Medical speciality, medication or skills: key factors of prehospital joint reduction. A prospective, multicenter cohort study

Practice Patterns of Athletic Trainers Regarding the On-Site Management of Patients With Joint Dislocations

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.

A systematic review of pre-hospital shoulder reduction techniques for anterior shoulder dislocation and the effect on patient return to function

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%.