David Baden

DISCUSSION, PERSPECTIVE

Although shoulder reduction techniques have been used for over 3,000 years, no “best treatment” consensus exists. This is especially true regarding pain management and reduction technique choice. The studies outlined in this thesis, and their discussions, have attempted to provide clarity on these issues. This chapter will further discuss study findings and their implications for medical practice. Future research directions will be discussed as well.

Chapter two provides a general description of current shoulder dislocation management. The influence of acute shoulder dislocation treatment on subsequent functional outcome is reviewed as well. Shoulder dislocations are painful and potentially damaging to bones, muscles, tendons, ligaments, nerves and vasculature. They often have long-lasting impact on daily activities and on the ability to participate in sports. Treatment beyond the acute phase focuses on preventing subsequent dislocations and returning the patient to normal function, if possible, thereby minimizing societal cost by maintaining patient functionality. Patients with a first time dislocation often receive limited and inadequate information on long-term treatment options like surgical repair and non-surgical physical rehabilitation. Shared decision-making is important as treatment should fit individual expectations and needs.

To provide insights on current treatment strategies for patients with anterior shoulder dislocations presenting to Dutch Emergency Departments (ED), chapter three reports the results of a survey of emergency physicians in The Netherlands. The survey focused on (administration of) pain relief, reduction technique of choice, and possible complications. It was distributed to members of the Dutch Society of Emergency Physicians (NVSHA). Results indicated that 44% of respondents used a traction method first. Biomechanical techniques were used by 40% of respondents in their initial reduction attempts. Only 12% favored a lever technique as their first approach, and 4% of the techniques could not be classified. Complications were inconsistently reported, making analysis impossible. A wide range of pain medications were used. Most commonly, an intravenous opiate was employed. The anesthetic agent, Propofol, was the most used sedative. Most respondents reported a first-attempt success rate of 75% or higher, regardless of reduction technique used. Overall, the survey indicated that a wide variety of shoulder reduction management strategies—in technique and pain relief—are currently employed in Dutch EDs.

ED overcrowding is a significant issue in The Netherlands, making ED length-of-stay (LOS) increasingly important. Chapter four outlines a retrospective study, conducted in two Dutch hospitals, detailing the factors influencing ED-LOS for patients with a dislocated shoulder. Data were collected from 2010 to 2016 on patients over the age of 12 presenting with a dislocated shoulder. Electronic health records were abstracted for: trauma mechanism, reduction method(s), medication used to treat pain and facilitate reduction, complications, and ED-LOS. During the study period, 716 anterior shoulder dislocations (ASD) were seen in 574 patients, of which 374 (65.2%) were male. First-time ASDs numbered 389 (54.3%). Median LOS was 92 minutes (Interquartile range: 66 minutes). LOS was shorter in: younger patients, those with recurrent dislocations and when analgesics were not given. Use of a lever or traction technique led to increased ED medication use but did not significantly influence ED-LOS.

A systematic review of shoulder reduction success rates without the use of analgesic medication is reported in chapter five. Additionally, a discussion of complication risks and the impact of reduction technique on patients’ pain experience is included. Randomized and observational studies comparing two or more reduction techniques for anterior shoulder dislocations in the ED, without the use of sedation or intra-articular lidocaine injections, are included. Reduction techniques are grouped as biomechanical reduction technique (BRT), leverage, or traction-countertraction (TCT) technique. Over 2,700 article titles and abstracts were screened. Nine articles, with a total of 987 patients, are included in the analysis. Success rates were 0.80 (95% CI 0.74; 0.85), 0.81 (95% CI 0.63; 0.92) and 0.80 (95% CI 0.56; 0.93) for BRT, leverage and TCT, respectively. No success rate differences were observed between the three different reduction groups. In the network meta-analysis, similar, but more precise effect estimates were found. In a post-hoc analysis, the BRT group was more successful than the combined leverage and TCT group with a relative risk of 1.33 (95% CI: 1.19, 1.48). Patients in the BRT group reported significantly less pain with a VAS difference of -2.8 (95% CI -4.2, -1.4) and -0.3 (95% CI -0.6, -0.1) compared to leverage and TCT, respectively. BRT reductions were successful significantly faster than either leverage or TCT, 53 seconds (95% CI: -76, -30) versus 194 seconds (95% CI: -226, -161). These data suggest that BRT may be the optimal treatment for ASDs given high success rates, less patient discomfort, and shortest performance duration.

A variety of BRT are described. Chapter six proposes an RCT protocol whereby different BRTs can be compared. The RCT’s results are presented in Chapter seven. Three hundred and eight patients were enrolled and divided into two groups based on ability to adduct their injured arms. The arm-adduction-able group contained 134 patients. The arm-adduction-unable group had 174 patients. Patients in the arm-adduction-able group were randomized to treatment with Cunningham, modified Milch, or scapular manipulation. Those in the arm-adduction-unable group were randomized to either modified Milch or scapular manipulation. Primary outcomes were ED LOS and pain during reduction assessed by the numerical pain scale. Secondary outcomes included: reduction time, reduction success rate, use of analgesics or sedatives, and complications. In both groups no differences in ED LOS or reported pain were observed in the adduction-able group. The modified Milch technique had the highest first-reduction-attempt success rate, at 52% (p=0.016). In the adduction-unable group, modified Milch also had the best success rate, of 51% (p=0.040), as a first reduction technique. Complications were not seen with any of the reduction methods used.

VIEWPOINT

As indicated, it is striking that for a condition as common and painful as shoulder dislocation, most research is found methodologically and substantively inconsistent. This thesis conducts a systemic research into the subject of shoulder dislocations using a pragmatic approach. This is particularly relevant since several notable gaps in current knowledge exist. Objective information and prospective validation of outcomes is needed. Literature heterogeneity hampers direct technique comparison and has profound implications for daily emergency medicine practice. It is also unclear whether confounders such as the provision of pain medications, medical staff education, and medical staff experience with certain techniques influence studies and their outcomes.

All this means that informed choices had to be made in this thesis. These choices are guided by daily practice experience since information was found noticeably lacking in the available