Duration and Position of Immobilization for Patients with Primary Traumatic Anterior Shoulder Dislocation.
Date First Published:
December 3, 2013
Last Updated:
December 9, 2013
Report by:
Stephen Houmes, Medical Student (University of Washington School of Medicine)
Three-Part Question:
In an [adult with first time traumatic anterior shoulder dislocation], what is the appropriate [duration and position of immobilization] for [decreasing the rate of recurrent shoulder dislocation]?
Clinical Scenario:
A 25 year old female presents to the emergency department after falling from her bicycle on to her left shoulder. After x-ray and physical exam, she is determined to have sustained an uncomplicated anterior shoulder dislocation and undergoes closed reduction. She has no prior history of shoulder dislocation. You wonder how long her shoulder should be immobilized, and whether you should place her shoulder in external or internal rotation.
Search Strategy:
PubMed search using the MeSH interface. ((("Shoulder Dislocation"[Mesh]) AND "Immobilization"[Mesh] AND "External") LIMIT English Language
Outcome:
32 papers were returned of which 6 papers, Level II evidence or higher, were found relevant to the question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence Liavaag, S., Brox, J., Pripp, H., Enger, M., Soldal, L., and Svenningsen, S. 2011 Norway | 188 patients stratified by age 16-24yrs or 25-49yrs with primary anterior traumatic dislocation randomly assigned to immobilization in either internal or external rotation | Randomized Controlled Trial | Recurrent shoulder dislocation | Of 23 of 93 (24.7%) internal rotation group, and 28 of 91 (30.8%) external rotation report recurent dislocation at >2 years follow up | Limit to age 40 years; Glenohumeral fracture results in exclusion; Self Report Questionnaire Follow-up |
| Compliance with treatment | Internal rotation group 47.4%, External rotation group 67.7% with treatment of 3 weeks | ||||
| Recurrent shoulder dislocation - Age stratified | Age 16-22: 32 of 63 patients; Age 23-29: 13 of 51 patients; Age 30 to 40: 6 of 70 patients report recurrence of dislocation with no significant difference between internal and external rotation groups | ||||
| Immobilization of the shoulder in external rotation for prevention of recurrence in acute anterior dislocation Taskoparan, H., Tunay, S., Kilincoglu, V., Bilgic, S., Yrttas, Y., and Komurcu, M 2010 Turkey | 33 patients (31 male). 21 of 33 were between 21 and 30 years of age with acute primary traumatic anterior shoulder dislocation assessed for functionality at 6 months and mean exam at 20.8 months. | Randomized Controlled Trial | Recurrent shoulder dislocation | Recurrent dislocations reported in 1 of 16 patients in external rotation group and 5 of 17 in internal rotation group | Predominantly male cohort; Compliance with treatment not assessed; Follow-up not clearly reported; Small sample size |
| Rowe and Constant-Murlay functionality scores at 6 months | No significant difference in scores between patients assigned to internal and external rotation groups | ||||
| Position and duration of immobilization after primary anterior dislocation: a systematic review and meta-analysis of the literature Paterson, W., Throckmorton, T., Koester, M., Azar, F., and Kuhn, J. 2010 USA | Pooled patient data in patients 30 years old or less placed in internal rotation for <1 week or >3 weeks. 1 week (n=97), 3 weeks (n=93) Pooled patient data in patients placed in internal or external rotation sling immobilization. Internal (n=63) and external (n=88) rotation. |
Systematic Review and Meta-Analysis | Recurrent shoulder dislocation with duration of internal immobilization | Patients <30 years of age show recurrent instability in 40 of 97 (41%) patients immobilized in internal rotation for 1 week or less. 34 of 93 (37%) patients immobilized in internal rotation for 3 weeks or longer experienced recurrent shoulder instability | No age stratification |
| Recurrent shoulder dislocation with position of immobilization | Pooled data of 3 studies in patients immobilized in external and internal rotation show that 25 of 63 (40%) of internal and 22 of 88 (25%) of external rotation patients experienced shoulder instability | ||||
