Acupuncture is a feasible alternative to procedural sedation for shoulder reduction in the emergency department.

Treating shoulder dislocations is common in the emergency department and often requires procedural sedation. The use of acupuncture for treatment of chronic pain has been shown to be successful in various outpatient settings, and some EDs have recently incorporated acupuncture as an analgesia adjunct for chronic painful conditions to avoid opioid therapy. Limited data describe acupuncture to facilitate ED procedures. Here we present two cases of acute shoulder dislocation that were successfully treated with acupuncture as an alternative to parenteral pharmacologic procedural sedation. A 50 year old male sustained an anterior shoulder dislocation after an altercation, and a 59 year old female sustained an anterior dislocation after a fall. Instead of using conventional pharmacologic sedation and analgesia during shoulder reduction, both were treated with acupuncture in the ED. Reduction in both cases was rapid, safe, and avoided use of any parenteral medications, procedural sedation monitoring, or prolonged nurse observation. Using acupuncture as alternative to opioids for ED procedures deserves future study for orthopedic and other common ED procedures.

Comparative Analysis of Therapeutic Outcomes Between Modified Loop Plate and Hook Plate for Treating Acute Acromioclavicular Joint Dislocation.

Objective: This study aimed to evaluate the clinical efficacy of an enhanced minimally invasive NICE joint technique combined with dual adjustable loop steel plate internal fixation for treating acute acromioclavicular joint dislocation. Methods: A retrospective analysis was conducted on 63 surgical patients treated with acute acromioclavicular joint dislocation from May 2017 to March 2022. Among them, 33 cases were treated with the clavicle hook plate, and 30 cases were treated with the minimally invasive loop plate. We compared hospitalization duration, incision length, surgical duration, intraoperative bleeding, visual analogue pain scale scores, shoulder joint Constant scores at 6 months before and after surgery, and the incidence of complications between the two groups. Results: The comparison between the two groups, including hospitalization duration, incision length, surgical duration, intraoperative bleeding volume, and shoulder joint Constant score at 6 months post-surgery, revealed statistically significant differences where the loop plate group had better results. One case (1/33) experienced postoperative complications in the hook plate group, including screw loosening and plate failure. Additionally, there were 8 cases (8/33) of subacromial osteolysis, 10 cases (10/33) of acromial impact, and 5 cases (5/33) of residual shoulder pain. Conversely, only 1 case (1/30) in the loop plate group had residual shoulder pain. Conclusions: The surgical technique involving the reconstruction of the coracoclavicular ligament using an enhanced minimally invasive NICE junction combined with double adjustable loop steel plate placement in the clavicular small bone canal is characterized by simplicity, safety, minimal invasiveness, excellent functional recovery, fewer complications, and superior clinical efficacy compared to clavicular hook steel plates.

Investigating the Effects of EMGBF Combined with Different Motion Directions on Improving Upper Limb Function, iEMC, and Pain in Patients with Shoulder Dislocation.

The dislocation of the shoulder is a common complication of stroke, which is easy to occur after 3 months of stroke, with an incidence of 70%. There is no single standard for the pathogenesis of the disease, but the atrophy of the associated stability muscle, such as the triangle muscle, the oblique, and the upper muscle of the gonfield, may be the cause of the disease. In order to observe the effects of Electromyographic Biofeedback (EMGBF) combined with different motion directions on upper limb function with shoulder dislocation, a total of 84 patients with shoulder dislocation from May 2020 to February 2022 are selected for the study. The experimental results show that after treatment, upper limb motor function, iEMC, pain score, Barthel index, and quality of life score in the observation group are significantly higher than those in the control group, with statistical significance.

Effect of Using the Modified Milch Technique on Quality of Life in Patients with Anterior Dislocation of the Shoulder Joint.

