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Three Part Question

In [patients presenting with first episode anterior shoulder dislocation] does [post-reduction immobilization in external rotation compared to internal rotation] reduce [the rate of recurrent dislocation]?

Clinical Scenario

A 25-year-old athlete suffers a first-time anterior shoulder dislocation. After reduction in the emergency department, you wonder whether immobilizing the shoulder in external rotation instead of internal rotation could better prevent recurrent dislocations.

Search Strategy

Ovid MEDLINE(R) ALL <1946 to January 25, 2024>
[exp Shoulder Dislocation/ OR anterior shoulder dislocation.mp.] AND [external.mp.] AND [internal.mp.]

Search Outcome

A total of 238 papers were found in the initial search. The inclusion criteria was limited to randomized control trials. Using two independent reviewers, seven papers were deemed to be relevant to the research question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kamran Heidari 2014 Iran	102 patients (age range 15-55 years; 91 males and 11 females) with primary anterior dislocation of the shoulder were randomized to be immobilized in external rotation and internal rotation for three weeks	Randomized controlled trial	Dislocation recurrence at 24-month follow-up	The recurrence rate was 2/51 (3.9%) with external rotation and 17/51 (33.3%) with internal rotation (p<0.001).	Short follow-up time of 24 months. Smaller sample size.
Eiji Itoi 2022 Japan	198 patients with a first-time anterior dislocation of the shoulder were initially enrolled, 159 patients were available for the 2-year follow-up, and 56 patients were available at the 18-year follow-up (27 in the external rotation group and 29 in the internal rotation group). Both groups were immobilized for three weeks.	Randomized controlled trial	Dislocation recurrence at 18-year follow-up	The recurrence rate was 9/27 (33%) in the external rotation group and 16/29 (55%) in the internal rotation group (p=0.100)	The follow-up rate at 18 years was only 35%, which introduces loss to follow up bias.
Sigurd Liavaag 2011 United States	188 patients with a primary anterior traumatic shoulder dislocation were randomly assigned to treatment with immobilization in either internal rotation (n=95) or external rotation (n=93) for three weeks.	Randomized controlled trial	Dislocation recurrence at 24-month follow-up	The recurrence rate was 28/91 (30.8%) with external rotation and 23/93 (24.7%) with internal rotation (p=0.36)	Very low compliance rate in both groups (47.4% in the internal rotation group vs 67.7% in the external rotation group), potentially underestimating true effect of immobilization in external rotation for decreasing rate of recurrent dislocations.
Daniel B Whelan 2014 United States	60 patients under the age of 35 with a primary anterior shoulder dislocation were randomly assigned to treatment with immobilization in either external rotation (n=31) or internal rotation (n=29) for four weeks.	Randomized controlled trial	Dislocation recurrence at 24-month follow-up	The recurrence rate was 6/27 (22%) with external rotation and 8/25 (32%) with internal rotation (p=0.42).	Small sample size. Moderate loss to follow-up (17%).
H. Taskoparan 2010 Turkey	33 patients (31 males and 2 females) with acute primary traumatic anterior shoulder dislocation immobilized at internal (n=17) or external rotation (n=16) for three weeks.	Randomized controlled trial	Dislocation recurrence at 21-month follow-up	The recurrence rate was 1/16 (6.3%) with external rotation and 5/17 (29.4%) in the internal rotation group (p=0.035)	Small sample size. Potential bias due to non-blinding of outcome assessors. Short follow-up period.

Comment(s)

Immobilization in external rotation as opposed to internal rotation may reduce the rate of recurrent shoulder dislocations. However, the overall body of research is limited by variability in findings, partly due to methodological challenges such as small sample sizes and varying follow-up durations.

Clinical Bottom Line

In cases of first-time anterior shoulder dislocation, there is insufficient evidence to demonstrate superiority of immobilization in external rotation versus internal rotation in reducing recurrent dislocations.

References

1. A. Finestone Bracing in external rotation for traumatic anterior dislocation of the shoulder The Journal of Bone and Joint Surgery 2009 Jul;91(7):918-21.
2. Jean-Christophe Murray Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial
3. Kamran Heidari Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation
4. Eiji Itoi Long-term effect of immobilization in external rotation after first-time shoulder dislocation: an average 18-year follow-up
5. Sigurd Liavaag Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence: a randomized controlled trial
6. Daniel B Whelan External rotation immobilization for primary shoulder dislocation: a randomized controlled trial
7. H. Taskoparan Immobilization of the shoulder in external rotation for prevention of recurrence in acute anterior dislocation