| Bracing in external rotation for traumatic anterior dislocation of the shoulder Finestrone, A., Milgrom, C., Radeva-Petrova, D.R., Rath, E., Barchilon, V,. Beyth, S., Jaber, S., and Safran, O 2009 Israel | 51 male patients with primary traumatic anterior dislocation of shoulder randomly assigned to internal vs. external rotation | Randomized Controlled Trial | Recurrent shoulder dislocation | 37% of patients assigned to external rotation and 41.7% assigned to internal rotation sustained further dislocation with average follow up 33.4 months post injury. (p = 0.74). | Low generalizability. Limited to all male patient cohort between ages 17 and 27; Motor vehicle accident or associated glenohumeral fracture exclusion |
| How long should acute anterior dislocations of the shoulder be immobilized in external rotation Scheibel, M., Kuke, A., Nikulka, C., Magasch, P., Ziesler, O., and Schroeder, J 2009 Germany | 22 patients with traumatic anteroinferior dislocation of shoulder | Cohort Study | Coaptation of anteroinferior labrum by MRI visualisation after position and duration of external rotation(3 vs. 5 weeks) | No statistic differences found between internal, neutral, moderate external and maximal external rotation on MRI following 3 vs. 5 weeks of immobilization in external rotation | Small sample size; Significant age disparity between group assignment |
| Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence: A randomized controlled trial Itoi, E., Hatakeyama, Y., Sato, T., Kido, T., Minagawa, H., Yamamoto, N., Wakabayashi, I., and Nozaka, K 2007 Japan | 188 patients with anterior dislocation of the shoulder assigned to internal (n=94) or external(n=104) rotation for 3 weeks with minimum 2 year follow up | Randomized Controlled Trial | Recurrent dislocation or subluxation | 79% follow-up rate. Recurrence rate in internal rotation group is 31 of 74 (42%) and external rotation group 22 of 85 (26%) and reported RRR of 32%. | Limited to patients age 30 and younger |
| Compliance with treatment | 79% compliance in internal rotation group and 82% compliance in external rotation group |
Author Commentary:
Classic teaching for treatment of uncomplicated primary anterior shoulder dislocation include closed reduction followed by immobilization for 3 weeks in a shoulder sling, often in internal rotation. Sustaining an anterior shoulder dislocation significantly increases the risk of recurrent dislocations, specifically in the 30 year and younger age group. Data in the 1990’s led primarily by Itoi et al suggested that healing of associated labrum injuries might be improved if shoulder is immobilized in external rotation, providing better coaptation of the lesion and increasing shoulder stability. Earlier BETs were completed with preliminary data or with short follow-up time. The studies listed all include a minimum follow-up time of one year. The data presented suggests there may be some benefit of immobilization in external rotation for patients age 30 or younger with primary traumatic anterior shoulder dislocation.
Bottom Line:
At least one to three weeks of immobilization is recommended in patients with primary anterior dislocation. Duration should be catered to patient comfort and preference. Some evidence that immobilization in external rotation for up to 3 weeks from time of injury appears to decrease rates of recurrent dislocation in patients under 30 years of age.
References:
- Liavaag, S., Brox, J., Pripp, H., Enger, M., Soldal, L., and Svenningsen, S. . Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence
- Taskoparan, H., Tunay, S., Kilincoglu, V., Bilgic, S., Yrttas, Y., and Komurcu, M. Immobilization of the shoulder in external rotation for prevention of recurrence in acute anterior dislocation
- Paterson, W., Throckmorton, T., Koester, M., Azar, F., and Kuhn, J. . Position and duration of immobilization after primary anterior dislocation: a systematic review and meta-analysis of the literature
- Finestrone, A., Milgrom, C., Radeva-Petrova, D.R., Rath, E., Barchilon, V,. Beyth, S., Jaber, S., and Safran, O. Bracing in external rotation for traumatic anterior dislocation of the shoulder
- Scheibel, M., Kuke, A., Nikulka, C., Magasch, P., Ziesler, O., and Schroeder, J. How long should acute anterior dislocations of the shoulder be immobilized in external rotation
- Itoi, E., Hatakeyama, Y., Sato, T., Kido, T., Minagawa, H., Yamamoto, N., Wakabayashi, I., and Nozaka, K. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence: A randomized controlled trial