Objective: To evaluate the effect of the Milch technique on quality of life (QoL) in patients with anterior dislocation of the shoulder joint. Methods: A total of 126 patients undergoing manual reduction for anterior dislocation of the shoulder in our hospital from January 2021 to January 2022 were prospectively enrolled in this study. The randomized number table method was used to divide patients into the study group (63 patients) and the control group (63 patients). The study group was treated with a modified Milch technique while the control group was treated with the Hippocratic method. Success rate and complications were compared to evaluate the effectiveness of manual reduction. Clinical assessment of shoulder function included the Constant-Murley Score and visual analog scale (VAS) before, during and after manual reduction. Results: The success rate of primary and secondary reduction in the study group was significantly higher than in the control group (87.30% vs 61.90, respectively; P = .001; 11.11% vs 25.40%, respectively; P = .038). The failure rate in the study group was significantly lower than in the control group (1.59% vs 12.70%, respectively; P = .015). The time required for reduction in the study and control groups was 58.87 ± 7.92 seconds and 93.09 ± 8.01 seconds, respectively; a significant difference (t = -24.113; P < .001). There was no statistically significant difference in VAS scores before and during reduction in the 2 groups. After reduction, VAS scores in the study group were significantly lower than in the control group (1.02 ± 0.01 vs 1.14 ± 0.26, respectively; P < .001). There were no significant differences in pain level, activities of daily living, joint range of motion or muscle strength between the 2 groups before and after reduction (P > .05). After reduction, health status, emotional function, mental health, physiological function, physiological function, physical pain, vitality and social function scores in the study group were significantly higher than in the control group (P < .05). There were 4 avulsion fractures and 2 humeral fractures in the control group; no complications occurred in the study group, with a significant difference (χ2 = 6.289; P = .012). Conclusion: The Milch technique can improve the QoL in patients with anterior dislocation of the shoulder, and the success rate of the reduction is high.

Suspension fixation of iliac bone grafts under arthroscopy is an effective method for the treatment of unstable bony Bankart disease of the shoulder joint in patients with joint relaxation.

PURPOSE: To evaluate the results of arthroscopic autologous iliac bone graft suspension fixation combined with the Remplissage procedure in the treatment of recurrent shoulder dislocation with bony Bankart lesions and joint hyperlaxity. METHODS: From 2018 to 2020, 22 patients with joint laxity underwent arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure due to recurrent shoulder dislocation. Clinical assessment included range of motion (forward flexion, abduction, 90° external rotation, conventional external rotation, adduction, and internal rotation), visual analog scale (VAS) score, Rowe score, University of California Los Angeles (UCLA) score, and Western Ontario Shoulder Instability Index (WOSI) score. Post-operatively, the healing of the bone graft was evaluated with computed tomography (CT) scanning. RESULTS: All 22 patients were followed up for a mean of 19.3 ± 4.1 months. CT imaging showed that the healing time of the bone graft was 6-8 weeks. The patient satisfaction rate was 100%, there were no cases of redislocation, all patients returned to their preinjury training state, and the fear test was negative. At the final follow-up, the UCLA, VAS, Rowe, and WOSI scores were 29.8 ± 2.1, 2.2 ± 0.8, 89.4 ± 4.2, and 482.3 ± 46.2, respectively (p < 0.001). CONCLUSION: Arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure are effective in preventing recurrent instability with joint hyperlaxity. Furthermore, no patient had redislocation. LEVEL OF EVIDENCE: IV.

Study protocol: hypnosis versus standard care for shoulder dislocation reduction in the emergency department - a multicentre, randomised, controlled study protocol.

INTRODUCTION: Anterior shoulder dislocation is a common reason for consultation at the emergency department (ED). Hypnosis could be a safe and effective alternative therapy for pain relief during shoulder dislocation reduction but nowadays, evidence is not sufficient. The main objective of this study is to show that reduction under hypnosis is associated with a decrease in the use of analgesic compared with usual care. METHODS AND ANALYSIS: We will conduct an interventional, controlled, multicentre, randomised study. A total of 44 patients with shoulder dislocation will be randomised in two groups: the hypnosis group (N=22) and the usual care group (N=22). The primary endpoint will be the comparison of morphine equivalent analgesic consumption during a shoulder dislocation reduction manoeuvre. Secondary endpoints will include haemodynamic parameters monitoring, patient and practitioner satisfaction using a Likert scale, use of coanalgesic or sedative drugs, number of reduction attempts and time spent at ED. Adverse events will be recorded. Statistical analysis will include parametric tests, multivariate linear regression and descriptive statistics. ETHICS AND DISSEMINATION: This study has received ethics approval from the Comité de Protection des Personnes of Sud-Est IV on 03/11/2021 (ANSM informed on 19 November 2021). The results will be published in scientific articles and communicated in national and international conferences. TRIAL REGISTRATION NUMBER: ClinicalTrial.gov: NCT04992598; National Clinical trial no ID RCB : 2021-A01382-39.

BET 1: Can acute shoulder dislocations be reduced using intra-articular local anaesthetic infiltration as an alternative to intravenous analgesia with or without sedation?

A short cut review was carried out to establish whether intra-articular injection of local anaesthetic is an effective alternative to intravenous analgesia with or without sedation to facilitate reduction of acute shoulder dislocations. Eleven studies were considered relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these studies are tabulated. The clinical bottom line is that intra-articular injection of local anaesthetic is a safe and effective method of providing procedural analgesia for the reduction of acute shoulder dislocations.

