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Three Part Question

In [adults with shoulder dislocation] is [ultrasound as effective as plain film x-ray] at [detecting relocation following reduction]?

Clinical Scenario

A 29 year old man presents to the emergency department with a first-time, left anterior shoulder dislocation. A detailed history and exmaination post-reduction does not suggest a fracture, but you are not clinically certain the joint is relocated. You wonder if ultrasound technology could be used, as an alternative to plain film X-ray, to determine if reduction was successful.

Search Strategy

Ovid MEDLINE(R) 1950 to June Week 4 2009

[shoulder dislocation.mp OR exp Shoulder Dislocation OR shoulder subluxation.mp OR shoulder instability.mp OR unstable shoulder.mp OR dislocated shoulder.mp OR glenohumeral instability.mp OR glenohumeral subluxation.mp OR glenohumeral dislocation.mp OR unstable glenohumeral joint.mp] AND [exp Ultrasonics OR ultrasound.mp OR exp Ultrasonography OR x ray.mp OR exp X-Rays OR exp Radiography OR radiography.mp OR plain film x ray.mp] AND [reduction.mp OR relocation.mp] Limit to english language and humans.

Search Outcome

48 papers were returned with only 1 relevant to the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Halberg MJ, Sweeney TW, Owens WB 2009 USA	Two case reports: with patients aged 83 and 50 presenting to the mergency department with an anterior and posterior shoulder dislocation respectively.	Non-analytical study: Case report (level of evidence = 3)	Verification of successful joint reduction by emergency physician.	Use of post reduction x rays confirmed successful verification of joint relocation with ultrasound imaging.	Low level of evidence - small number of patient cases reported. Errors were highlighted in a correspondence by Yuen - author assigned error to typography.

Comment(s)

Low level evidence. Large randomised controlled trials are needed to support the results of these case reports and to allow clinical practice to be altered safely. If the level of evidence was higher the physician may have had choice as to the technique they employed depending upon their past experience and training.

Clinical Bottom Line

Plain film X-rays is still the method of choice for detecting relocation following reduction.

References

1. Halberg MJ, Sweeney TW, Owens WB Bedside ultrasound for verification of shoulder reduction Am J Emerg Med 2009 May;27(4):503-4