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Woyke S, Pawlak J, Cappello TD, Schultheiss G, Mayer H, Witt U, Strapazzon G, Brugger H, Jacob M. Shoulder reduction on the scene: current practice and outcome of the Bavarian Mountain Rescue Service-a prospective observational study. Sci Rep 2023; 13:20212. [PMID: 37980383 PMCID: PMC10657475 DOI: 10.1038/s41598-023-47464-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/14/2023] [Indexed: 11/20/2023] Open
Abstract
Out-of-hospital reduction of shoulder dislocations using the Campell method is recommended by the International Commission for Alpine Rescue and applied in the Bavarian Mountain Rescue Service (Bergwacht Bayern, BWB) protocols. This prospective observational study includes patients out-of-hospital with suspected shoulder dislocation and treated and evacuated by the BWB. Data were systematically collected using three questionnaires: one completed on-site by the rescuer, the second in hospital by the physician and the third within 28 (8-143) days after the accident by the patient. The suspected diagnosis of shoulder dislocation was confirmed in hospital in 37 (84%) of 44 cases. Concomitant injuries in other body regions were found in eight (16%) of 49 cases and were associated with incorrect diagnosis (p = 0.002). Younger age (p = 0.043) and first shoulder dislocation event (p = 0.038) were associated with a higher success rate for reduction attempts. Out-of-hospital reduction of shoulder dislocations leads to significant pain relief and no poorer long-term outcome. Signs that are associated with successful out-of-hospital reduction (younger age and first event), but also those that are associated with incorrect diagnosis (concomitant injuries) should be considered before trying to reduce shoulder dislocation on site. The considerable rate of incorrect first diagnosis on site should give rise to an intensive discussion around teaching and training for this intervention.Trial registration: This study is registered with the German Registry for Clinical Trials (DRKS00023377).
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Affiliation(s)
- Simon Woyke
- Bavarian Mountain Rescue Service, Am Sportpark 6, 83646, Bad Tölz, Germany
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Johannes Pawlak
- Bavarian Mountain Rescue Service, Am Sportpark 6, 83646, Bad Tölz, Germany.
- Landesamt für Gesundheit und Lebensmittelsicherheit, Task Force Infectiology, Munich, Germany.
| | - Tomas Dal Cappello
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Georg Schultheiss
- Bavarian Mountain Rescue Service, Am Sportpark 6, 83646, Bad Tölz, Germany
- Department of Anaesthesiology and Intensive Care Medicine, RoMed Clinic Bad Aibling, Bad Aibling, Germany
| | - Herbert Mayer
- Bavarian Mountain Rescue Service, Am Sportpark 6, 83646, Bad Tölz, Germany
- Department of Traumatology and Orthopedic Surgery, Clinic Immenstadt, Immenstadt, Germany
| | - Ulrike Witt
- Bavarian Mountain Rescue Service, Am Sportpark 6, 83646, Bad Tölz, Germany
- Emergency Department, Krankenhaus Agatharied, Hausham, Germany
| | - Giacomo Strapazzon
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
| | - Hermann Brugger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
| | - Matthias Jacob
- Bavarian Mountain Rescue Service, Am Sportpark 6, 83646, Bad Tölz, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Barmherzige Brüder Klinikum St. Elisabeth Straubing GmbH, Straubing, Germany
- Faculty of Medicine, Ludwig Maximilian University, Munich, Germany
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Oldrini I, Coventry L, Novak A, Gwilym S, Metcalfe D. Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies. Emerg Med J 2022; 40:379-384. [PMID: 36450522 DOI: 10.1136/emermed-2022-212696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/21/2022] [Indexed: 12/02/2022]
Abstract
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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Affiliation(s)
- Ilaria Oldrini
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Laura Coventry
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Alex Novak
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Steve Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Trauma Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Metcalfe
- Warwick Medical School, University of Warwick, Coventry, UK
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Fleischhacker E, Maßen F, Gassner C, Helfen T. Sportverletzungen backstage – von der Akutversorgung zum exzellenten funktionellen Outcome. Notf Rett Med 2022. [DOI: 10.1007/s10049-022-01061-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Mulvey JM, Carson IN, Palmer KA. Closed Reduction of Anterior Shoulder Dislocations Performed by Ski Patrollers in the Alpine Prehospital Environment: A Retrospective Review Demonstrating Efficacy in a Canadian Ski Resort. Wilderness Environ Med 2021; 32:441-449. [PMID: 34635430 DOI: 10.1016/j.wem.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 06/28/2021] [Accepted: 07/14/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Shoulder dislocations are common ski hill injuries. Rapid reduction is known to improve outcomes; however, advanced providers are not always available to provide care to these patients. In 2017, nonmedical ski patrollers at Sunshine Village ski resort in Alberta, Canada, were trained to perform anterior shoulder dislocation (ASD) reductions. Program success was determined by a chart review after the 2020 ski season. METHODS This study retrospectively reviewed data on patients who presented to Sunshine Village ski patrol with a suspected ASD and who met the study inclusion criteria from November 2017 through March 2020. Data were collected from ski patrol electronic patient care records regarding general demographics, reduction technique used, analgesia administration, and reduction success rates. RESULTS Ninety-six cases were available for review after exclusions. Trained nonmedical ski patrollers successfully reduced 82 of these cases, resulting in an overall reduction success rate of 89%. Sixty-three (66%) of these patients had experienced first-time dislocations. Eighty-two (87%) patients were male, with a median age of 25 y. The most used technique was the Cunningham method (75%), and analgesia was administered to 70% of patients. CONCLUSIONS This retrospective study documents the results of a quality assurance review of the treatment of ASD at Sunshine Village ski resort. With a success rate of 89%, the evidence supports the conclusion that nonmedical ski patrollers can successfully perform ASD reductions. We believe training ski patrollers to reduce ASD improved patient care in our austere environment by providing early definitive treatment with a high success rate.
