1
|
Pringle BD, Hurley GA, McGrath TA, Reed JR, Zapata I, Ross DW. Austere Diagnosis and Reduction of Anterior Shoulder Dislocations: 10-Year Review of a Ski Patrol-Based Program with Emergency Medical Technicians. Wilderness Environ Med 2023; 34:410-419. [PMID: 37451956 DOI: 10.1016/j.wem.2023.05.012] [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: 02/06/2023] [Revised: 05/10/2023] [Accepted: 05/31/2023] [Indexed: 07/18/2023]
Abstract
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.
Collapse
Affiliation(s)
- Brian D Pringle
- Division of Clinical Medicine and Surgery, Rocky Vista University, Parker, CO.
| | | | - Todd A McGrath
- Wolf Creek Ski Patrol, Pagosa Springs, CO; Department of Emergency Medicine, San Juan Regional Medical Center, Farmington, NM
| | | | - Isain Zapata
- Department of Biomedical Sciences, Rocky Vista University, Parker, CO
| | - David W Ross
- Division of Clinical Medicine and Surgery, Rocky Vista University, Parker, CO
| |
Collapse
|
2
|
Lorente A, Mariscal G, Barrios C, Lorente R. Nerve Injuries after Glenohumeral Dislocation, a Systematic Review of Incidence and Risk Factors. J Clin Med 2023; 12:4546. [PMID: 37445581 DOI: 10.3390/jcm12134546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023] Open
Abstract
Glenohumeral dislocation is a common shoulder injury that can result in nerve injury. However, the full impact of these injuries on patient function and recovery remains unclear. This systematic review aimed to determine (1) the incidence, (2) risk factors, and (3) functional outcomes following nerve injuries after glenohumeral dislocation. The study followed PRISMA guidelines and used the PICO strategy. PubMed, EMBASE, Scopus, and Cochrane Collaboration Library databases were searched for studies. Two reviewers independently assessed the study eligibility, and data extraction was conducted by two authors. The quality of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Thirteen studies comprising 17,087 patients were included. The incidence of nerve injury ranged from 0.4% to 65.5%, with the axillary nerve being most commonly affected. The time to reduction did not significantly affect the incidence of nerve injury. The mechanism of injury, the affected side, associated injuries, and recovery time were found to be potential risk factors for nerve injury. Motor recovery was incomplete in many patients, and sensory recovery was less complete. By synthesizing the available evidence, this systematic review underscores the importance of considering nerve injury in the management of patients with glenohumeral dislocations. Future research can build on these findings to develop targeted prevention and treatment approaches that optimize patient outcomes.
Collapse
Affiliation(s)
- Alejandro Lorente
- Department of Traumatology and Orthopaedic Surgery, University Hospital Ramón y Cajal, 28034 Madrid, Spain
| | - Gonzalo Mariscal
- Institute for Research on Musculoskeletal Disorders, School of Medicine, Valencia Catholic University, 46001 Valencia, Spain
| | - Carlos Barrios
- Institute for Research on Musculoskeletal Disorders, School of Medicine, Valencia Catholic University, 46001 Valencia, Spain
| | - Rafael Lorente
- Department of Orthopedic Surgery and Traumatology, University Hospital of Badajoz, 06006 Badajoz, Spain
| |
Collapse
|
3
|
Stannard JT, Stannard JP. Fractures and Dislocations on the Playing Field: Which Are Emergent and What to Do? Clin Sports Med 2023; 42:515-524. [PMID: 37208062 DOI: 10.1016/j.csm.2023.02.012] [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: 05/21/2023]
Abstract
High-energy injuries, including fractures and dislocations, are occurring with increasing frequency in athletic competitions with the increasing size and speed of players. Common fractures and dislocations will be discussed in this article. We will evaluate emergent versus routine injuries and discuss appropriate treatment at the athletic venue. Fractures that can be seen with athletic activities include cervical spine; knee osteochondral fractures; tibia, ankle, and clavicle. Dislocations that will be considered include knee, patella, hip, shoulder, sternoclavicular joint, and proximal interphalangeal joint of the finger. These injuries vary significantly both in severity and in the emergent nature of the injury.