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%.

Shoulder-Pacemaker Treatment Concept for Posterior Positional Functional Shoulder Instability: A Prospective Clinical Trial.

BACKGROUND: Pathological muscle activation patterns of the external rotators and periscapular muscles can result in posterior positional functional shoulder instability (PP-FSI). In several patients, physical therapy and surgical treatment are not successful. PURPOSE: The shoulder-pacemaker treatment concept was evaluated prospectively in patients with PP-FSI and previously failed conventional therapy attempt. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A negative selection of 24 consecutive cases of noncontrollable PP-FSI in 16 patients with previously failed conventional therapy were included in this prospective study. The shoulder-pacemaker treatment consisted of an electrical muscle stimulation-based therapy protocol with 9 to 18 one-hour treatment sessions. Two patients were excluded because of nonadherence to the training schedule, leaving a final study cohort of 21 cases in 14 patients. Follow-up included assessment of clinical function, impairment during daily activities and sports, satisfaction, Western Ontario Shoulder Instability Index (WOSI), Rowe score, and Subjective Shoulder Value at 0 weeks, 2 weeks, 4 weeks, 3 months, 6 months, 12 months, and 24 months after intervention. RESULTS: WOSI, Subjective Shoulder Value, and Rowe score showed a highly significant improvement at all time points of follow-up (P < .001). Young age (P = .005), low weight (P = .019), shoulder activity level (P = .003), unilateral affliction (P = .046), and higher baseline WOSI score (P = .04) were associated with a better treatment effect. Cases with increased glenoid retroversion, posterior scapulohumeral decentering, and dysplastic bony glenoid shape showed a trend toward shorter treatment effect duration. No complications during the intervention or follow-up period were observed. CONCLUSION: The shoulder-pacemaker therapy concept is an effective treatment with rapid improvement and sustained outcome over the course of 2 years in patients with noncontrollable PP-FSI with previously failed conventional treatment. Young and more athletic patients with lower weight and unilateral pathology respond best to the treatment.

Complications of biceps tenodesis based on location, fixation, and indication: a review of 1526 shoulders.

BACKGROUND: Long head of the biceps tendon (LHBT) tenodesis is predominantly performed for 2 reasons: anterior shoulder pain (ASP) or structural reasons (partial tear, dislocation). METHODS: Between 2006 and 2014, all cases of primary LHBT tenodesis performed at an integrated health care system were retrospectively reviewed. Complications were analyzed by tenodesis location (below or out of the groove [OOG] vs leaving tendon in the groove [ITG]), fixation method (soft tissue vs implant), and indication (preoperative ASP vs structural). RESULTS: Among 1526 shoulders, persistent ASP did not differ by fixation method (11.0% for implant vs 12.8% for soft tissue, P = .550) or location (10.8% for OOG vs 12.9% for ITG, P = .472). Soft-tissue tenodesis cases had more frequent new-onset ASP (11.9% vs 2.6%, P < .001) and subjective weakness (8.50% vs 3.92%, P < .001) but less frequent revisions (0% vs 1.19%, P = .03) than implant tenodesis cases. No difference was found between ITG and OOG for persistent ASP (12.9% vs 10.8%, P = .550), new-onset ASP (6.5% vs 2.8%, P = .339), cramping (1.70% vs 2.31%, P = .737), deformity (4.72% vs 4.62%, P = .532), or subjective weakness (6.23% vs 4.32%, P = .334), but ITG cases had more revisions (1.51% vs 0.60%, P = .001). Among implant tenodesis cases, 1 shoulder (0.085%) sustained a fracture. CONCLUSION: The overall complication rate of LHBT tenodesis was low. Of the shoulders, 10.8% to 12.9% continued to have ASP, regardless of whether the LHBT was left ITG. Soft-tissue tenodesis cases had higher rates of new-onset ASP and subjective weakness. No significant difference for tenodesis ITG or OOG was found in biceps-related complications.

Bilateral anterior shoulder dislocation as a result of manipulation: A case report.

RATIONALE: Bilateral anterior shoulder dislocation is clinically rare and has been reported to be related to high-speed sports. PATIENT CONCERNS: A 76-year-old woman presented with bilateral shoulders pain after traditional Chinese manipulation. DIAGNOSES: She was diagnosed with bilateral anterior dislocations, and a closed reduction was immediately performed. INTERVENTION: The patient was referred for rehabilitation 3 days later, and bilateral rotator cuff injuries were identified from musculoskeletal ultrasound. After 4 weeks of physical therapy, the patient's shoulder pain had reduced and the passive ROM was nearly full. OUTCOMES: At 1-year follow-up, only mild intermittent shoulder pain was noted, and there was no limitation of shoulder ROM. LESSONS: This case illustrates that patients with acute shoulder injuries who receive proper diagnosis and treatment can achieve good outcomes. Therefore, patients with musculoskeletal disorders should seek qualified specialists for accurate diagnosis and appropriate management.

