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. 2019 Jan 3;2019(1):CD011051. doi: 10.1002/14651858.CD011051.pub2

Closed reduction methods for acute anterior shoulder dislocation

Kanthan Theivendran 1,2,✉, Raj R Thakrar 2, Subodh C Deshmukh 2, Kerry Dwan 3
PMCID: PMC6353084

Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To compare the effects of different methods of closed reduction of acute anterior shoulder dislocation.

Background

Description of the condition

Anterior glenohumeral dislocation of the shoulder joint describes the forward‐directed displacement of the humeral head (top end of the upper arm bone) out of the socket (glenoid) of the shoulder joint. Usually people present with complete dislocation or they describe symptoms of instability, where the humeral head can move into a partially dislocated (subluxed) position but often spontaneously returns to its original position.

Although shoulder dislocation can occur in other directions, anterior glenohumeral dislocations are the most common, comprising between 85% to 98% of all shoulder dislocations (DePalma 1973; Rowe 1963). In contrast, posterior shoulder dislocations, which involve backward‐directed displacement, make up only 2% to 3% of all glenohumeral dislocations (Rowe 1963).

Shoulder dislocations occur with a reported incidence ranging from 8.2 to 23.9 per 100,000 persons per year (Kazar 1969; Nordqvist 1995; Owens 2007; Simonet 1984). A Danish population‐based study documenting shoulder dislocations over a five‐year period found that the overall incidence rate was 17 in 100,000 per year (Kroner 1989). Kroner 1989 found that most anterior shoulder dislocations happened in younger people during sporting activities. In older people, dislocations often result from a fall from standing height. The general mechanism of injury is a fall onto the outstretched arm in abduction (away from the body) with external rotation; this results in levering the head of the humerus anteriorly (in front) of the glenoid (socket) of the shoulder joint. Another mechanism is a direct impact at the back of the shoulder, which levers the humeral head out of the socket resulting in an anterior shoulder dislocation.

Shoulder dislocations are related to a traumatic event in up to 96% of cases (Rowe 1956). Dislocation can also occur in individuals with generalised ligament laxity. One study found a 46% incidence of ligament laxity in people who sustained a sports‐related shoulder dislocation (Akhtar 2010).

Subsequent to dislocation, the shoulder is less stable and more susceptible to re‐dislocation. Prospective and retrospective studies of the natural history of initial (primary) shoulder dislocations suggest that recurrence depends primarily on age and activity level. Hovelius 2008 reported on 227 study participants with primary anterior shoulder dislocation who were managed non‐operatively and found the rate of recurrence lower in people over 30 years (27%) compared with under 23 years (72%). In a prospective study of 252 participants with anterior dislocations, a recurrence rate of 87% was found in people aged 15 to 20 years (Robinson 2006).

The goal of treatment after anterior shoulder dislocation is to restore pain‐free, functional range of movement whilst maintaining shoulder stability. This is usually achieved by non‐surgical means, starting with closed reduction, where the humeral head (ball) is manoeuvred back onto the glenoid (socket). This is followed by a period of three to six weeks of immobilisation in a sling, and subsequent structured physiotherapy exercises. Surgical intervention is generally reserved for recurrence or instability (Handoll 2004; Handoll 2006). Most closed reductions are performed in the emergency department using intravenous analgesia with sedation (Chong 2006), although other forms of analgesia such as intra‐articular injections and inhaled nitrous oxide have also been used. Closed shoulder reduction can be also performed without any analgesia (O'Connor 2006).

Description of the intervention

Many techniques have been described for reduction of anterior shoulder dislocations. In perhaps the oldest, the Hippocratic technique, longitudinal traction was applied on the dislocated upper extremity with counterforce against the humeral head in the axilla (arm pit). Typically, a ball of the physician's heel was used for countertraction. However, given the numerous accounts of neurovascular complications and traumatic injuries, this technique is uncommon nowadays. An example of a less forceful method is the Milch technique, where the shoulder is gently abducted and externally rotated with one of the physician's hands placed over the humeral head; the physician then gently pushes the humeral head back onto the glenoid while the arm is in full abduction. Janecki 1982 reported that there were no neurovascular injuries or fracture complications encountered in a series of 50 consecutive anterior dislocations reduced with this technique.

