Rotation Brace Research Articles

Knee braces and foot orthoses multimodal treatment of medial knee osteoarthritis

BackgroundKnee braces and lateral wedge foot orthoses are two treatment options recommended for medial knee osteoarthritis, but the combination of both of them could further improve their effectiveness. Research questionThe aim was to evaluate whether the combination of lateral wedge foot orthoses with two types of knee brace enhances the biomechanical effects and pain relief during the stance phase of gait while maintaining comfort. MethodsTen patients with medial knee osteoarthritis were fitted with a standard valgus brace, an unloader brace with valgus and external rotation functions, and 7° lateral wedge foot orthoses. The pain relief, comfort, kinematics and kinetics of the lower limb were measured during walking without orthotics, with the combined and with the isolated treatments. ResultsThe valgus and external rotation brace significantly reduced the knee adduction moment and allowed more knee flexion both in isolation and in combination to foot orthoses compared to the valgus brace or without treatment. Pain relief was not significant with the different orthotic treatment modalities. The valgus brace and combined treatment with either brace significantly increased the discomfort level, whereas the valgus and external rotation brace or foot orthoses in isolation did not induce significant discomfort. SignificanceAmongst the tested orthotic treatment modalities, the valgus and external rotation brace obtained better biomechanical outcomes while maintaining comfort. The combined treatment with foot orthoses enhanced the effectiveness of the valgus brace, however foot orthoses may be unnecessary with the valgus and external rotation brace.

Lower trapezius transfer for massive posterosuperior rotator cuff defects.

To present the arthroscopically assisted lower trapezius transfer technique that restores shoulder external rotation and forward elevation, with low complication rates and fast recovery. Massive irreparable posterosuperior rotator cuff tears in active young patients with fatty infiltration ≥ III, osteoarthrosis Hamada ≤ 3, normal function of lower trapezius, and without glenohumeral stiffness. Absolute: Active soft tissue infection and trapezius muscle paralysis. Relative: medical comorbidities, inability to follow postoperative recommendations, advanced age, advanced degenerative changes (Hamada > 3), deltoid deficiency, and forward elevation < 60º. Beach chair position. Lower trapezius harvesting, allograft preparation, arthroscopic evaluation and rotator cuff partial repair, allograft passage, allograft intraarticular arthroscopic attachment, lower trapezius-allograft open attachment and wound closure. Avoidance of internal rotation with an external rotation brace for 6weeks. At 6weeks progressively appropriate physical therapy. Unrestricted activity at 6months. At mean follow-up of 14months, good results were reported (pain, range of motion, and Subjective Shoulder Value and Disabilities of the Arm and Shoulder and Hand scores). Long-term symptoms, Hamada 3rotator cuff arthropathy, and true pseudo paralysis were associated with negative clinical outcomes, but subscapularis pathology and teres minor fatty atrophy were not. Alow complication rate was described. Arthroscopically assisted lower trapezius transfer may restore motion and strength in external rotation. Good results with low complication rates have been reported. It has become the authors' procedure of choice in young active patients with irreparable massive rotator cuff tears.

External rotation bracing for first-time anterior dislocation of the shoulder: A discontinued randomised controlled trial comparing external rotation bracing with conventional sling.

Itoi etal. introduced the concept of bracing in abduction and external rotation to treat traumatic anterior shoulder dislocations. However, controversy remains as studies have reported variable results. Our study investigates whether there is a difference in outcomes between treatment with a conventional sling or external rotation brace. A prospective, multi-centre randomised control trial was conducted between 2006 and 2010. The study was discontinued early with 72 (36 cases in each group) first-time anterior shoulder dislocations recruited. The re-dislocation rate over 24 months was comparable 30% (95% CI: 17-47) sling vs. 24% (95% CI: 13-41) external rotation bracing. Sixteen percent (95% CI: 7-32) of sling patients and 12% (95% CI: 5-27) of external rotation-bracing patients had shoulder stabilisation surgery within 24 months of the initial dislocation (p > 0.05). There was no difference in OSI scores at 24 months between the two treatment groups and intolerability of the external rotation brace was high. Recruitment to this study was difficult, and lost-to-follow-up rates were high leading to early discontinuation of the study. The results suggest that ER bracing is unlikely to provide clinical benefit in traumatic first-time anterior shoulder dislocation.

