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Three Part Question

In [adult patients with recurrent non-traumatic anterior shoulder dislocations] are [post reduction x-rays] a [mandatory requirement in all cases]?

Clinical Scenario

A 28 year old male attends at 7.30am having dislocated his shoulder again, this time when making the bed that morning. He states he is awaiting an elective orthopaedic procedure planned later this year. This is his 3rd non traumatic dislocation in the last 2 months. The shoulder is clinically relocated with ease using morphine and entonox only. A pre-reduction x-ray was not taken as the diagnosis was clinically obvious.
You are confident that the shoulder is relocated and wonder if a post reduction film is still required.

Search Strategy

Medline from 1950 – Feb 2007
Embase 1980 – 2007
Basic search using keywords: "shoulder", "dislocation" and "radiography"

Search Outcome

239 articles through Medline, of which 3 were relevant
179 articles through Embase of which 1 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. March 1996. USA	131 adults presenting to university affiliated level 1 trauma centre diagnosed with anterior dislocation. All patients had pre and post-reduction films.	Retrospective chart review of all patients from 1990 – 1994 given discharge diagnosis of dislocation.	Determine the incidence of clinically significant fractures picked up on post-reduction films that were not seen on pre-reduction films.	3 new fractures were picked up on post-reduction films; 2 were Bankart Lesions and 1 was a greater tuberosity fracture. 1 persistent dislocation was picked up; this was the only finding that changed management in the emergency department.	Retrospective study with potential for missing data. Requires validation via prospective study.
Shuster, M. 1999 Canada	97 patients (82 male) identified as possible shoulder dislocation presenting to 2 ski-hill clinics and 1 rural hospital between Nov 1996 – May 1997. Median age 28.	Prospective observational	1. If experienced physicians can identify patients with anterior shoulder dislocations without pre-reduction x-ray. 2. If pre-reduction films significantly delay time to reduction. 3. If experienced physicians can successfully reduce shoulder dislocation when pre-reduction films are not readily available.	Physicians were 100% accurate when "certain" of diagnosis of dislocation. The physician was "certain" of relocation in 97.7% of the attempted relocations, and was 100% accurate when certain. No fracture was identified on post-reduction film that was not already seen on a pre-reduction film.	Small study size. Very specific patient group (young active skiers). All dislocations caused by trauma. Non randomized study. Observational study – no predetermined protocols therefore patient management was physician dependant.
Hendey, GW. April 2000. USA	All adult patients suspected of having shoulder dislocation presenting to a university affiliated level 1 trauma centre between May 1997 – Oct 1999. 104 patients enrolled. Patients further separated into 2 groups: Group 1 = recurrent dislocation with an atraumatic mechanism. Group 2 = all others i.e. first time dislocation or blunt injury	Prospective observational study.	1. To determine physicians ability to detect dislocation and relocation clinically. 2. To identify any associated fractures or persistent dislocation not previously suspected.	Physicians were 100% accurate when "confident" about joint position in Group 1 and 98% accurate in Group 2 (in 1 case the pre-reduction assessment was of dislocation when the diagnosis was a humeral head fracture). No unsuspected dislocations or fractures occurred in Group 1. There was 1 persistent dislocation in Group 2.There were no new post reduction fractures. Neither pre or post-reduction films were likely to change ED management in Group 1 patients.	Differing levels of experience in reporting physicians (87% were post graduate year 2-4 physicians). No standardisation of patient assessment in predicting fracture dislocations.
Hendey, GW et al. 2006. USA	100 adults presenting to a university affiliated level 1 trauma centre with suspected shoulder dislocation. 79 men, 21 women. Mean age 34.	Prospective cohort study	1. To validate a clinical decision algorithm. 2. To determine reduction in x-ray utilization. 3. To determine if any fractures were missed. 4. To determine reduction in ED stay time. 5. To assess patient satisfaction with selective approach.	46% overall reduction in Xray utilization; Median ED stay times reduced (Pre and post films = 288 mins, No films = 155 mins); No missed fractures or persistent dislocations detected; 99% overall patient satisfaction with their ED care in all groups.	Small study size. Numerous protocol violations skewing results.

Comment(s)

Eliminating post reduction x-rays might miss certain lesions especially Bankhart Lesions, which themselves predispose to recurrent dislocations. It could be argued that it is important to identify these lesions so that surgical correction can be considered. However the researched literature states that "Surgical intervention for patients with recurrent dislocation is based more on the patient's age and frequency of dislocation than on prognostic radiographic findings". There may be concerns of missed fractures occuring at the time of dislocation despite atraumatic or trivial mechanism of injury. The researched literature states "fracture dislocation can be predicted by three clinical variables: 1st time dislocation, blunt traumatic mechanism, age over 40 years". If none of these are present, post reduction radiography is unlikely to reveal any acute fractures. Emergency physicians may feel obliged to perform post reduction films prior to referral to orthopaedic clinic, believing that these will be required in any case for prognostic reasons. The researched literature states that this was not the case as on follow up, no additional films were taken when the prognosis was evident therefore resulting in an overall decrease in post-reduction x-ray utilisation and not just a shift in where these x-rays were performed. Some emergency physicians may feel that post reduction films provide medico-legal proof of relocation. The researched literature states that documention of the relief of pain, normalization of anatomy, improved range of movement and the feeling of a "clunk" is adequate medico-legal evidence of clinical relocation.

Clinical Bottom Line

In adult patients with recurrent non-traumatic anterior shoulder dislocations post reduction films are not a requirement unless the clinician is unsure of dislocation or relocation.

References

1. Hendy, Gregory W et al. Clinically Significant Abnormalities in Post Reduction Radiographs After Anterior Shoulder Dislocation Annals of Emergency Medicine October 1996; 399 - 402
2. Shuster, Micheal et al. Pre-reduction Radiographs in Clinically Evident Anterior Shoulder Dislocation. American Journal of Emergency Medicine. November 1999; Vol17, Number 7, Pages 653 - 658
3. Hendy, Gregory W. Necessity of Radiogrpahs in the Emergency Department Management of Shoulder Dislocations. Annals of Emergency Medicine August 2000; Pages 108 - 113
4. Hendy, Gregory W et al. Selective Radiography in 100 Patients with Suspected Shoulder Dislocation. The Journal of Emergency Medicine 2006; Vol 31, Number 1, Pages 23 - 28