Overall, closed reduction methods generally involve one or more manoeuvres to relocate the humeral head back into place. These can be classified according to their principal mode of action.

Traction‐countertraction methods are exemplified by the Hippocratic (Mattick 2000) and Stimson (Stimson 1900) techniques whereby longitudinal force is applied whilst providing an opposite counteractive force. Other examples of methods using traction‐countertraction are Manes (Manes 1980), Eskimo (Poulsen 1988) and Snowbird (Westin 1995). More modern techniques have been described, including the FARES (Fast, Reliable and Safe) method, where traction is applied with vertical oscillating movements of the arm whilst increasing abduction (Sayegh 2009).

Leverage manoeuvres are exemplified by the Kocher technique (Kocher 1870), which involves external rotation followed adduction and internal rotation of the shoulder, and the Milch technique (Milch 1938), which uses abduction and external rotation over the patient's head. Other examples are Cunningham (Cunningham 2003), Eachempati (Eachempati 2004) and Spaso (Ugras 2008).

Other techniques include scapular manipulation (McNamara 1993), where the scapula is rotated manually in order for the humeral head to fall back into place while the arm is kept in traction.

How the intervention might work

The aim of closed reduction of acute anterior shoulder dislocation is to restore (reduce) the normal anatomical position of the humeral head joint surface with the joint surface of the glenoid. The repositioning of the humeral head back onto the glenoid of the shoulder joint should restore pain‐free movement and function of the arm. The method or manipulative technique to achieve this reduction without operative (surgical) intervention should be quick, effective and simple to perform and should require minimal force, analgesia and assistance from other people (such as for applying traction). The technique should not damage the shoulder joint structures (e.g. labrum, humeral head) or the surrounding nerves or vessels. The obstacles to relocating the humeral head are both static barriers, principally the glenoid rim, and dynamic forces from muscles that continue to pull on the displaced humeral head. Reduction methods represent different ways of circumventing these barriers, set in the context of the above aims.

The rates of success and complications following closed reduction vary according to the method used (Miller 2002; Riebel 1991). Although most anterior shoulder dislocations can be easily reduced in the emergency department, some dislocations still require more than one method and in 5% to 10% of cases reduction can only be achieved under general anaesthesia in the operating room (Riebel 1991; Ufberg 2004). On the whole the type of reduction technique performed is generally based on the individual physician's experience and the method he or she was trained in.

A failure to reduce a dislocated shoulder successfully within the first 24 hours carries the risk that it will be difficult to achieve a stable closed reduction (Hovelius 1996). Late reduction may cause muscle spasm along with possible engaging dislocation. This is where after dislocation the shoulder is 'locked' in a dislocated position with the posterior humeral head impacted onto the anterior rim of the glenoid (an engaging Hills Sach's lesion). In this situation it may be impossible to reduce the dislocation in the emergency care setting and open reduction in theatre may be required.

Why it is important to do this review

Closed reduction is the primary treatment for most cases of acute anterior shoulder dislocation, which is a fairly common and painful injury that can occur at any age. It is important to identify and summarise the current evidence from randomised controlled trials in order to determine the most effective and safe method of closed reduction that also has the best long‐term outcome, including the lowest rate of subsequent recurrence.

Objectives

To compare the effects of different methods of closed reduction of acute anterior shoulder dislocation.

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials and quasi‐randomised (using a method of allocating participants to a treatment that is not strictly random, e.g. by hospital number) controlled trials evaluating closed reduction methods for acute anterior shoulder dislocation.

Types of participants

People who have an acute anterior shoulder dislocation that is considered suitable by the trial investigators for reduction by closed methods (non‐surgical procedure). This can be a primary or first‐time dislocation or a re‐dislocation. Closed reduction can take place in any setting. Ideally, the acute anterior shoulder dislocation should have been confirmed by physical examination and radiography or other imaging technique. Where trials do not specify their method of diagnosis or base their diagnosis on physical examination alone, we will consider the potential for misdiagnosis, such as a missed proximal humeral fracture. We will exclude trials focusing on people with fracture‐dislocations of the proximal humerus.

Although we will not exclude trials including patients presenting more that 24 hours after injury, we anticipate that most trials will exclude these late presentations as they are generally treated in theatre.