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.

Traumatic First Time Shoulder Dislocation: Surgery vs Non-Operative Treatment.

Management of first shoulder dislocation following reduction remains controversial. The two main options are immobilisation and arthroscopic stabilisation. The aim of this article is to highlight some of the issues that influence decision making when discussing management options with these patients, including natural history of the first time dislocation, outcomes of surgery and non-operative management particularly on the risk of future osteoarthritis (OA), the effects of delaying surgery and the optimal method of immobilisation. Extensive literature review was performed looking for previous publication addressing 4 points. i) Natural history of primary shoulder dislocation ii) Effect of surgical intervention on natural history iii) Risk of long term osteoarthritis with and without surgical intervention iv) Immobilisation techniques post reduction. Individuals younger than 25 years old are likely to re-dislocate with non-operative management. Surgery reduces risk of recurrent instability. Patients with recurrent instability appear to be at a higher risk of OA. Those who have surgical stabilisation do not appear to be at a higher risk than those who dislocate just once, but are less likely to develop OA than those with recurrent instability. Delaying surgery makes the stabilisation more demanding due to elongation of capsule, progressive labro-ligamentous injury, prevalence and severity of glenoid bone loss. Recent studies have failed to match the preliminary outcomes associated with external rotation braces. Defining the best timing and type of treatment remains a challenge and should be tailored to each individual's age, occupation and degree of physical activity.

Does a brace influence clinical outcomes after arthroscopic rotator cuff repair?

The goal of this study was to report the clinical effects of two different braces after rotator cuff repair. Forty patients who underwent an arthroscopic rotator cuff repair were prospectively allocated in this study. Twenty patients were immobilized in 15° external rotation brace (ER Group), and twenty were immobilised in an internal rotation sling (IR Group). For all patients, four surveys were done: in the immediate pre-operative period (T0), at 1 month (T1), at 3 months (T2) and at 6 months after surgery (T3). Range of motion and pain were evaluated by an independent physician. Self-Assessment Scales [(University California Los Angeles Shoulder Rating Scale (UCLA), Disability of the Arm Shoulder and Hand (DASH), Visual Analog Scale (VAS), Simple Shoulder Test (SST) and Physician Assessment Scale (Constant)] were also administered. Abduction and ER2 (external rotation with arm in abduction) were significantly greater in the ER group at T1, T2 and T3, ER1 (external rotation with arm at side) was significantly greater in the ER group at T1 and T2, IR2 (internal rotation) was significantly greater in the ER group at T1, and FFL (forward flexion) was significantly greater in the ER group at T1. VAS was significantly lower in the ER group at T1 and T2 and T3. About the Self-Assessment Shoulder Scales after 3 and 6 months, no differences were found. SST showed a lesser functional limitation for the ER group at T3. Patients operated with isolated superior or posterosuperior rotator cuff tear immobilised with brace in 15° of ER position showed less pain and a better passive range of motion at short time after surgery.

