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Three Part Question

In [adult patients with clinically Evident non traumatic Anterior Shoulder dislocation] does [pre-reduction shoulder Xrays] [change our management]?

Clinical Scenario

A 35 year old accountant with recurrent shoulder dislocation presented to Emergency department with yet another episode of dislocation that happened this time while lifting a heavy load in his garage. The department is busy and he is in severe pain and considering his history you would like to reduce the shoulder without taking a pre-reduction shoulder X-ray but you are obliged by departmental policy to do the x-ray. You wonder if the pre reduction x-ray in this case would change your management.

Search Strategy

Medline through Ovid interface from 1966 to August week 2 2006
Embase and Cinahl, through Dialog datastar interface from 1974 to August 2006
PubMed central 1966 to August 2006
[{shoulder.mp. or exp Shoulder Joint/ or exp Shoulder Dislocation/ or exp Shoulder/ or exp Shoulder Fractures/ AND dislocation.mp. or exp Dislocations/} AND { exp Radiography/ or radiograph$.mp./ OR xrays.mp. or exp X-Rays/ OR roentgenogram.mp.}], Limit to (humans and english language and "all adult (19 plus years)")

Search Outcome

353 articles through Ovid and 260 articles through Dialog datastar retrieved of which only 3 were relevant. A further search in PubMed central and on related articles retrieved 1 article which was relevant. Total of 4 articles appraised.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hendey GW August 2000 USA	University affiliated level 1 trauma centre Emergency department. 104 Patients with suspected shoulder dislocations. 28 patients has recurrent atraumatic dislocations (group 1). 76 had no previous shoulder dislocation or had blunt trauma (group 2)	Prospective Observational study	Accuracy of Assessment of joint position by Emergency physician when clinically certain.	Accuracy of Emergency physicians in assessing position of joint 'when confident' for group 1 : 100% (95%CI; 92%-100%) And for group 2: 98% in pre reduction assessment (95%CI; 91%-100%). And 100% in post reduction of position (95% CI; 93%-100%)	Small numbers No standardized protocol or training for assessment of joint position or arrangement for expression of degree of uncertainty among physicians about the joint position.
			Pre and post reduction radiology reports of films.	No fracture in group one Ten patients in group 2 had fracture dislocations
Schuster M et al. November 1999 Canada	97 patients suspected shoulder dislocation Men 82 Mean age 33.5 Range 16-75 Rural hospital and Ski Hill clinics. Nearly 90% happened during skiing (post injury dislocations).	Prospective Observational cohort study	Accuracy of Emergency Physician in diagnosing dislocated shoulder.	Accuracy of Emergency Physician100% (95% CI; 94.8%-100%).	Non randomized. No protocol in the way the patients treated followed, non standard approach to treatment. Small study size and unconventional comparison of practice of small clinic with hospital.
			Pre reduction radiograph does not alter the patients' management.	All fractures identified in pre reduction radiograph were seen in post reduction radiograph.
			Pre reduction x rays delay time to reduction.	No fracture required surgical intervention. Mean time of reduction was 26 min shorter when no pre-reduction x ray involved.
Hendey GW et al. July 2006 USA	100 patients with suspected dislocation of shoulder, (94 had dislocation) in a university affiliated level 1 trauma centre, emergency department. Minors, incarcerated and intoxicated patients as well as those who refused the consent excluded 79 men 59 recurrent dislocations 40 atraumatic 87 Dislocations without fracture	Prospective cohort study (validation study for shoulder dislocation - radiography decision rule).	Primary out come; Validation of dicision rule.	Considering the number of patients needed to power the study to 95% CI, use of this protocol was successful but not possible to validate with this study.	Physicians were allowed to deviate from protocol. Up to 39% of all patients lost in long term follow up. Hill sachs and Bankart lesions were not included as clinically significant injuries.
			Secondary outcomes were; 1 - Reduction in x-ray utilization.	46% overall reduction in x-ray usage.
			2 - Missed fracture or dislocation by application of the rule.	Only 61% traceable patient in follow up of which no missed fracture or dislocation were discovered by the investigators.
			3 - Total treatment time comparison.	Mean time in ED if both pre and post films taken 288 mins If either pre or post films taken 245
			4 - Assess patient satisfaction	76 patients were contacted within the first day post visit and 75 (99%) were satisfied with the care their received in Emergency department.
Shuster M et al. March 2002 Canada	Convenience sample of 63 patients with suspected shoulder dislocation, in a rural community hospital Emergency department. Supporting large ski and snowboarding recreational area. 87.3% male. Age range 17-79y Mean age: 33y 86% has ski or snowboard injuries.	Prospective cohort study.(validation of decision rule)	Accuracy of Emergency physician in diagnosing shoulder dislocation, when certain.	Physician accuracy of diagnosis of shoulder dislocation when certain 100% (59/59) Degree of certainty 93.7% (59/63)	Small numbers Treatment guideline not enforced (82.5% followed the guideline). No control group allocated. Not possible to account for all patients post reduction pathology
			Reduction on use of x ray usage.	Use of treatment guideline reduced pre- reduction X rays by 88.9%, (95% CI, 78.4%-95.4%) p<0.0001. Omitting pre-reduction radiograph with use of a guideline can be safe when treating EP is certain of diagnosis.

Comment(s)

None of the above studies directly answered the clinical question, they are small in size and guideline usage left to the discretion of the treating physician. it is well pointed out that when there is a clinically evident anterior shoulder dislocation secondary to non-traumatic mechanism in patients with known recurrent dislocation, the possibility of major fracture after application of modern reduction manoeuvres is virtually zero(1,2). These studies also show that when an experienced Emergency Physician is certain of joint position and dislocation, he/or she is almost always correct, with 100% accuracy (1,4,5). Presence of Hill Sachs or Bankart lesions although could be important in non-urgent treatment of a selected group of patients, they usually do not affect patient management in urgent settings.

Clinical Bottom Line

It is reasonably safe to omit pre-reduction radiographs in patients with atraumatic recurrent shoulder dislocations when the Emergency Physician is clinically certain of dislocation.

References

1. Hendey GW. Necessity of Radiographs in the emergency department management of shoulder dislocation. Annals of Emergency Medicine August 2000 36;2:108-113.
2. Shuster M, Riyad B. Abu-Laban, Jeff Boyd. Prereduction Radiographs in clinically evident anterior shoulder dislocation. American Journal of Emergency Medicine November 1999;17(7): 653-658.
3. Hendey GW, Chally MK, Stewart VB. Selective radiography in 100 patients with suspected shoulder dislocation. The journal of Emergency Medicine July 2006;31(1):23-28.
4. Shuster M, Riyad B. Abul Ladan, Jeff Boyd , Charles Gauthier, Lance Shephard, Chris Turner. Prospective Evaluation of a Guideline for the selective elimination of pre reduction radiographs in clinically obvious anterior shoulder dislocation. Canadian Journal of Emergency Medicine CJEM 2002;4(4):257-262.
5. Hendey GW, Kinlaw K. Clinically significant abnormalities in post-reduction radiographs after anterior shoulder dislocation. Ann Emerg Med 1996;28:399-402.