Closed reduction of glenohumeral dislocations with associated tuberosity fracture in the emergency department is safe

Mackenzie, Samuel P.; Hackney, Rosemary Jane; Crosbie, Gearóid; Ruthven, Alasdair K Barbour; Keating, J. F.

doi:10.1016/j.injury.2020.09.062

Cited by 3 publications

(6 citation statements)

References 12 publications

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“…Clinicians should make their own judgement about the likelihood of fracture given each mechanism of injury and think more broadly than the specific high-risk mechanisms described by the FQR. However, reassuringly, all of the ‘missed’ injuries reported among younger patients by Ong et al 20 and Bolvardi et al 21 were greater tuberosity fractures20 and so would not have precluded closed reduction in the ED 6…”

Section: Discussionmentioning

confidence: 99%

“…All eight studies defined clinically significant fractures as including all fracture patterns except for Hill-Sachs lesions. However, the most common bony injury (isolated tuberosity fractures) does not preclude closed reduction in the ED,6 7 and so identifying this injury may not affect the immediate management. Nevertheless, there are a number of reasons why it might be helpful to identify this fracture before reduction.…”

Section: Discussionmentioning

confidence: 99%

“…However, up to 25% of shoulder dislocations are associated with fracture of the proximal humerus 3–5. Concomitant fractures are important to identify as fracture of the humeral neck contraindicates closed reduction in the ED 6 7. Although tuberosity fractures are not an absolute contraindication,6 7 they are important to identify as they increase the risk of iatrogenic humeral neck fracture during attempts at reduction 8.…”

Section: Introductionmentioning

confidence: 99%

“…Concomitant fractures are important to identify as fracture of the humeral neck contraindicates closed reduction in the ED 6 7. Although tuberosity fractures are not an absolute contraindication,6 7 they are important to identify as they increase the risk of iatrogenic humeral neck fracture during attempts at reduction 8. It is therefore conventional to obtain plain radiographs before attempting closed reduction of a clinically dislocated shoulder 2.…”

Section: Introductionmentioning

confidence: 99%

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Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies

et al. 2022

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BackgroundPrereduction radiographs are conventionally used to exclude fracture before attempts to reduce a dislocated shoulder in the ED. However, this step increases cost, exposes patients to ionising radiation and may delay closed reduction. Some studies have suggested that prereduction imaging may be omitted for a subgroup of patients with shoulder dislocations.ObjectivesTo determine whether clinical predictors can identify patients who may safely undergo closed reduction of a dislocated shoulder without prereduction radiographs.MethodsA systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. The search was updated to 23 June 2022 and language limits were not applied. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data were pooled and meta-analysed by fitting univariate random effects and multilevel mixed effects logistic regression models.ResultsEight studies reported data on 2087 shoulder dislocations and 343 concomitant fractures. The most important potential sources of bias were unclear blinding of those undertaking the clinical (6/8 studies) and radiographic (3/8 studies) assessment. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (positive likelihood ratio (LR+) 1.8, 95% CI 1.5 to 2.1; negative likelihood ratio (LR−) 0.4, 95% CI 0.2 to 0.6), female sex (LR+ 2.0, 95% CI 1.6 to 2.4; LR− 0.7, 95% CI 0.6 to 0.8), first-time dislocation (LR+ 1.7, 95% CI 1.4 to 2.0; LR− 0.2, 95% CI 0.1 to 0.5) and presence of humeral ecchymosis (LR+ 3.0–5.7, LR− 0.8–1.1). The most important mechanisms of injury were high-energy mechanism fall (LR+ 2.0–9.8, LR− 0.4–0.8), fall >1 flight of stairs (LR+ 3.8, 95% CI 0.6 to 13.1; LR− 1.0, 95% CI 0.9 to 1.0) and motor vehicle collision (LR+ 2.3, 95% CI 0.5 to 4.0; LR− 0.9, 95% CI 0.9 to 1.0). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6% to 99.2%) and a specificity of 33.3% (95% CI 23.1% to 45.3%), but the Fresno-Quebec rule identified all clinically important fractures across two studies: sensitivity of 100% (95% CI 89% to 100%) in the derivation dataset and 100% (95% CI 90% to 100%) in the validation study. The specificity of the Fresno-Quebec rule ranged from 34% (95% CI 28% to 41%) in the derivation dataset to 24% (95% CI 16% to 33%) in the validation study.ConclusionClinical prediction rules may have a role in supporting shared decision making after shoulder dislocation, particularly in the prehospital and remote environments when delay to imaging is anticipated.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies

et al. 2022

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“…3,30,33,35 However, the foundation of this perceived need is not well supported, since these concomitant injuries rarely affect short-term management. 25,[36][37][38] A pressing question posed by this study is whether the attempted reduction of suspected ASD can be performed safely when significant fracture-dislocations or misdiagnoses cannot be ruled out by imaging. Although concern for displacing a fracture is reasonable, studies have shown that worsening radiographic abnormalities from reduction attempts are exceedingly rare 31,33 and that biomechanical techniques, such as those used in this study, can be safe and effective even with clinically significant fracture-dislocations.…”

Section: Discussionmentioning

confidence: 99%

Austere Diagnosis and Reduction of Anterior Shoulder Dislocations: 10-Year Review of a Ski Patrol-Based Program with Emergency Medical Technicians

Pringle

Hurley²,

McGrath

et al. 2023

Wilderness & Environmental Medicine

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Introduction-Glenohumeral dislocations present a challenging management dilemma in austere settings where patient transport time may be prolonged. Expeditious reduction is preferable, but treatment is commonly expected to take place within a hospital or comparable facility. Through a novel shoulder injury program, professional ski patrollers trained as emergency medical technicians (EMTs) have diagnosed and reduced anterior shoulder dislocations using biomechanical techniques without sedation or analgesia for over 20 y. Summary records have been maintained to track the performance and safety of this program.Methods-Five hundred forty-six records of winter sports-related shoulder injuries from 2009-10 to 2019-20 were retrospectively analyzed to determine the assessment performance and dislocation reduction efficacy of EMTs, with the intent of ascertaining whether EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations without premedication in a remote and resource-limited setting.Results-EMTs identified anterior shoulder dislocations with 98% sensitivity and 96% diagnostic accuracy. The overall success rate of reduction attempts was 86%, or 88% when limited to confirmed anterior dislocations. Two fracture-dislocations and 4 misdiagnoses were manipulated. No instances of iatrogenic harm were identified, and no patients who underwent successful reductions required ambulance transportation.Conclusions-With appropriate education and within a structured program, EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations using biomechanical techniques without premedication in remote and resource-limited environments. Implementation of similar programs in austere settings has the potential to improve patient care. Further, using biomechanical reduction techniques may reduce reliance on procedural sedation irrespective of care setting.

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Bilateral fracture-dislocation of the shoulder following a seizure- A case report & review of literature

Pathinathan

Perera

Marasinghe

et al. 2022

Annals of Medicine &Amp; Surgery

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Closed reduction of glenohumeral dislocations with associated tuberosity fracture in the emergency department is safe

Cited by 3 publications

References 12 publications

Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies

Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies

Austere Diagnosis and Reduction of Anterior Shoulder Dislocations: 10-Year Review of a Ski Patrol-Based Program with Emergency Medical Technicians

Bilateral fracture-dislocation of the shoulder following a seizure- A case report & review of literature

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