Effectiveness of neuromuscular electrical stimulation for management of shoulder subluxation post-stroke: a systematic review with meta-analysis.

OBJECTIVES: To examine the effectiveness of neuromuscular electrical stimulation (NMES) for the management of shoulder subluxation after stroke including assessment of short (1 hour or less) and long (more than one hour) daily treatment duration. DATA SOURCES: MEDLINE, CENTRAL, CINAHL, WOS, KoreaMed, RISS and reference lists from inception to January 2017 Review methods: We considered randomized controlled trials that reported neuromuscular electrical stimulation for the treatment of shoulder subluxation post-stroke. Two reviewers independently selected trials for inclusion, assessed trial quality, and extracted data. RESULTS: Eleven studies were included (432 participants); seven studies were good quality, four were fair. There was a significant treatment effect of neuromuscular electrical stimulation for reduction of subluxation for persons with acute and subacute stroke (SMD:-1.11; 95% CI:-1.53, -0.68) with either short (SMD:-0.91; 95% CI:-1.43, -0.40) or long (SMD:-1.49; 95% CI:-2.31, -0.67) daily treatment duration. The effect for patients with chronic stroke was not significant (SMD:-1.25; 95% CI:-2.60, 0.11). There was no significant effect of neuromuscular electrical stimulation on arm function or shoulder pain. CONCLUSION: This meta-analysis suggests a beneficial effect of neuromuscular electrical stimulation, with either short or long daily treatment duration, for reducing shoulder subluxation in persons with acute and subacute stroke. No significant benefits were observed for persons with chronic stroke or for improving arm function or reducing shoulder pain.

Long-Lever-Arm Manipulation Under Anesthesia With Resultant Traumatic Anterior Shoulder Dislocation.

The patient was a 61-year-old woman who underwent long-lever manipulation under anesthesia (MUA) for adhesive capsulitis. Two weeks following MUA, the constellation of clinical findings raised concern for possible adverse outcomes. Radiographs were obtained, as well as subsequent magnetic resonance imaging and computed tomography scans. Images revealed anterior shoulder dislocation with Bankart and Hill-Sachs lesions, and an anterior rotator cuff tear. J Orthop Sports Phys Ther 2016;46(8):707. doi:10.2519/jospt.2016.0412.

Surgical treatment of scapulohumeral subluxation in an alpaca (Vicugna pacos) using osteotomy of the acromion, open reduction and extracapsular tension sutures.

CASE HISTORY AND CLINICAL FINDINGS: A 3.3-year-old male alpaca, weighing 60 kg was referred for investigation of a severe left forelimb lameness of 4 weeks duration. A scapulohumeral subluxation had been diagnosed radiographically by the referring veterinarian. CLINICAL FINDINGS AND DIAGNOSIS: Based on clinical, ultrasonographic and radiographic findings the diagnosis of cranio-lateral subluxation of the left humeral head was confirmed. In addition, a full thickness lesion (approximately 1×1 cm) of the articular cartilage on the caudomedial aspect of the humeral head was diagnosed by arthroscopy. TREATMENT AND OUTCOME: Treatment included open reduction with internal fixation. Severe muscle contraction and local tissue fibrosis around the scapulohumeral joint (SHJ) required osteotomy of the acromion 3 cm proximal to the distal acromial edge, to allow adequate access. Internal stabilisation was achieved by placing tension band sutures between one cortical screw in the scapular neck and two cortical screws, with washers, craniolaterally on the greater tubercle of the humerus. Post-surgery, a carpal flexion sling was applied with the carpus maintained in 70° flexion for 4 weeks to avoid postoperative weight-bearing. An exercise programme was started 8 days after surgery and continued for 12 weeks. The alpaca had an uneventful postsurgical recovery and showed no lameness after 8 weeks. The long-term outcome was excellent; 21 months after surgery the alpaca was sound and the range of movement of the left SHJ was equal to the right SHJ. CLINICAL RELEVANCE: Even in this chronic case of subluxation of the SHJ of 4 weeks duration, surgical treatment using osteotomy of the acromion, open reduction and internal fixation with extracapsular scapulohumeral tension sutures resulted in an excellent long-term outcome in this alpaca, despite the presence of a cartilage lesion.