Types of interventions

Various methods (manipulative manoeuvres) of closed reduction of anterior shoulder dislocation have been described. We aim to compare different methods of putting the shoulder joint back into its normal position (reduction) without the need for surgery. We will group reduction techniques according to their principal mode of action: traction‐countertraction, leverage and scapular manipulation.

We plan the following comparisons based on the principal modes of action.

  • Leverage versus traction‐countertraction

  • Scapular manipulation versus traction‐countertraction

  • Scapular manipulation versus leverage

When comparing techniques with similar modes of action, the control comparison will be the older or more established of the methods used.

Types of outcome measures

Primary outcomes

  • Reduction success. We will define this as a successful reduction after up to two attempts with the same technique, without requiring a major change in analgesia or anaesthesia. We will collect other definitions of reduction success used by study authors under the secondary outcome 'reduction failure'.

  • Pain scores (visual analogue scale) measured during the procedure.

  • Complications: for example, early complications can include fractures of the proximal humerus and nerve injuries; complete failure requiring general anaesthesia, surgery or both.

Secondary outcomes

  • 'Reduction failure' (lack of success) as defined by study authors. This could include a change in technique, more than two attempts at reduction and complete failure.

  • Patient satisfaction with intervention.

  • Number of attempts at reduction.

  • Subsequent recurrence of dislocation, preferably assessed at one year or more.

  • Long‐term shoulder function assessed using validated patient‐reported outcome measures such as the Oxford Shoulder Instability Score (Dawson 1999) and Western Ontario Shoulder Instability Score (WOSI) (Kirkley 1998), preferably assessed at one year.

  • Duration of reduction procedure (time taken to put the shoulder back into joint from start of closed reduction procedure).

Search methods for identification of studies

Electronic searches

We will search the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to present), the Cochrane Central Register of Controlled Trials (in The Cochrane Library, current issue), MEDLINE (1946 to present) and EMBASE (1980 to present). We will also search the World Health Organization International Clinical Trials Registry platform and Current Controlled Trials to identify ongoing and recently completed trials. We will apply no restrictions based on language or publication status.

In MEDLINE (Ovid Online), we will combine a subject‐specific strategy with a modified version of the of the Cochrane Highly Sensitive Search Strategy for identifying randomised trials (sensitivity‐maximising version) (Lefebvre 2011). Search strategies for MEDLINE, The Cochrane Library and EMBASE can be found in Appendix 1.

Searching other resources

We will check reference lists of articles. We will also attempt to contact researchers in the field for information on existing or ongoing trials. We will search specific proceedings of shoulder and elbow surgery meetings and conferences from the following sources: British Elbow and Shoulder Society (2001 onwards); American Orthopaedic Trauma Association (1996 onwards); The Bone and Joint Journal Orthopaedic Proceedings (2001 onwards) and American Shoulder and Elbow Society (2005 onwards).

Data collection and analysis

Selection of studies

Two review authors (KT and RT) will independently examine the titles and abstracts of articles identified via the search for potentially eligible trials. After obtaining the full texts of these trials, where possible, the same two authors will then independently perform study selection based on our inclusion criteria. Any disagreement will be discussed and, if necessary, a third author (SD) will arbitrate. Where necessary, we will attempt to contact trial authors for clarification of study methods.

Data extraction and management

Two review authors (KT and RT) will independently extract data from each included trial using a piloted data extraction form. We will resolve any differences in data extraction by consensus, and by referring back to the original article. When necessary, we will seek information from the study authors. Disagreement will be resolved by discussion and, where necessary, in consultation with a third review author (SD).

Assessment of risk of bias in included studies

Two review authors (RT and KD) will independently assess the risk of bias of the included studies using The Cochrane Collaboration's 'Risk of bias' tool (Higgins 2011). We will assess the following domains: random sequence generation;
 allocation concealment;
 blinding of participants and personnel;
 blinding of outcome assessment;
 completeness of outcome data;
 selective reporting
 and other bias. We will attempt to locate trial registrations of included trials in trial registries; this will include the UK National Research Register (NRR) Archive, where appropriate. We will consider two sources of other bias: that from major imbalances in baseline characteristics (age, time from injury, primary or recurrent dislocations) and additional performance bias arising from differences in the level of experience of the care providers with the methods of reduction under test.