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Affiliation(s)
- Jamin M Mulvey
- Shock Trauma Air Rescue Service, Calgary, Canada; Section of Pediatric Anesthesia, Alberta Children's Hospital, University of Calgary, Calgary, Canada
| | - Ira N Carson
- University of Alberta, School of Medicine, Edmonton, Canada
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Wright CJ, Diede MT. Practice Patterns of Athletic Trainers Regarding the On-Site Management of Patients With Joint Dislocations. J Athl Train 2021; 56:980-992. [PMID: 34530435 DOI: 10.4085/1062-6050-364-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT As part of clinical practice, athletic trainers (ATs) provide immediate management of patients with acute joint dislocations. Management techniques may include on-site closed joint reduction of the dislocated joint. Although joint reduction is part of the 2020 educational standards, currently practicing ATs may have various levels of exposure, knowledge, and skills. OBJECTIVE To capture AT self-reported knowledge and practice patterns concerning closed joint reductions. DESIGN Cohort study. SETTING Online survey (Qualtrics). PATIENTS OR OTHER PARTICIPANTS The survey link was emailed to 5000 certified ATs. A total of 772 responses were completed by certified ATs with clinical practice experience (15.4% response rate). MAIN OUTCOME MEASURE(S) Participants were asked to complete a survey about their practice patterns concerning patients with closed joint reductions, which included questions about the types of closed reductions ATs performed most commonly, the frequency of on-site reduction by ATs, and participants' demographic information. Additionally, the survey addressed the ATs' training and comfort level in performing closed reductions and knowledge of standing orders and the state practice act. RESULTS Ninety percent (n = 694) of ATs reported ever performing a closed reduction (either with or without a physician present), with 10% (n = 78) stating they had never performed a joint reduction. The interphalangeal joint of the finger (73.2% of ATs), shoulder (63.3%), and patella (48.2%) were cited as the 3 most common reductions performed without a physician present. Only 46.5% (n = 359) of ATs indicated receiving training in joint-reduction techniques as part of their precertification athletic training curriculum or program; a greater percentage (64%) said they learned directly from a physician. Fewer than 60% of ATs reported having standing orders related to joint reductions. CONCLUSIONS Considering the high percentage of ATs who reported performing closed joint reductions and the low percentage with formal training, further development of joint-reduction training and standing orders is warranted.