Shoulder Injury - Bicycling

HISTORY: A 44-year-old left-hand dominant male triathlete sustained a right shoulder injury in a biking accident. He was riding his bike down the road when a car door opened, and he hit the door causing his bike to flip over. He immediately had right shoulder pain and could not move his arm. He had no previous history of shoulder injury or pain. He was within blocks of his orthopedist so he went to the office where radiographs were taken. He was told they were normal and to do ROM exercises. After 2 weeks he was still symptomatic so an MRI was obtained. He presented to our clinic 3 weeks after the injury. He was very active and wanted to return to triathlons. PHYSICAL EXAMINATION: He was in no distress. He had no swelling and vascular examination was normal. He had extremely limited range of shoulder motion with no external rotation without pain. He was neurologically intact including motor and sensation to his right extremity. He had full range of motion of his fingers, wrist and elbow. DIFFERENTIAL DIAGNOSIS: Fracture of scapula Fracture of proximal humerus Dislocated shoulder TEST AND RESULTS: Plain anterior-posterior and axillary radiographs of the shoulder: chronic locked posterior dislocation of right shoulder MRI and CT of shoulder confirms diagnosis with no fractures FINAL WORKING DIAGNOSIS: Fixed sub-acute posterior dislocation of right shoulder. TREATMENT AND OUTCOMES: Four weeks after injury, obtained a closed reduction under anesthesia but stable only in abducted position. Consequently applied body spica cast with arm in abduction and slight external rotation. Arm in body spica cast for 5 weeks. Allowed passive and active range of motion of wrist, hand, and fingers, but not elbow or shoulder. Vicodin for pain. Arm portion of the cast bivalved at 2 weeks to allow for elbow range of motion. Cast removed at 5 weeks post-op. Radiographs before and after cast removal showed the humeral head to be in good position. Transitioned to external rotation brace and started gentle ROM of shoulder. Radiographs at 2 months showed the humeral head was concentric in the glenoid. External rotation brace discontinued. At 3 months post-op, started physical therapy and returned to indoor biking, running, and swimming with the exception of overhead strokes. Returned to triathlon events at 13 months post-op.

Comments on “Low-Cost Alternative External Rotation Shoulder Brace and Review of Treatment in Acute Shoulder Dislocations”

Lacy K, Cooke C, Cooke P, et al. Low-cost alternative external rotation shoulder brace and review of treatment in acute shoulder dislocations. West J Emerg Med. 2015;16(1):114–120. To the Editor: We read the paper of Lacy et al. (2015) with interest.1 The authors present a narrative review of the use of external rotation bracing in acute shoulder dislocations. One of the weaknesses of a narrative review is that it is more likely to be subject to reporting bias. In their review the authors focus on published studies that demonstrated successful outcomes. The first two originate from Itoi et al. whose 2003 randomized controlled trial popularized the concept of external rotation bracing in this patient group.2,3 However, their good results have not been replicated in three subsequent randomized controlled trials.4–6 The third study cited concluded that external rotation bracing was advantageous.7 However, the major confounding factor in that study was that the internal rotation group had a younger mean age. As this is a well-established risk factor for re-dislocation the results of this study should be interpreted with caution.8,9 Furthermore, a recent systematic review and meta-analysis also concluded that ER bracing is not advantageous.10,11 We feel that the narrative review in this publication does not provide a balanced overview of the clinical studies available and we question the value of external rotation in the management of these patients. Lacy et al. also describe the production of a low-cost external rotation brace that is more cost effective than those commercially available. The image of the sling provided demonstrates that this device produces only a small degree of external rotation. A recent systematic review demonstrated that reduction of the labrum is only achieved in 35% of cases when the arm is positioned in over 30 degrees of external rotation.12 However, the clinical studies previously discussed3–5,7 only achieved 10 to 20 degrees of rotation, and the illustration of the described technique in this paper suggests even less was achieved with this alternative brace. As a result, its effectiveness in achieving labral reduction and shoulder stability cannot be extrapolated from previous studies where a higher degree of rotation was obtained. An additional factor not addressed is the acceptability of the splint to patients. External rotation bracing is extremely inconvenient and poorly tolerated. Its prescription is associated with poor compliance, which may limit effectiveness.3–5 In closing we commend the authors on their innovative thinking and consider their design to be a cost-effective alternative to commercially available external rotation braces for posterior dislocations. However, the lack of any clear advantage to external rotation bracing for anterior shoulder dislocations in previous systematic reviews and meta-analysis should limit the subjection of patients to this poorly tolerated brace. The cheaper, more readily available internal rotation sling remains the standard treatment for these patients.