We will judge each of these domains as being at low risk of bias, high risk of bias or unclear risk of bias (either lack of information or uncertainty over the potential for bias). Disagreement will be resolved by discussion and, where necessary, in consultation with a third review author (SD).

Measures of treatment effect

We will calculate risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes (such as reduction success) and mean differences with 95% CIs for continuous outcomes (such as pain measured with a visual analogue scale). When pooling continuous outcome data, we will use mean differences and 95% CIs where similar scales are used to measure the same outcome and standardised mean differences (SMD) and 95% CIs where different scales are used to measure the same outcome.

Unit of analysis issues

We anticipate that the units of randomisation and analysis in the included trials will be the individual participant. Exceptionally, people may present with bilateral dislocations, which may be randomised to a single procedure for each limb. Therefore, a trial including people with bilateral dislocations may present results for limbs rather than individuals. We will ignore this type of discrepancy between the unit of analysis and randomisation if we assess it as being unlikely to change the trial results. Where we pool data, we will perform a sensitivity analysis to examine the effects of excluding incorrectly reported trials from the analysis.

Dealing with missing data

Where appropriate, we will perform intention‐to‐treat analyses in which all randomised participants are analysed in the groups to which they were originally assigned. We will attempt to contact authors of primary studies to request missing data from trials such as means, standard deviations or number of events. Where standard deviations from continuous data have not been reported, we will calculate standard deviations, if possible, from standard errors, P values or confidence intervals, using the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). If we are unable to do this, we will not impute standard deviations from similar studies.

Assessment of heterogeneity

We will assess clinical heterogeneity within all comparisons of all included trials. We will assess statistical heterogeneity by visual inspection of graphs (e.g. forest plots) and calculation of the I² statistic, which provides an estimate of the percentage of variability due to heterogeneity rather than to chance alone. We will judge there to be 'considerable heterogeneity' if the I² estimate is 75% or more (Higgins 2003; Higgins 2011).

Assessment of reporting biases

We will investigate the possibility of publication bias by constructing a funnel plot if there are data from more than 10 trials.

Data synthesis

When considered appropriate, we will pool results of comparable groups of trials using both fixed‐effect and random‐effects models. The choice of the model to report will be guided by careful consideration of the extent of heterogeneity and whether it can be explained, in addition to other factors, such as the number and size of included studies. We will use 95% CIs throughout. We will consider not pooling data where there is considerable heterogeneity (I² > 75%) that cannot be explained by the diversity of methodological or clinical features among trials. Where it is inappropriate to pool data, we will still present trial data in the analyses or tables for illustrative purposes and will report these in the text.

Subgroup analysis and investigation of heterogeneity

Where data allow, we will analyse variations of similar techniques or methods of reduction.

If possible, and where relevant, we will conduct the following subgroup analyses:

  • participants with first time versus recurrent dislocation;

  • age range: less than 30 years, older than 30 years (Hovelius 2008);

  • athletes versus non‐athletes;

  • the use/type of anaesthesia/sedation (including sedation, intra‐articular anaesthetic and intravenous analgesia).

The age ranges have been chosen to reflect those reported in an important long‐term study by Hovelius 2008, highlighting the higher chances of recurrence of dislocation in the younger age category.

We will investigate whether the results of subgroups are significantly different by inspecting the overlap of confidence intervals and performing the test for subgroup differences available in Review Manager 5.2 (RevMan 2012).

Sensitivity analysis

Where possible, we plan to conduct sensitivity analyses examining various aspects of trial and review methodology. These will include examining the effects of:

  • excluding trials at high or unclear risk of bias, such as selection bias arising from the lack of allocation concealment;

  • excluding trials only reported in conference abstracts;

  • excluding trials with unit of analyses problems related to the inclusion of participants with bilateral dislocations;

  • the choice of statistical model for pooling (fixed‐effect versus random‐effects);

  • missing data.

Assessing the quality of the evidence

We will use the GRADE approach to assess the quality of evidence related to each of the primary outcomes listed in Types of outcome measures (Higgins 2011; see section 12.2). Where there are sufficient data, we will summarise the results for the main comparisons described in Types of interventions in 'Summary of findings' tables.

Acknowledgements

We would like to thank Lindsey Elstub for general helpful advice and support. We are also grateful to Joanne Elliott for advice on developing the search strategies. We would like to thank Keith Hill and Kash Khan for their feedback at editorial and external review. We would like to thank Laura MacDonald and Helen Handoll for continued support and final revision of the protocol.

