• 
• 

Three Part Question

[In adult patients with anterior shoulder dislocation] is [Milch method better than traction counter-traction] at [successful reduction and/or decreasing length of stay in the ED]

Clinical Scenario

Mrs. Jones is a 25 y/o F with reccurent shoulder dislocation who presents with anterior shoulder dislocation. After your second attempt using traction counter-traction under sedation with Propofol x-ray confirms failed reduction. You wonder should I have started with a different method.

Search Strategy

Ovid MEDLINE(R) and Ovid OLDMEDLINE(R) <1946 to October Week 1 2013> and EBM Reviews - Cochrane Database of Systematic Reviews <2005 to September 2013>

Medline: [(exp Shoulder Dislocation/ and anterior$.mp. and milch.mp.) or (exp Shoulder Dislocation/ and anterior$.mp. and (traction$ adj3 (countertraction$ or counter-traction$)).mp.)]
Cochrane: [(((Shoulder$ or glenohumor$) adj5 Dislocat$ adj7 anterior$) or (traction$ adj3 (countertraction$ or counter-traction$)) or milch).mp.]

Search Outcome

Altogether 22 papers were found in Medline and 10 in Cochrane, of which 30 were irrelevant or of insufficient quality. No further relevant papers were found by scanning the references of relevant papers. All relevant papers are summarized in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Singh et al 2012 Malaysia	56 non-randomized consecutive patients presenting to Emergency unit w/ anterior shoulder dislocation from Oct. 2006 – Sept. 2007	Prospective, non randomized, Cohort Study, Treatment Study (Level II)	success rate of reduction, length of stay	Success rate: modified milch vs traction counter traction was 83.9% vs 100% (P = .058), Duration of hospital stay: median .59hr vs 4hrs (P <.01) Mean drop in pain score for MM technique 2.07 pre to intraprocedural and 4.40 pre to post procedural phase	sample size estimate not preformed (possibly why success rate comparison did not reach statistical significance), orthopedic residents performing the procedure, Pain score drop was not compared between both groups
Harnroongroj et al 2011 Thailand	Chart review 2001-2010, 76 patients with one or more episodes of anterior shoulder dislocation	Retrospective Cohort (level 3b)	successful reduction, post reduction complication rate, patient satisfaction score	successful reduction TAE vs TCT was 90.63% vs 100% (P = 0.071) no post reduction complication in both groups Patient satisfaction score TAE vs TCT was 9.38/10 and 7.94/10 (P = 0.007)	sample size estimate not performed, small sample size (possibly why difference in success rate did not show statistical significance. This study compared TAE which is similar too but not Milch. I was unable to locate the full article, this information is from abstract.

Comment(s)

While these studies did not show a statistical significance in the success rate of modified milch compared to TCT under sedation, it is possible TCT might be proven more effective with larger sample size. One study did show significant pain reduction using MM with out sedation even during the procedure. In the first study there was a significant reduction in hospital length of stay with Modified Milch.

Clinical Bottom Line

While TCT success rate is very near 100%, there is evidence that patients can tolerate more gentle methods of shoulder reduction with high success, avoiding the need for sedation and increased length of stay. If unsuccessful there is no contraindication to proceed with TCT under sedation.

References

1. Singh S. Yong CK. Mariapan S. Closed reduction techniques in acute anterior shoulder dislocation: modified Milch technique compared with traction-countertraction technique Journal of Shoulder & Elbow Surgery 21(12):1706-11, 2012 Dec
2. Harnroongroj T. Wangphanich J. Harnroongroj T. Efficacy of gentle traction, abduction and external rotation maneuver under sedative-free for reduction of acute anterior shoulder dislocation: retrospective comparative study. Journal of the Medical Association of Thailand 94(12):1482-6, 2011 Dec.