significantly lower recurrence rate

18. Weak recommendation, moderate quality of evidence
ER immobilization had lesser recurrence rate (esp. perform in day1), return to pre-injury sports activity level, better compliance
ER immobilization reduces the risk of recurrence and particularly beneficial for pts < 30 yrs old
Therapeutic Level II
Weak recommendation, moderate quality of evidence
(Itoi E J Bone Joint Surg Am 2007;89: )

19. AlcareTM, Tokyo, Japan

20. Duration of Immobilization

21. Fact The Bankart lesion has an ability to heal
Controversial for duration of immobilization
Position is more important than duration

22. 216 pts, prospective study 2 yrs
Sling/swathe 3-4 wks/sling 1-3 wks/sling 1 wk + avoid ABER 3 wks
Age group (<22, 23-29,30-40), recurrence rate, associated fractures

23. Recurrence depends on age more than duration of immobilization
Recurrence varied in 3 age groups but did not vary according to methods
Recurrence depends on age more than duration of immobilization
Prognostic Level II
Strong recommendation, moderate quality of evidence
(Hovelius L J Bone Joint Surg Am 1983;65: 343-9)

24. Post-reduction Protocol

25. Physiotherapy
Shoulder muscles contribute to both mobility and stability of the joint
Instability is specific to certain end-range positions
To improve treatment, we should focus the contribution of the muscles to glenohumeral joint stability in clinically relevant position.

26. Concavity-compression Mechanism
Compression of the humeral head against the concave glenoid allows concentric rotation of the humeral head on the glenoid
Mid range: Muscles may be the primary stabilizers of the shoulder joint while the capsuloligamentous structures are lax
End range: Muscles act to protect the capsuloligamentous structures by limit the joints motion & decrease strain in these structures

27. The area of the glenoid’s articular surface available for humeral head compression
The angle between of the center of the glenoid and the end of the effective glenoid arc

28. Shoulder Muscle and Glenohumeral Stability
50% decrease in the rotator cuff muscle % increase displacement of the head in all joint positions
(Wuelker N J Shoulder Elbow Surg 1998;7:43-52)
Deltoids and pectoralis major decrease stability of the shoulder joint
Bench-press: anterior deltoid and p. major spasm and led to dislocate
(Arciero RA J Shoulder Elbow Surg 1997;6:318-20)

29. Shoulder Muscles Training
To determine the effect of increasing magnitude of individual muscle forces on the line of resultant forces
Lines of action were less anteriorly directed when magnitude of SST, IST or TMi were increased, tending to improve the stability
(Labriola JE J Shoulder Elbow Surg
2004;14(1S):32S-38S)

30. In end-range: simulated in RC forces tended to improve stability whereas increased deltoid or p. major tended to decrease stability
Therapeutic Level IV
Strong recommendation, moderate quality of evidence

31. Modality Uses 30 in-season athletes (first time =21)
Early mobilization, physical therapy and bracing
26/30 returned to their sports for the complete season at 10.2 days
Average 1.4 recur episodes/season/pts

32. Range of motion exercises
wand exercises, strengthening the RC with free-weight
Periscapular strengthening

33. Strong recommendation, very poor quality of evidence
Duke Wyre Brace
Sully Brace
This conservative treatment can be effective option of young athletes who need to their sports in-season
Therapeutic Level IV
Strong recommendation, very poor quality of evidence
(Buss DD Am J Sports Med 2004;32(6): )

34. Prognostic Factors

35. Prognostic Factors
Subcoracoid is a worse prognosis compare to axillary dislocation
Age on first-time dislocation
Associated disruption of soft-tissue envelope or osseous restraints
(Hovelius L J Bone Joint Surg Am 2008;90:945-52)

36. 538 pts, prospective observational cohort study, follow-up 3 yrs
3.2% sustained early redislocation within 6 wks
High energy injury(13.7), neurologic deficit(2.0), large RC tear(29.8), glenoid rim(7.0)/GT fracture(33.5)

37. Strong recommendation, moderate quality of evidence
First-time dislocators who have severe disruption of RC (tear) or fracture of glenoid/humeral head is high risk for redislocation
Prognostic Level III
Strong recommendation, moderate quality of evidence
(Robinson CM J Bone Joint Surg Am 2002;84:1552-9)

38. Conclusion
Immobilization: many evidence suggested that conventional position could not reach the best anatomic healing
immobilization in ER is more hazardous and awkward for people
need a good quality RCT study and independent investigators for ER/IR immobilization

39. Conclusion
Duration: inconclusive for exact time of immobilization but shorter period is preferable
Post-reduction: selective shoulder muscles training is advisable

40. Thank you