Immobilization In External Rotation Research Articles

Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies

Background: Arthroscopic stabilization has been established as a superior treatment option for primary glenohumeral instability when compared with immobilization in internal rotation. However, immobilization in external rotation (ER) has recently gained interest as a viable nonoperative treatment option for patients with shoulder instability. Purpose: To compare the rates of recurrent instability and subsequent surgery in patients undergoing treatment for primary anterior shoulder dislocation with arthroscopic stabilization versus immobilization in ER. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that’evaluated patients being treated for primary anterior glenohumeral dislocation with either arthroscopic stabilization or immobilization in ER. The search phrase used various combinations of the keywords/phrases “primary closed reduction,”“anterior shoulder dislocation,”“traumatic,”“primary,”“treatment,”“management,”“immobilization,”“external rotation,”“surgical,”“operative,”“nonoperative,” and “conservative.” Inclusion criteria included patients undergoing treatment for primary anterior glenohumeral joint dislocation with either immobilization in ER or arthroscopic stabilization. Rates of recurrent instability, subsequent stabilization surgery, return to sports, positive postintervention apprehension tests, and patient-reported outcomes were evaluated. Results: The 30 studies that met inclusion criteria included 760 patients undergoing arthroscopic stabilization (mean age, 23.1 years; mean follow-up time, 55.1 months) and 409 patients undergoing immobilization in ER (mean age, 29.8 years; mean follow-up time, 28.8 months). Overall, 8.8% of operative patients experienced recurrent instability at latest follow-up compared with 21.3% of patients who had undergone ER immobilization (P < .0001). Similarly, 5.7% of operative patients had undergone a subsequent stabilization procedure at latest follow-up compared with 11.3% of patients who had undergone ER immobilization (P = .0015). A higher rate of return to sports was found in the operative group (P < .05), but no other differences were found between groups. Conclusion: Patients undergoing arthroscopic treatment for primary anterior glenohumeral dislocation with arthroscopic stabilization can be expected to experience significantly lower rates of recurrent instability and subsequent stabilization procedures compared with patients undergoing ER immobilization.

Long-Term Effects of Immobilization in External Rotation after First-time Dislocation of the Shoulder: An 18-Year Follow-Up

Immobilization in external rotation after a first-time shoulder dislocation has been introduced to reduce the risk of recurrence compared to immobilization in internal rotation; however, its long-term effects remain unknown. This study aimed to determine the long-term effect of immobilization in external rotation after a first-time shoulder dislocation.

Long-term effect of immobilization in external rotation after first-time shoulder dislocation: an average 18-year follow-up.

Immobilization in external rotation (ER) after a first-time shoulder dislocation was introduced to reduce the risk of recurrence compared with immobilization in internal rotation (IR), but its efficacy remains controversial. The purpose of this study was to determine the long-term effect of immobilization in ER after a first-time shoulder dislocation. Between October 2000 and March 2004, 198 patients with a first-time anterior dislocation of the shoulder (average age 37) were randomly assigned to immobilization in ER (ER group = 104 shoulders) or IR (IR group = 94 shoulders) for 3 weeks. At an average 2-year follow-up, 159 patients (80.3%) were available for evaluation. In the current study, these 159 patients were further followed up and interviewed by telephone. The following items were evaluated: recurrent instability, apprehensive feeling, surgical intervention, limitation in the range of motion, return to sports, and the Single Assessment Numeric Evaluation (SANE) score. The average follow-up period was 18.2 years (range, 16-20 years). Fifty-six patients were available for follow-up with the follow-up rate of 35%. The number of recurrent patients was 6 of 27 (22%) in the ER group and 6 of 29 (21%) in the IR group (P = .889). The number of surgically stabilized patients was 3 of 27 (11%) in the ER group and 10 of 29 (34%) in the IR group (P = .038). In total, the recurrence rate was 33% (9 of 27) in the ER group and 55% (16 of 29) in the IR group (P = .100). Adding the surgical cases and those with the SANE score ≤70% as failure cases, the failure rate in the ER group (26%) was significantly lower than that in the IR group (52%) (P = .048). Among those who survived without surgical intervention, there were no significant differences in apprehensive feeling, return to sports, limited range of motion, and the SANE score between the groups. Immobilization in ER reduced the risk of surgical intervention compared with IR in the long term.

Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial

Background: Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD). Purpose: The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded. Results: Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded. Conclusion: Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.

Conservative management of first-time traumatic anterior shoulder dislocation

AbstractTraumatic anterior shoulder dislocation is a common injury in young and active patients and the proper treatment is still a matter of debate. The recurrence rate after conservative management remains high and, therefore, primary surgical intervention is sometimes recommended in very young patients whose risk of recurrences is highest. Immobilization in external rotation, first described by Itoi, is a promising conservative option as it provides adequate labral reduction and low recurrence rates. Recent meta-analyzes could not unequivocally demonstrate its superiority over internal rotation immobilization. However, biomechanical and early clinical results show a better effect on reduction of the labrum and lower recurrence rates for immobilization in a combination of abduction/external rotation than for external rotation alone. The present article aims to provide an overview of the conservative management of first-time traumatic shoulder dislocation in order to provide the treating physician or surgeon with the best current evidence as a basis for developing the appropriate treatment strategy for the patient.

Immobilization in External Rotation Reduces the Risk of Recurrence After Primary Anterior Shoulder Dislocation: A Meta-analysis.

Background:The best method for nonsurgical treatment after primary dislocation of the shoulder is not clear. The efficacy of immobilization with the arm in external rotation (ER) compared with internal rotation (IR) remains controversial.Purpose:To determine the efficacy of ER immobilization versus IR immobilization on recurrence rate after primary dislocation of the shoulder from the evidence of randomized controlled trials.Study Design:Systematic review; Level of evidence, 2.Methods:Electronic databases (MEDLINE [Ovid SP], PubMed, Web of Science, EBM reviews, and CINAHL) and available proceedings according to the abstracts of major international meetings related to or including shoulder injuries and trauma were used to search for randomized controlled trials. Two independent investigators determined eligibility and carried out data extraction from the selected studies.Results:A total of 9 studies (817 patients) were selected for this meta-analysis. They included 668 male and 149 female patients, with a mean age ranging from 20.3 to 37.5 years. In the 9 pooled studies, the recurrence rate of shoulder dislocation was 21.5% (84/390) in the ER group versus 34.9% (130/373) in the IR group. ER immobilization significantly reduced the recurrence rate compared with IR immobilization (risk ratio, 0.56; P = .007). In the subgroup analysis of those immobilized full-time, ER immobilization was significantly more effective than IR immobilization in reducing the recurrence rate (risk ratio, 0.57; P = .01). In the subgroup analysis of age, ER immobilization was significantly more effective than IR immobilization in those aged 20 to 40 years but not in those younger than 20 years.Conclusion:This meta-analysis demonstrates that ER immobilization reduces the recurrence rate after primary shoulder dislocation compared with IR immobilization in patients older than 20 years. When treating a patient with primary shoulder dislocation, the clinician should provide this information to the patient before a treatment method is selected.

Immobilization in external rotation vs internal rotation after shoulder dislocation: A systematic review and meta-analysis protocol.

Background:Dislocation of shoulder joint is the most prone to occurrence in all joints of human body, which is common in young people and has a high recurrence rate. It is mainly treated by conservative treatment. External rotation and internal rotation fixation are 2 common conservative therapies in clinical practice. Therefore, we conduct this systematic review and meta-analysis to evaluate the efficacy and safety of the 2 treatments.Methods:Nine electronic databases, PubMed, Web of Science, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov, CNKI, Wanfang Database and VIP Database, will be searched to find and include randomized controlled trials that meet inclusion criteria. RevMan5.3 will be used for data analysis and synthesis in this study. Subgroup analysis and sensitivity analysis will also be performed if necessary. In addition, GRADE will be used in the evaluation of evidence hierarchy.Results:This study will analyze and integrate the original evidence so far for clinical efficacy and safety of immobilization in external rotation and internal rotation on shoulder dislocation.Conclusion:The conclusion of this study will conclude higher evidence and suggestions for the treatment of shoulder dislocation, so as to further guide clinical decision making.PROSPERO registration number:CRD42018106030.

Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.

Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.

Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial

IntroductionPatients that sustain anterior shoulder dislocation frequently experience recurrence. Immobilisation in external rotation has been proposed as a treatment that could lower this risk. HypothesisThere is a difference in recurrence rates between immobilization in internal or external rotation following a first-time anterior shoulder dislocation. Patients and methodsSingle-center randomized controlled trial. Fifty patients with a first episode of traumatic anterior dislocation were randomly assigned to immobilization in internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. Clinical follow-up: 24 months. Additionally, some patients underwent a magnetic resonance imaging with intra-articular contrast (MR arthrography) within seven days after trauma, and then at three months. Primary outcome: recurrence of dislocation. Secondary outcome: healing rate of labral lesions on MR arthrography. ResultsFollow-up rate in the IR and ER group was 92% and 96% respectively. Recurrence rate did not show a statistically significant difference overall (IR 47.8% vs. ER 29.2%; p=0.188), but showed a significant difference favouring ER in the 20–40 years subgroup (IR 50% vs. ER 6.4%; p=0.044). Labral lesions’ healing rate was 46.2% vs. 60% (IR vs ER; p=0.680). The recurrence rate among those with healed vs. non-healed labrum (regardless of immobilization) was 11.1% vs. 77.7% (p=0.001). DiscussionThis study suggests that immobilization in ER compared to IR reduces the risk of recurrence after a first-time anterior shoulder dislocation in patients aged between 20 and 40 years. Level of evidenceII, low-powered prospective randomized trial.

First-time anterior shoulder dislocation natural history and epidemiology: immobilization versus early surgical repair

Traumatic anterior shoulder dislocations are a common problem. There is a high rate of recurrent instability, especially in patients <30 years of age that are involved in high level sports. The purpose of this review is to discuss the natural history after a first-time shoulder dislocation and provide a brief overview of management options. Initial nonoperative management consists of immobilization in internal rotation for 1–3 weeks. The current evidence does not support immobilization in external rotation or for longer periods of time. For those patients who are at a high risk of recurrent instability, the evidence suggests that early surgical repair to address the pathology can be undertaken. This has shown to be clinically and fiscally effective while improving patient outcomes.

Position of Immobilization After First-Time Traumatic Anterior Glenohumeral Dislocation: A Literature Review.

Anterior glenohumeral dislocation affects about 2% of the general population during the lifetime. The incidence of traumatic glenohumeral dislocation ranges from 8.2 to 26.69 per 100 000 population per year. The most common complication is recurrent dislocation occurring in 17–96% of the patients. The majority of patients are treated conservatively by closed reduction and immobilization in internal rotation for 2–3 weeks. However, no clear conservative treatment protocol exists. Immobilization in external rotation can be considered an alternative. A range of external rotation braces are commercially available.The purpose of this work was to review the current literature on conservative management of glenohumeral dislocation and to compare the results of immobilization in internal and external rotation.A comprehensive literature search and review was performed using the keywords “glenohumeral dislocation”, “shoulder dislocation”, “immobilization”, “external rotation”, and “recurrent dislocation” in PubMed, MEDLINE, Cochrane Library, Scopus, and Google Scholar databases from their inceptions to May 2016.Three cadaveric studies, 6 imaging studies, 10 clinical studies, and 4 meta-analyses were identified. The total number of 734 patients were included in the clinical studies.Literature analysis revealed better coaptation of the labrum on the glenoid rim in external rotation in cadaveric and imaging studies. However, this tendency was not confirmed by lower redislocation rates or better quality of life in clinical studies.On the basis of the available literature, we cannot confirm the superiority of immobilization in external rotation after glenohumeral dislocation when compared to internal rotation. A yet-to-be-determined group of patients with specific labroligamentous injury pattern may benefit from immobilization in external rotation. Further studies are needed to identify these patients.

Étude IRM prospective sur l’influence de l’immobilisation en rotation externe sur la réduction et la cicatrisation des lésions capsulolabrales après une primoluxation de l’épaule