Appendices

Appendix 1. Search strategies

The Cochrane Library (Wiley Online Library)

#1 MeSH descriptor: [Shoulder Dislocation] this term only #2 ((shoulder* or glenohumeral) near/3 (dislocat* or sublux* or lux*)):ti,ab,kw (Word variations have been searched) #3 #1 or #2 #4 closed or conservativ* or nonoperativ* or non operativ*:ti,ab,kw (Word variations have been searched) #5 reduc* or maneuv* or manoeuvr* or manipulat* or reposition* or traction or counter traction or countertraction or TCT or leverage or direct pressure*:ti,ab,kw (Word variations have been searched) #6 Hippocratic or Stimson or Kocher or Milch or FARES or Spaso or Eskimo or Manes or Cunningham or Eachempati or Snowbird:ti,ab,kw (Word variations have been searched) #7 #4 or #5 or #6 #8 #3 and #7

MEDLINE (Ovid Online)

1 Shoulder Dislocation/ 2 ((shoulder* or glenohumeral) adj3 (dislocat* or sublux* or lux*)).tw. 3 1 or 2 4 (closed or conservativ* or nonoperativ* or non operativ*).tw. 5 (reduc* or man?euv* or manipulat* or reposition* or traction or counter traction or countertraction or TCT or leverage or direct pressure*).tw. 6 (Hippocratic or Stimson or Kocher or Milch or FARES or Spaso or Eskimo or Manes or Cunningham or Eachempati or Snowbird).tw. 7 4 or 5 or 6 8 3 and 7 9 Randomized controlled trial.pt. 10 Controlled clinical trial.pt. 11 randomized.ab. 12 placebo.ab. 13 randomly.ab. 14 trial.ab. 15 groups.ab. 16 or/9‐15 17 exp Animals/ not Humans/ 18 16 not 17 19 8 and 18

EMBASE (Ovid Online)

1 Shoulder Dislocation/ 2 ((shoulder* or glenohumeral) adj3 (dislocat* or sublux* or lux*)).tw. 3 1 or 2 4 (closed or conservativ* or nonoperativ* or non operativ*).tw. 5 (reduc* or man?euv* or manipulat* or reposition* or traction or counter traction or countertraction or TCT or leverage or direct pressure*).tw. 6 (Hippocratic or Stimson or Kocher or Milch or FARES or Spaso or Eskimo or Manes or Cunningham or Eachempati or Snowbird).tw. 7 4 or 5 or 6 8 3 and 7 9 Randomized controlled trial/ 10 Clinical trial/ 11 Controlled clinical trial/ 12 Randomization/ 13 Single blind procedure/ 14 Double blind procedure/ 15 Crossover procedure/ 16 Placebo/ 17 Prospective study/ 18 ((clinical or controlled or comparative or placebo or prospective* or randomi#ed) adj3 (trial or study)).tw. 19 (random* adj7 (allocat* or allot* or assign* or basis* or divid* or order*)).tw. 20 ((singl* or doubl* or trebl* or tripl*) adj7 (blind* or mask*)).tw. 21 (cross?over* or (cross adj1 over*)).tw. 22 ((allocat* or allot* or assign* or divid*) adj3 (condition* or experiment* or intervention* or treatment* or therap* or control* or group*)).tw. 23 RCT.tw. 24 or/9‐23 25 Case Study/ or Abstract Report/ or Letter/ 26 24 not 25 27 8 and 26

What's new

Date Event Description
3 January 2019 Amended Protocol withdrawn due to lack of progress
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Contributions of authors

KT: conceiving the review, designing and writing the protocol. KT is also the guarantor of the review RT: providing general advice on drafts of the protocol SD: providing general advice on drafts of the protocol KD: providing general advice on drafts of the protocol

Sources of support

Internal sources

  • Royal Orthopaedic Hospital, Birmingham, UK.

  • University Hospital Birmingham, UK.

External sources

  • No sources of support supplied

Declarations of interest

Kanthan Theivendran: none known Raj R Thakrar: none known Subodh C Deshmukh: none known Kerry Dwan: none known

Notes

This protocol was withdrawn in January 2019 due to lack of progress.

Withdrawn from publication for reasons stated in the review

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