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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

Search Outcome

32 papers were returned of which 6 papers, Level II evidence or higher, were found relevant to the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Liavaag, S et al 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
Taskoparan, H et al, 2010, Turkey 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
Paterson, W et al 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
Finestone, A et al 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
Scheibel, M et al 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
Itoi, E et al 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

Comment(s)

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.

Clinical 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

1. 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 Journal of Bone and Joint Surgery 2011; 897-904
2. 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 Acta Orthop Traumatol Turc. 2010; 278-284
3. 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 Journal of Bone and Joint Surgery 2010; 2924-2933
4. 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 Journal of Bone and Joint Surgery 2009; 918-921
5. 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 American Journal of Sports Medicine 2009; 1309-1317
6. 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 Journal of Bone and Joint Surgery 2007; 2124-2131