IntroductionThe healing of the labral, capsular and glenohumeral ligament lesions represents the fundamental element to avoid recurrence of an anteromedial glenohumeral dislocation. The position of immobilization after a first anterior shoulder dislocation has been a controversial topic over the past decade. Few studies have demonstrated the superiority of the immobilization in external rotation position in the healing process. We have assessed through an MRI control, the effect of this immobilization on the labral, capsular and glenohumeral ligament injuries caused by the anteromedial dislocation of the shoulder. Patients and methodOur prospective study was carried on a duration of 1 year. Only patients with a primary anteromedial shoulder dislocation to sports subjects and having already accepted our protocol of stabilization in external rotation were included. Two MRIs was performed for each patient: immediately after reduction and 6 months later according to the same protocol: an acquisition in internal rotation (IR), followed by an acquisition in external rotation (ER). Hemarthrosis, rotator cuff, bone lesions, labral and capsular lesions were assessed and analyzed. ResultsWe selected 20 patients (19 men) with an average age of 24 years. Seventy-five percent of the dislocations were extracoracoid and 25% sub-coracoid. The reduction was done in the hospital after anteroposterior radiography of shoulder. All the patients were immobilized in an external rotation position using a thermoformable orthosis during 3 weeks followed by 6 weeks of rehabilitation. During the initial MRI: the hemarthrosis was almost constant; all separated labrums were reduced by external rotation including 10 completely. In all patients, the subscapularis was detached and totally reduced by external rotation in 60% of cases. After 6 months, the MRI showed that among the 18 patients with lesions labral, 15 have a complete healing without detachment and 3 patients had kept a residual detachment in internal rotation. The subscapularis was completely healed in 90% of cases. ConclusionThe immobilization in external rotation position allows a reduction of the hemarthrosis, the anterior capsular detachment and the labral lesions. Indeed, the immobilization in external rotation is constraining for the patient, yet the results seem encouraging.

Management of shoulder instability: the current state of treatment among German orthopaedic surgeons.

The aim of this study was to evaluate the current state of treatment in traumatic anterior shoulder dislocation in Germany and to detect changes over the last 12years. Seven hundred ninety-six trauma and/or orthopaedic departments were found in the German hospital directory 2012. The websites of each department were searched for the email address of the responsible shoulder surgeon (if applicable) or the head of the department. Seven hundred forty-six email addresses were found, and emails with the request to participate in an online survey were sent in January 2013. Six hundred seventy-five emails probably reached the correct addressee. Seventy-one emails were rejected, and no contact could be made. One-hundred ninety-one (28%) participated in the study. The data were compared to similar data from a survey on shoulder dislocation performed in the same department and published in 2001. After the first-time traumatic shoulder dislocation in patients aged younger than 30years participating in sports, 14% of the participants would prefer conservative treatment, 83% arthroscopic, and 3% open surgery. When surgery was indicated, arthroscopic Bankart repair was the treatment of choice for 93% of the participants. In 2001, 27% had indicated conservative treatment after the first-time shoulder dislocation in active patients younger than 30years. When surgery was indicated, 66% had performed arthroscopic and 34% open stabilization. For the standard arthroscopic Bankart repair without concomitant injuries, 41% of the participants use two and 54% three suture anchors. Knotless anchors were preferred by 72%. In the case of glenoid bone loss greater than 25%, only 46% perform a procedure for glenoid bone augmentation. Fifteen percent of the participants always recommended immobilization in external rotation after traumatic first-time shoulder dislocation. The majority of participants recommend arthroscopic Bankart repair with two or three suture anchors in young persons with the first-time dislocations. Compared to 2001 less recommend conservative treatment, complex "open" surgical procedures are no longer used. The knowledge that a Bankart procedure likely fails in significant glenoid bone loss is not implemented in the clinical practice. Thus, there is a need to educate surgeons on this topic.

Less than 60% return to preinjury sports activities after primary anterior shoulder dislocation treated with immobilisation only

BackgroundShoulder dislocation is a common injury among young athletes, especially those who play contact sports.ObjectiveThe aim of this systematic review is to investigate the return to preinjury sporting activities in patients who have undergone a conservative treatment with immobilisation after a primary anterior shoulder dislocation.Data sourcesWe conducted electronic searches without restriction of language on the EMBASE and PUBMED databases, using the term ‘shoulder dislocation’ for each database.Study selectionAll prospective studies that have evaluated the role of immobilisation for first-time shoulder dislocation were included in this review.Synthesis methods and risk of biasAuthor's name, year of publication, design of study, population, sample size, follow-up times, immobilisation method, and the rate of patients' return to preinjury sporting activities were extracted from the selected articles. The instrument used for assessing the risk of bias of the included articles was the PEDro scale.ResultsA total of 7397 studies were found. From the four studies included in this review four of them used external rotation (ER) as treatment for three weeks. A total of 214 participants were recruited for ER and 169 for internal rotation (IR). On average, 58.9% (95% CI 51.1% to 64.7%) for immobilisation in ER and 42.6% (95% CI 34.5% to 49.8%) for immobilisation in IR returned to preinjury sports activities. PEDro scores for the included studies ranged from 3 to 6.ConclusionsOn the basis of the best available evidence that the studies reported, on average <60% return to preinjury sports activity level.