Does External Rotation Bracing for Anterior Shoulder Dislocation Actually Result in Reduction of the Labrum?

Background: External rotation (ER) bracing has been shown to improve labral reduction in cadaveric studies, but this has not translated to universal improvement in re-dislocation rates in clinical series. Purpose: To systematically review and critically appraise the literature that investigates how well the labrum is actually reduced by ER in patients who have had an anterior shoulder dislocation. Study Design: Systematic review. Methods: We conducted a systematic review of the literature using the online databases Medline, EMBASE, and the Cochrane Controlled Trial Register. Studies were included if they reported on the difference in labral reduction after ER and internal rotation bracing in patients who had a traumatic anterior shoulder dislocation. Results: Of the 6 studies included, 5 assessed labral reduction on magnetic resonance imaging and 1 arthroscopically. Each study reported an overall improvement in labral reduction with ER, but anatomic reduction was not commonly achieved. This was despite the use of extreme positions that are unlikely to be well tolerated. Conclusion: External rotation results in anatomic reduction of the labrum in only 35% of cases. We postulate that failure to reduce the labrum may be a contraindication to ER bracing and propose further study to determine whether acute MRI could be used to help identify patients in whom ER achieves labral reduction in a comfortable position. This approach also has the advantage of avoiding the significant inconvenience of ER bracing in those in whom the labrum does not reduce and are therefore theoretically less likely to benefit. However, it is a novel strategy with significant resource implications and therefore warrants further study.

Manipulation and brace fixing for the treatment of congenital clubfoot in newborns and infants.

BackgroundAs one of the most common congenital deformities in children, clubfoot has long been a challenge for orthopedic surgeons. This paper describes the experience of our team with manipulation and above-the-knee brace fixation without percutaneous Achilles tenotomy for the treatment of clubfoot in newborns and infants.MethodsIn the orthopedic department of our hospital, 32 infants and newborns (56 feet) with congenital clubfoot underwent manipulation and above-the-knee brace fixation between 2008 and 2012. External rotation brace was used for 1–4 years during the night after deformity correction. Prospective follow-up for a mean duration of 29 months (range, 12–48 months) was carried out. The efficacy of the treatment was assessed by Pirani’s scoring system before and after treatment.ResultsFifty-two feet achieved a normal appearance within 3 to 6 months (average, 4.2 months) after treatment. Two patients had skin pressure sores due to improper brace care, but these healed with no scarring after timely treatment. The mean Pirani score 1 year after treatment was 0.21 ± 0.09, whereas it was 4.93 ± 1.02 before treatment (p = 0.0078). No patient required treatment with percutaneous Achilles tenotomy.ConclusionThe manipulation and brace fixation used in this study offer an effective method for correcting clubfoot deformity in newborns and infants. This treatment can be an alternative choice to percutaneous Achilles tenotomy.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2474-15-363) contains supplementary material, which is available to authorized users.

Immobilization with an external rotation brace was similar to an internal rotation sling for shoulder dislocation.

The Journal of Bone and Joint Surgery: August 20, 2014 - Volume 96 - Issue 16 - p 1398 doi: 10.2106/JBJS.9616.ebo209

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.

How Does External Rotation Bracing Influence Motion and Functional Scores After Arthroscopic Shoulder Stabilization?