Bilateral Shoulder Dislocation Presenting as a Unilateral Shoulder Dislocation: Case Report.

Shoulder dislocations are a common condition seen by orthopedic surgeons and emergency medicine physicians. Shoulder dislocations typically present unilaterally and are anterior in nature. Bilateral simultaneous posterior shoulder dislocations are typically associated with seizure or electrocution and are more common than bilateral simultaneous anterior dislocations, which occur because of trauma or fall. In a traumatic setting, a shoulder dislocation may be accompanied by a distracting injury, and a thorough examination must be conducted to avoid overlooking concomitant diagnosis. The authors highlight the case of a patient who presented to the emergency department with the rare incidence of traumatic bilateral anterior shoulder dislocations, which resolved after 2 closed reductions. Orthopedic surgery and emergency medicine teams must maintain a high index of suspicion for injury to the contralateral limb to avoid missing pathologic changes due to distracting injuries.

Tragic result of traditional Chinese medicine manipulation: an unusual case report of bilateral anterior shoulder dislocations.

BACKGROUND: In Taiwan, there is a good universal healthcare system to the patients; however, the majority of Taiwanese seek the complementary and alternative medicine when they are injured or ill. The traditional Chinese medicine, which is a branch of complementary alternative medicine, is prevalent in Taiwan. Without proper sequence of maneuvers, either traditional Chinese medicine or conventional medicine might cause unexpected complications. We report a case of 76-year-old woman who was manipulated by a bonesetter, leading to bilateral anterior shoulder dislocations. To the authors' best knowledge, this injury mechanism of bilateral shoulder dislocations has not been reported in the literature. Since the traditional Chinese medicine is popular in Taiwan, proper training with better skills for the practitioners should be emphasized. We highlight the integration and collaboration of traditional Chinese medicine with western medicine to achieve a better health care for the patients. CASE PRESENTATION: A 76-year-old Taiwanese woman has been suffering from soreness and stiffness of bilateral shoulders for 6 months. She went to a bonesetter for mobilization for her shoulders. After manipulations for bilateral shoulders, the woman experienced locked both shoulders with sharp pain. She came to our institute, where the radiographs confirmed bilateral anterior shoulder dislocations. Closed reduction for the dislocations was done by the physician. The patient returned to good range of motion of bilateral shoulders after subsequent rehabilitation without any neurologic deficits. CONCLUSIONS: To the authors' best knowledge, this unusual injury of bilateral anterior shoulder dislocations had not been reported. The possible mechanism of this injury and the health belief of traditional Chinese medicine in Taiwan are discussed. Improper shoulder manipulations would lead to unexpected complication in any medical practices. We suggest that both traditional Chinese medicine and conventional medicine should follow specific sequences of manipulations; Collaboration and integration with each other could achieve a better healthcare for the patients.

Functional outcome and quality of life after rehabilitation for voluntary posterior shoulder dislocation: a prospective blinded cohort study.

BACKGROUND: Voluntary posterior instability of the shoulder is a rare condition in which the patient is able to cause a subluxation by voluntary muscle activation. A shoulder rehabilitation program aimed to correct abnormal muscle patterns and restore correct scapular motion may provide good results and improve the quality of life of these patients. METHODS: Fifteen subjects (six males, nine females; mean age 19 years) underwent physical examination and clinical tests [Disability of the Arm, Shoulder and Hand (DASH) score, Shoulder Pain and Disability Index (SPADI), and modified Rowe score] and compiled the patient global assessment (PGA). Articular or rotator cuff lesions were excluded by X-rays and MRI. The rehabilitation program included three phases: (1) assessment and correction of abnormal muscle patterns, (2) restoration of correct scapular motion, and (3) strengthening of scapular and posterior glenohumeral muscles. Follow-up was at 3, 6, 12, and 24 months. RESULTS: DASH and SPADI scores improved significantly at 3 (p < 0.01), 6 (p < 0.009), 12 (p < 0.001), and 24 months (p < 0.001). The Rowe score was fair at 3 months and good at 6, 12, and 24 months. Active flexion, abduction, and external rotation increased at all follow-up points (p < 0.01), whereas internal rotation remained unchanged (p > 0.05). PGA values were high. Compliance was good without serious adverse events reported during the treatment. A correlation was found between age and DASH changes (Spearman's ρ -0.56; p = 0.0455). CONCLUSIONS: Our findings stress the value of a rehabilitation program that teaches subjects with voluntary instability how to correct abnormal muscle patterns to restore scapular motion, and the importance of adopting home rehabilitation exercises as a part of the normal lifestyle.