Immobilization in External Rotation Versus Internal Rotation After Primary Anterior Shoulder Dislocation

Background: The recurrence rate after primary anterior shoulder dislocation is high, especially in young, active individuals. Recent studies have suggested external rotation immobilization as a method to reduce the rate of recurrent shoulder dislocation in comparison to traditional sling immobilization. Purpose: To assess and summarize evidence from randomized controlled trials on the effect of internal rotation versus external rotation immobilization on the rate of recurrence after primary anterior shoulder dislocation. Study Design: Meta-analysis. Methods: PubMed, MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and abstracts from recent proceedings were searched for eligible studies. Two reviewers selected studies for inclusion, assessed methodological quality, and extracted data. Results: Six randomized controlled trials (632 patients) were included in this review. Demographic and prognostic variables measured at baseline were similar in the pooled groups. The average age was 30.1 years in the pooled external rotation group and 30.3 years in the pooled internal rotation group. Two studies found that external rotation immobilization reduced the rate of recurrence after initial anterior shoulder dislocation compared with conventional internal rotation immobilization, whereas 4 studies failed to find a significant difference between the 2 groups. This meta-analysis suggested no overall significant difference in the rate of recurrence among patients treated with internal rotation versus external rotation immobilization (risk ratio, 0.69; 95% CI, 0.42-1.14; P = .15). There was no significant difference in the rate of compliance between internal and external rotation immobilization (P = .43). The Western Ontario Shoulder Instability Index scores were pooled across 3 studies, and there was no significant difference between the 2 groups (P = .54). Conclusion: Immobilization in external rotation is not significantly more effective in reducing the recurrence rate after primary anterior shoulder dislocation than immobilization in internal rotation. Additionally, this review suggests that there is minimal difference in patients’ perceptions of their health-related quality of life after immobilization in internal versus external rotation.

Arm Abduction Provides a Better Reduction of the Bankart Lesion During Immobilization in External Rotation After an Initial Shoulder Dislocation

Background: Shoulder dislocation often recurs, especially in the younger population. Immobilization in external rotation, in which a Bankart lesion is displaced in the anterior, medial, and inferior directions, was introduced as a new method of nonoperative treatment, but its clinical efficiency is controversial. In terms of reducing the lesion, it is reasonable to incorporate not only external rotation, which makes the anterior soft tissues tight to push the lesion posteriorly and laterally, but also abduction, which makes the inferior soft tissues tight to push the lesion superiorly. Hypothesis: Abducting the arm during immobilization in external rotation will improve the reduction of a Bankart lesion. Study Design: Controlled laboratory study. Methods: There were 37 patients with initial shoulder dislocation enrolled in this study. After reduction, MRI was taken in 4 positions of the shoulder: adduction and internal rotation (Add-IR), adduction and external rotation (Add-ER), 30° of abduction and 30° of external rotation (Abd-30ER), and 30° of abduction and 60° of external rotation (Abd-60ER). On radial slices, the separation, displacement of the labrum, and opening angle of the capsule were measured. Results: Add-ER improved the reduction of the anterior labrum but not the inferior labrum when compared with Add-IR. Both Abd-30ER and Abd-60ER improved the reduction of the inferior labrum as compared with Add-IR. Furthermore, Abd-60ER improved the reduction more than Add-ER. Conclusion: Among the 4 positions tested, Abd-60ER is the best position in terms of reducing the Bankart lesion. Clinical Relevance: Abducting the shoulder during immobilization in external rotation is demonstrated to improve the reduction of the Bankart lesion. Therefore, this position is expected to reduce the recurrence rate after initial dislocation of the shoulder. Future clinical trials are necessary.

Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation

We aimed to compare the effectiveness of immobilization in abduction and external rotation vs immobilization in adduction and internal rotation after primary anterior dislocation of the shoulder. The study randomized 102 patients (age range, 15-55 years) with the diagnosis of primary anterior dislocation of the shoulder to receive immobilization in adduction and internal rotation (AdIR, n = 51) using sling and swathe bandage or immobilization in abduction and external rotation (AbER, n = 51) with a stabilizer brace. Patients received a rehabilitation program 3 weeks after the intervention. After a 24-month follow-up, 33.3% in the AdIR group and 3.9% in the AbER group had recurrence (P < .001). The difference in the recurrence rate was greater in the subgroup aged between 31 and 40 years (44.8% in the AdIR group and 3.8% in the AbER group, P < .001). Ten patients in the AbER group (19.6%) and 3 in the AdIR group (5.8%) discontinued shoulder immobilization before 3 weeks (P = .03). In patients without recurrence, the anterior apprehension test was positive in 6 of 34 in the AdIR group (17.6%) and in 4 of 49 in the AbER group (8.1%, P = .19). Immobilization with the shoulder joint in abduction and external rotation is an effective method to reduce the risk of recurrence after primary anterior shoulder dislocations and should be preferred to the traditional method of immobilization in adduction and internal rotation in clinical practice.

CORR Insights(®): external rotation immobilization for primary shoulder dislocation: a randomized controlled trial.

CORR Insights(®): external rotation immobilization for primary shoulder dislocation: a randomized controlled trial.

External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial

The traditional treatment for primary anterior shoulder dislocations has been immobilization in a sling with the arm in a position of adduction and internal rotation. However, recent basic science and clinical data have suggested recurrent instability may be reduced with immobilization in external rotation after primary shoulder dislocation. We performed a randomized controlled trial to compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients. Sixty patients younger than 35 years of age with primary, traumatic, anterior shoulder dislocations were randomized (concealed, computer-generated) to immobilization with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean of 4 days after closed reduction (range, 1-7 days). Patients with large bony lesions or polytrauma were excluded. The two groups were similar at baseline. Both groups were immobilized for 4 weeks with identical therapy protocols thereafter. Blinded assessments were completed by independent observers for a minimum of 12 months (mean, 25 months; range, 12-43 months). Recurrent instability was defined as a second documented anterior dislocation or multiple episodes of shoulder subluxation severe enough for the patient to request surgical stabilization. Validated disease-specific quality-of-life data (Western Ontario Shoulder Instability index [WOSI], American Shoulder and Elbow Surgeons evaluation [ASES]) were also collected. Ten patients (17%, five from each group) were lost to followup. Reported compliance with immobilization in both groups was excellent (80%). With the numbers available, there was no difference in the rate of recurrent instability between groups: 10 of 27 patients (37%) with the external rotation brace versus 10 of 25 patients (40%) with the sling redislocated or developed symptomatic recurrent instability (p = 0.41). WOSI scores were not different between groups (p = 0.74) and, although the difference in ASES scores approached statistical significance (p = 0.05), the magnitude of this difference was small and of uncertain clinical importance. Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Further studies with larger numbers may elucidate whether functional outcomes, compliance, or comfort with immobilization can be improved with this device. Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder dislocation

The objective of this study was to systematically review and quantitatively synthesize the data on recurrence rates after shoulder immobilization in internal versus external rotation in first-time, traumatic shoulder dislocations. We performed a systematic search of the keywords "(((external rotation) OR internal rotation) AND immobilization) AND shoulder" in the online databases PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Library. Random-effects models were used to calculate the cumulatively pooled risk ratios (RRs) of recurrent shoulder dislocations. All analyses were also stratified by age. We included 5 studies with a total of 471 patients (230 internal rotation and 241 external rotation) published between 2001 and 2011 in English. The pooled random-effects RR for recurrence of shoulder dislocations at all ages was 0.74 (95% confidence interval [CI], 0.44-1.27; P = .278). The RR was 0.70 (95% CI, 0.38 to 1.29; P = .250) for patients aged 30 years or younger and 0.78 (95% CI, 0.32 to 1.88; P = .579) for those aged older than 30 years. The current best evidence does not support a relative effectiveness of immobilization in external rotation compared with internal rotation to avoid recurrent shoulder dislocations in patients with traumatic anterior shoulder dislocations.