After arthroscopic shoulder stabilization, the loss of motion or delayed recovery of motion remains a clinical problem and may lead to poor patient satisfaction. There remains no consensus regarding the optimal position for postoperative immobilization and it is not known whether the position for shoulder immobilization has an effect on motion and functional recovery. We asked: (1) Do patients treated with external rotation (ER) bracing after arthroscopic anterior shoulder stabilization reliably regain ROM and shoulder function? And (2) what is the frequency of recurrent instability and brace-related complications associated with the use of ER bracing? Forty consecutive patients with a primary diagnosis of anterior shoulder instability underwent arthroscopic stabilization and received postoperative ER bracing; 33 patients (83%; mean age, 23 years; range, 13-44 years) were followed for at least 1 year postoperatively and seven patients were lost to followup. Shoulder ROM and functional scores were recorded preoperatively and at 2 weeks, 12 weeks, 6 months, and greater than 1 year (mean, 16 months) after surgery. All patients recovered their preoperative ROM and most patients achieved normal ROM by 3 months after surgery. Significant improvements in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Shoulder Instability (WOSI) scores were observed at each postoperative time point. The mean (± SD) final scores were 95 ± 9 for the ASES and 87% ± 17% for the WOSI (p < 0.001 compared to preoperative scores). One patient (3%) developed recurrent instability. No patients underwent reoperation for the injured shoulder for any reason during the followup period. ER bracing after arthroscopic shoulder stabilization is associated with a predictable recovery of ROM and functional score improvement. Future studies comparing ER bracing to traditional sling use should be conducted to determine the optimal method of postoperative immobilization. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Modified McLaughlin Technique for Neglected Locked Posterior Dislocation of the Shoulder

Several surgical techniques have been described for the treatment of posterior shoulder dislocation depending on the time elapsed between injury and surgery and the size of the humeral head impression fracture. When the bone defect is between 25% and 50% of the articular surface of the head, the procedures of choice are autologous bone graft or allograft or subscapularis tendon or lesser tuberosity transfer. In neglected cases in which patients undergo surgery more than 3 weeks after injury, no standard accepted treatment for this injury exists. This article presents a modification of the McLaughlin technique for patients with neglected locked posterior dislocation of the shoulder. Using this technique, the shape of the humeral head was nearly restored with impaction of morselized bone allograft; two suture anchors were inserted into the defect, and the lesser tuberosity with the attached sub-scapularis tendon was transferred into the defect and secured with sutures. Postoperative rehabilitation included immobilization of the shoulder with an external rotation brace for 6 weeks followed by progressive passive, active-assisted, and active range of motion and rotator cuff strengthening exercises for another 6 weeks. This technique resulted in pain-free range of motion, a stable shoulder, and good joint congruency.

Immobilizing performances, comfort, and user-friendliness of the shoulder abduction-external rotation braces

Background.Shoulder external rotation braces used for patients with a first-time shoulder dislocation are designed with a variety of arm positions in abduction as well as external rotation. However, few studies have focused on their immobilizing performance, comfort, or user-friendliness. Especially, there have been no robust data of shoulder abduction-external rotation (A-ER) braces in comparison to those of external rotation (ER) braces.Methods.Four types of commercially available shoulder braces (two ER and two A-ER braces) were tested in 30 healthy participants. The angles of external rotation and abduction were measured for each brace at initial application, after simulated daily activities, and after reapplication. Then, subjects were asked to assess the discomfort of bracing and difficulty of reapplication using a visual analogue scale. Data were compared between the two ER braces and two A-ER braces as well as among the four braces.Results. For both external rotation angle and subjective assessment, there were no significant differences between the ER and A-ER braces. Among the four braces, the measurement of arm position demonstrated no significant differences, except the external rotation angles between the two ER braces. The A-ER braces were assessed to be significantly less comfortable than the ER braces in the subjective assessment.Conclusions. Immobilization using the A-ER braces could maintain the arm position in abduction-external rotation with comparable user-friendliness, although they tended to be less comfortable during daily activities compared to the ER braces.

