BRASD trial: biomechanical reposition techniques in anterior shoulder dislocation-a randomized multicenter clinical trial

Abstract

Background: Biomechanical reduction techniques for shoulder dislocations have demonstrated high reduction success rates with a limited pain experience for the patient. We postulated that the combination of biomechanical reduction techniques with the shortest length of stay would also have the lowest pain experience and the highest first reduction success rate.

Methods: A randomized multicenter clinical trial was performed to compare different biomechanical reduction techniques in treating anterior shoulder dislocations without the use of invasive pain relief. Patients who were able to perform adduction of the arm were randomly assigned to Cunningham, the modified Milch, and the scapular manipulation technique. Those who were not able to do so were randomly assigned to modified Milch and the scapular manipulation technique. Primary outcomes were emergency department length of stay and pain experienced during the reduction process, measured by the numeric pain rating scale. Secondary outcomes were reduction time, reduction success, use of analgesics or sedatives, and complications.

Results: Three hundred eight patients were included, of whom 134 were in the adduction group. In both groups, no differences in emergency department length of stay and experienced pain were observed between the treatment arms. In the adduction group, the modified Milch technique had the highest first reduction success rates 52% (p = 0.016), within protocol 61% (p = 0.94), and with sedation in the ED 100% ( -). In the no-adduction group, the modified Milch was also the most successful primary reduction technique with 51% success (p = 0.040), within protocol 66% (p = 0.90), and with sedation in the ED 98% (p = 0.93). No complications were recorded in any of the techniques.

Conclusion: A combination of biomechanical techniques resulted in a similar length of stay in the emergency department and showed similar pain scores with an overall high success rate of reduction. In both groups, the modified Milch had the highest first-reduction success rate.

Trial registration: Netherlands Trial Register NTR5839-1 April 2016. Ethical committee Noord-Holland with the CCMO-number NL54173.094.15.

Keywords: Anterior shoulder dislocation; Biomechanical reduction techniques; Emergency department; Length-of-stay; No medication; Reduction rate.

Fig. 1

Description of reduction techniques: The pictures were taken at the emergency department of the Diakonessenhuis by the authors from a volunteer. Scapular manipulation. How to perform. Seated scapular manipulation allows the patient to remain seated upright. Facing the patient, a physician or assistant grasps the wrist of the patient’s affected side and slowly raises this to the horizontal plane and let the palm of the hand face upwards (exorotation) (Fig. 1a). Firm, but gentle, forward traction is applied with counterbalancing provided by placing the palm of the extended free arm over the patient’s midclavicular region. The force required in applying this traction is not great. Once gentle traction is applied, a second physician or assistant manipulates the scapula by applying constant pressure on the abducted inferior tip of the scapula to the medial, while holding the upper part of the scapula and putting pressure on this to the lateral. This allows the abducted inferior tip of the scapula to be rotated bringing the scapular neck and glenoid fossa into the correct alignment (Fig. 1b). It sometimes takes some time (minutes) before the muscles relax and the scapula moves. The shoulder is reduced when the scapula moves and the assistant feels the humeral head moving back in anatomical position [15]. Modified Milch. How to perform. Dislocated shoulder of the seated patient is positioned in an analgesic position by externally rotating the extended arm and slightly abducting anterolateral. This will decrease tension on m. infraspinatus, m. terres minor, and m. supraspinatus (Fig. 1c). Gently abduct the exorotated arm until reduction is achieved, often around 140–160° (Fig. 1d). Placing a thumb in the armpit can prevent the humeral head from sliding medially. No traction is used, but the arm is kept on length by the physician. After completing the 180° abduction, the arm is moved back in front of the patient to a neutral position. The procedure is painless, but sometimes gives discomfort when the humeral head is moving back in place. If there is pain while abducting the arm the speed of movement should be slowed down and/or a more anterior or posterior trajectory of the abduction can be followed [9, 16]. Cunningham. How to perform. The patient sits upright against a hard surface (i.e., chair of upright bed), the affected arm adducted to the body and the elbow fully flexed. The operator kneels/sits next to the patient and places his wrist onto the patient’s forearm (no pressure, this adds discomfort to the patient), the patient’s hand resting on the operator’s shoulder (Fig. 1e). It is important to keep the injured arm close to the body of the patient and flex their elbow to relax the bicep muscle. The patient is asked to shrug the shoulders superiorly and posteriorly, which “squares off” the angle of the shoulder (reducing scapular anteversion and the static obstruction of the glenoid rim). Start with the trapezius and deltoid muscles and afterwards move to the bicep muscle (Fig. 1f). Then, the biceps is massaged at a mid-humeral level to specifically relax the muscle (removing dynamic obstruction). The massage by the physician is not to relax the muscles, but to make the patient conscious of their muscle tension. Reduction is often after a couples of minutes and is expected when the shoulder contour has been restored [9]

Fig. 2

Randomization and inclusion schedule