Collapse
Affiliation(s)
- James T Stannard
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, Columbia, MO 65212, USA
| | - James P Stannard
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1100 Virginia Avenue, Columbia, MO 65212, USA.
| |
Collapse
|
4
|
Patterns of Nerve Injury and Recovery Rates of Infraclavicular Brachial Plexus Lesions Following Anterior Shoulder Dislocation. J Hand Surg Am 2022; 47:1227.e1-1227.e7. [PMID: 34774345 DOI: 10.1016/j.jhsa.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 07/04/2021] [Accepted: 09/01/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE We reviewed our cases of infraclavicular brachial plexus injuries associated with anterior shoulder dislocation to determine patterns of injury, recovery rates, and factors associated with a poor motor outcome. METHODS This was a retrospective review of patients who had sustained a concomitant nerve injury following dislocation of the glenohumeral joint treated with closed manipulation. The data collected included patient demographics, injury factors, and patterns of neurological deficits. The Medical Research Council (MRC) grade for motor power was the primary outcome measure, where a grade of 4 or 5 was regarded as achieving good motor recovery. Univariate and multivariable analyses were used to identify factors associated with persistent motor weakness (MRC grades 0-3) at the final follow-up. RESULTS Between 2015 and 2019, 61 patients were assessed. There were 36 males and 25 females, with a median age of 64 years (interquartile range [IQR], 53-73 years). Four patterns of injury were identified: (1) isolated axillary nerve lesions; (2) single cord lesions; (3) combined lesions involving the medial and posterior cords; and (4) diffuse lesions affecting all 3 cords. Of 28 patients with isolated axillary nerve injuries, 22 recovered. All lateral cord injuries (11/11) and 20 of 24 posterior cord injuries recovered spontaneously. Recovery of hand intrinsic function from medial cord injuries had the worst outcome, with 14 of 27 patients not recovering beyond MRC grades 0 to 3. The median duration of dislocation before reduction was 6 hours (IQR, 3-12 hours). A multivariate analysis showed an association between the duration of shoulder dislocation and the likelihood of persistent motor weakness. CONCLUSIONS Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently. Persistent motor weakness may be associated with a prolonged duration of dislocation prior to glenohumeral relocation. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
Collapse
|
5
|
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.
Collapse
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
| | | |
Collapse
|
6
|
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%.
Collapse
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
| |
Collapse
|
7
|
Incidence, diagnostics and treatment algorithm of nerve lesions after traumatic shoulder dislocations: a retrospective multicenter study. Arch Orthop Trauma Surg 2020; 140:1175-1180. [PMID: 31980880 PMCID: PMC7429521 DOI: 10.1007/s00402-020-03348-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND The shoulder is the joint most prone to dislocating in the human body and accounts for 45% of all dislocations. In addition to ruptures of the soft tissue and bony injuries, lesions to vascular structures as well as the brachial plexus and its corresponding nerves might occur. With an incidence of up to 65%, nerve lesions are frequently reported after shoulder dislocations. The aim of this study is to obtain information on epidemiology, diagnostics, treatment and duration until remission or late sequelae after shoulder dislocation and concomitant nerve injury in a large patient cohort. METHODS The patient cohort consisted of 15,739 patients from three centres who had sustained a shoulder dislocation. All patient files were searched for concomitant injury of the brachial plexus or its corresponding nerves. For epidemiological data analysis, demographic data, clinical follow-ups, electromyography and nerve conduction velocity were evaluated. RESULTS In total, 60 patients (32 males, 28 females) with a mean age of 60 years (range 19-88 years) met the inclusion criteria. In the majority of patients (n = 51), the trauma mechanism was a trivial fall on the outstretched arm. The most frequent dislocation direction was anterior-caudal in 61.6%, followed by strictly caudal in 16.6%. The brachial plexus was injured in 46 patients (76.6%) and isolated nerve damage was documented in 14 patients (23.3%). Electroneurographic examinations were performed in less than half of the patients (38.3%). CONCLUSION A combination injury of shoulder dislocation and plexus lesion may occur at any age and sometimes has a poor outcome. Electroneurographic examinations should be implemented when managing these patients as a cost-effective and supportive examination. LEVEL OF EVIDENCE Level IV, retrospective study.
Collapse
|
8
|
Anterior Shoulder Dislocation during Breaststroke Swimming Technique: A Case Report and Review of the Literature. Case Rep Orthop 2019; 2019:9320569. [PMID: 31093402 PMCID: PMC6481107 DOI: 10.1155/2019/9320569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 04/02/2019] [Indexed: 11/17/2022] Open
Abstract
A 36-year-old woman presented with anterior shoulder dislocation as a result of breaststroke swimming training. She complained of pain and restriction of movement. A radiograph revealed the shoulder was dislocated, and the patient was treated successfully with closed reduction. The mechanism of injury seemed to be a relation between the initial pull phase of breaststroke technique and the weakest position of the shoulder in extension and external rotation. In our experience, if a patient has a history including a shoulder dislocation, this needs to be considered carefully before incorporating aquatic therapy into the rehabilitation program. Attention must also be given to the crucial timing of initiating swimming training.
Collapse
|