Bilateral Neglected Posterior Fracture–Dislocation of the Shoulders

Posterior dislocation of the shoulder is an uncommon injury. Diagnosis is difficult and often missed. Once diagnosed, management must be individualized depending on the amount of the defect of the humeral head and the time from injury. This article presents a case of a 40-year-old man with a 4-month history of bilateral locked posterior fracture-dislocation of the shoulders after a grand mal seizure. Imaging showed loss of the glenohumeral joint lines congruency, reverse Hill-Sachs lesions, and articular defects of 35% and 40% of the humeral heads. A modified McLaughlin technique was performed in both shoulders in a single stage. Through the standard deltopectoral approach, the lesser tuberosity was osteotomized with the subscapularis and capsule attached and elevated to expose the humeral head and glenoid. The shape of the humeral head was restored by packing the defect with morselized bone allograft. Before packing the allograft into the defect, 2 absorbable suture anchors were inserted at the bottom of the defect; the lesser tuberosity was transferred into the defect, and fixed with 2 transosseous horizontal mattress sutures. Stable fixation was evaluated intraoperatively, and the wound was closed in layers. Postoperatively, both shoulders were immobilized with external rotation braces for 6 weeks, followed by passive, active-assisted, and progressively active range of shoulder motion and rotator cuff strengthening exercises for the next 6 weeks. At 12 weeks postoperatively, full range of motion was accomplished, and full activity was allowed. At 22-month follow-up, the patient was satisfied with his level of function; both shoulder joints were painless and stable without apprehension or recurrence of instability. Radiographs showed congruent joints and complete incorporation of the allograft into the defect with restoration of the shape of the humeral head.

Traumatic anterior shoulder instability in the athlete

Anterior glenohumeral dislocation is common among athletes and may progress to recurrent instability. The pathoanatomy of instability and specific needs of each individual should be considered to prevent unnecessary absence from sport. Traditionally, primary dislocations have been managed with immobilization followed by rehabilitation exercises and a return to sporting activity. However, arthroscopic stabilization and external rotation bracing are increasingly used to prevent recurrent instability. In addition to the typical capsulolabral disruptions seen following a primary dislocation, patients with recurrent instability often have coexistent osseous injury to the humeral head and glenoid. In patients without significant bone loss, open soft-tissue stabilizations have long been considered the 'gold standard treatment' for recurrent instability, but with advances in technology, arthroscopic procedures have gained popularity. However, enthusiasm for arthroscopic repair has not been supported with evidence, and there is currently no consensus for treatment. In patients with greater bone loss, soft-tissue stabilization alone is insufficient to treat recurrent instability and open repair or bone augmentation should be considered. We explore the recent advances in epidemiology, classification, pathoanatomy and clinical assessment of young athletes with anterior shoulder instability, and compare the relative merits and outcomes of the different forms of treatment.

Habitual anterior dislocation of the hip in cerebral palsy

Habitual anterior dislocation of the hip joint is extremely rare. We believe this is the first case reported of a habitual anterior dislocation of the hip occurring in a child with cerebral palsy. The dislocation was painless, voluntary and used to occur every time the child would extend and externally rotate the limb. Operative intervention in the form of a varus derotation femoral osteotomy and anterior capsulorraphy was planned, but the caregivers of the patient were unwilling for the same. Hence, the patient was given an adduction and internal rotation brace and was counselled not to perform the activity needed to dislocate the hip. This case report calls attention to a unique problem previously not reported in cerebral palsy.

Immobilization in an External or Internal Rotation Brace Did Not Differ in Preventing Recurrent Shoulder Dislocation

Immobilization in an External or Internal Rotation Brace Did Not Differ in Preventing Recurrent Shoulder Dislocation

Bracing in external rotation for traumatic anterior dislocation of the shoulder

We undertook a prospective study in 51 male patients aged between 17 and 27 years to ascertain whether immobilisation after primary traumatic anterior dislocation of the shoulder in external rotation was more effective than immobilisation in internal rotation in preventing recurrent dislocation in a physically active population. Of the 51 patients, 24 were randomised to be treated by a traditional brace in internal rotation and 27 were immobilised in external rotation of 15 degrees to 20 degrees. After immobilisation, the patients undertook a standard regime of physiotherapy and were then assessed clinically for evidence of instability. When reviewed at a mean of 33.4 months (24 to 48) ten from the external rotation group (37%) and ten from the internal rotation group (41.7%) had sustained a further dislocation. There was no statistically significant difference (p = 0.74) between the groups. Our findings show that external rotation bracing may not be as effective as previously reported in preventing recurrent anterior dislocation of the shoulder.