{"id":6282,"date":"2026-03-31T14:32:41","date_gmt":"2026-03-31T14:32:41","guid":{"rendered":"https:\/\/www.proefschriftmaken.nl\/portfolio\/david-baden\/"},"modified":"2026-03-31T14:32:46","modified_gmt":"2026-03-31T14:32:46","slug":"david-baden","status":"publish","type":"us_portfolio","link":"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/david-baden\/","title":{"rendered":"David Baden"},"content":{"rendered":"","protected":false},"excerpt":{"rendered":"","protected":false},"author":8,"featured_media":6283,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"us_portfolio_category":[45],"class_list":["post-6282","us_portfolio","type-us_portfolio","status-publish","has-post-thumbnail","hentry","us_portfolio_category-new-template"],"acf":{"naam_van_het_proefschift":"\u2018To Pull or Not To Pull\u2019 Biomechanical Reduction Techniques in Anterior Shoulder Dislocations","samenvatting":"Tijdens een van mijn eerste diensten als arts-assistent op de spoedeisende hulp (SEH) kwam er een pati\u00ebnt met veel pijn binnen. Het enige wat hij kon uitbrengen was; \u201cHet is weer mijn schouder\u201d. Terwijl de pati\u00ebnt snel naar een lege brancard werd gebracht, waren de instructies van de dienstdoend SEH-arts duidelijk. We zouden deze schouder uit de kom (schouderluxatie) snel gaan terugplaatsen.\n\nEr werd een kortwerkend opiaat gegeven, een laken werd om de borst van de pati\u00ebnt geslagen en dat moest ik stevig vasthouden. Terwijl ik de tegendruk gaf, begon de SEH-arts steeds meer te hangen aan de arm van de ontwrichte schouder. Hoewel de pati\u00ebnt ons smeekte om te stoppen vanwege heftige pijn, gingen we door en stelden de pati\u00ebnt gerust dat het snel over zou zijn. Na een paar lange minuten hoorde we een duidelijke 'plop' en was er een voelbare klik, wat duidde op een succesvolle terugplaatsing (repositie). De pati\u00ebnt was direct opgelucht en was erg blij dat zijn schouder terug op z\u2019n plek was gezet. Ik was zeer tevreden met het duidelijk succesvolle resultaat van onze behandeling en ook onder de indruk van alles wat er was gebeurd.\n\nTerwijl ik nog stond bij te komen ontstond er in de teampost een levendige discussie. Want er waren wel vragen of dit nu de beste behandeling was geweest: dit was toch de meeste gangbare manier die zo al jaren plaats vond en ook in de richtlijn was vastgelegd? Of hadden we direct moeten inzetten op een roesje (sedatie) of algehele anesthesie op de operatiekamer bij zoveel pijn voor de pati\u00ebnt? En geeft dat dan weer niet extra belasting van ziekenhuispersoneel, ruimte en apparatuur, want nu was het toch ook gelukt? E\u00e9n opmerking trok extra mijn aandacht en bleef me bij: \u201cEr zijn technieken die minder pijnlijk zijn. Zou dat niet de optimale oplossing zijn?\u201d\n\nDe discussie eindigde niet met consensus over hoe we dit volgende keer moesten doen. Maar voor mij was dit wel het begin van een onderzoek en wetenschappelijke zoektocht naar de behandeling van schouderluxaties op de SEH.\n\nMijn focus van het onderzoek werd in brede zin: hoe kan een arts een pati\u00ebnt met een schouder uit de kom het beste, snel en effici\u00ebnt, helpen zonder veel extra pijn te veroorzaken, met een minimaal risico op extra schade aan de schouder en terwijl het personeel en apparatuur van de afdeling SEH verstandig worden gebruikt.\n\nSchouder anatomie \u2013 een zegen en een vloek\nDe functie van de schouder in het dagelijks leven is groot en dit is mede te danken aan een enorme mobiliteit. Hierdoor is het mogelijk om met de arm een grote reikwijdte te hebben van extensie, flexie, adductie, abductie en interne en externe rotatie. De ossale anatomie van een relatief grote humeruskop die articuleert met een kleinere benige kom of gleno\u00efd maakt dit mogelijk.\n\nHet enorme bereik van de schouder is tegelijk ook zijn zwakte, waardoor hij vatbaar is voor luxaties. Het labrum draagt bij aan de komvormigheid van het gleno\u00efd en zorgt voor extra stabiliteit. De schouderstabiliteit wordt ook verbeterd door de glenohumerale ligamenten en het gewrichtskapsel. De spieren die voor de stabiliteit zorgen zijn de rotator cuffspieren: musculus supraspinatus, subscapularis, infraspintus en teres minor. De deltoideus zorgt ervoor dat de arm kan worden opgeheven (zie figuur 1). Belangrijke aangrenzende neurovasculaire structuren zijn de nervus- en arteria axillaris (oksel zenuw en -slagader).\n\nFiguur 1: Schouderanatomie met botten en spieren die relevant zijn voor schouderluxatie","summary":"DISCUSSION, PERSPECTIVE\n\nAlthough shoulder reduction techniques have been used for over 3,000 years, no \u201cbest treatment\u201d 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.\n\nChapter 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.\n\nTo 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\u2014in technique and pain relief\u2014are currently employed in Dutch EDs.\n\nED 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.\n\nA 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\u2019 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.\n\nA variety of BRT are described. Chapter six proposes an RCT protocol whereby different BRTs can be compared. The RCT\u2019s 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.\n\nVIEWPOINT\n\nAs 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.\n\nAll 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","auteur":"David Baden","auteur_slug":"david-baden","publicatiedatum":"12 oktober 2023","taal":"EN","url_flipbook":"https:\/\/ebook.proefschriftmaken.nl\/ebook\/davidbaden?iframe=true","url_download_pdf":"","url_epub":"","ordernummer":"FTP-202603311429","isbn":"978-94-6469-558-8","doi_nummer":"","naam_universiteit":"Universiteit Utrecht","afbeeldingen":6284,"naam_student:":"","binnenwerk":"","universiteit":"Universiteit Utrecht","cover":"","afwerking":"","cover_afwerking":"","design":""},"_links":{"self":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/6282","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio"}],"about":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/types\/us_portfolio"}],"author":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/comments?post=6282"}],"version-history":[{"count":1,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/6282\/revisions"}],"predecessor-version":[{"id":6285,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/6282\/revisions\/6285"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media\/6283"}],"wp:attachment":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media?parent=6282"}],"wp:term":[{"taxonomy":"us_portfolio_category","embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio_category?post=6282"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}