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Affiliation(s)
| | - Mike T Diede
- Department of Exercise Sciences, Brigham Young University, Provo, UT
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Fennelly JT, Gourbault L, Neal-Smith G, Pradhan A, Gade V, Baxter JA. A systematic review of pre-hospital shoulder reduction techniques for anterior shoulder dislocation and the effect on patient return to function. Chin J Traumatol 2020; 23:295-301. [PMID: 32893114 PMCID: PMC7567901 DOI: 10.1016/j.cjtee.2020.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/11/2020] [Accepted: 06/06/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The majority of acute anterior shoulder dislocations are sustained during sports and wilderness activities. The management of acute dislocations in the pre-hospital setting is currently without guidelines based on the evidence. The study aims to assess the risk of acute complications in pre-hospital shoulder reduction and identify which pre-hospital reduction technique has the highest success rate in the published literature. METHODS The involved databases were Allied and Complementary Medicine, CENTRAL, CINAHL, Cochrane Database of Systematic Reviews, Embase, Europe PMC, Ovid MEDLINE®, Pedro, Proquest, Trip, and World Health Organization International Clinical Trials Registry platform. Only original research of high methodological quality was included, which was defined by the recently developed assessment tool-assessing the methodological quality of published papers (AMQPP) and investigated the management of acute anterior shoulder dislocations in the pre-hospital setting. RESULTS Two hundred and ninety-eight articles were identified and screened. A full text review was performed on 40 articles. Four articles published between 2015 and 2018 met the inclusion criteria. A total of 181 patients were included with the study duration ranging from 6 to 60 months. All studies reported zero immediate complication following pre-hospital reduction and there were no documented subsequent adverse events regardless of the technique used. Prompt resolution of neurological symptoms was observed following the early and successful pre-hospital reduction. First attempt success rate, when performed by skilled practitioners, ranged from 72.3% to 94.9%. CONCLUSION Pre-hospital shoulder reduction appears to be a safe and feasible option when carried out with the appropriate expertise. A novel reduction technique adapted from the mountain medicine diploma course at the University of Paris North was found to have the highest first attempt reduction success rate of 94.9%. Other techniques described in the literature included Hippocratic, Stimson's, Counter-traction and external rotation with the success rates ranging from 54% to 71.7%.
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Affiliation(s)
- Joseph T Fennelly
- Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury, HP21 8AL, UK
| | | | - Gregory Neal-Smith
- Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury, HP21 8AL, UK
| | - Akhilesh Pradhan
- Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury, HP21 8AL, UK.
| | - Venkat Gade
- Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury, HP21 8AL, UK
| | - Jonathan A Baxter
- Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury, HP21 8AL, UK
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Extremitätentrauma in der Schockraumphase. Notf Rett Med 2020. [DOI: 10.1007/s10049-020-00745-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Siebenbürger G, Zeckey C, Fürmetz J, Ockert B, Böcker W, Helfen T. Medical speciality, medication or skills: key factors of prehospital joint reduction. A prospective, multicenter cohort study. Eur J Trauma Emerg Surg 2018. [PMID: 29516125 DOI: 10.1007/s00068-018-0933-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Joint dislocations occur frequently in prehospital settings. The medical specialities of emergency physicians are heterogeneous. Decision making and the success rates of reduction attempt can vary greatly. The aim of this prospective multicentre study was to identify the factors most crucial for achieving successful prehospital reduction. METHODS Study was conducted from 05/2012-05/2015 investigating cases of shoulder, patella and ankle joint dislocations in 16 emergency physician rescue stations. Parameters included: affected joint, type and use of medication, incidence and circumstances of reduction or reduction attempt and medical specialty as well as subjective skill status. RESULTS In total 118 patients could be included. Mean age was 40.1 ± 21.3 years. Medical specialties were: n = 61 (51.7%) anaesthesiologists (A), n = 41 (34.5%) surgeons (S), and n = 16 (13.5%) internal medicine/others (I/O). Reduction attempt was performed in n = 97 (82.2%). With taking into account the complexity of the reduction (S) had significantly the highest success rates followed by (A) and (I/O). Regarding the applied medication there was neither a significant correlation between pain (p = 0.161) nor success of reduction (p = 0.09). A higher number of attempts does not improve the success rate (p ≤ 0.001), the pain level was no predictor for success of reduction attempt (p = 0.88). CONCLUSION A successful reduction is determined by the trias of affected joint, skill level and medical specialty of the physician. In each case this trias should be considered by the physician in charge and he must evaluate limitations and circumstances.
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Affiliation(s)
- Georg Siebenbürger
- Department of General-, Trauma- and Reconstructive Surgery, Munich University Hospital, Nußbaumstr. 20, 80336, Munich, Germany
| | - Christian Zeckey
- Department of General-, Trauma- and Reconstructive Surgery, Munich University Hospital, Nußbaumstr. 20, 80336, Munich, Germany
| | - Julian Fürmetz
- Department of General-, Trauma- and Reconstructive Surgery, Munich University Hospital, Nußbaumstr. 20, 80336, Munich, Germany
| | | | - Wolfgang Böcker
- Department of General-, Trauma- and Reconstructive Surgery, Munich University Hospital, Nußbaumstr. 20, 80336, Munich, Germany
| | - Tobias Helfen
- Department of General-, Trauma- and Reconstructive Surgery, Munich University Hospital, Nußbaumstr. 20, 80336, Munich, Germany.
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