Page 36 - JSOM Fall 2018

Comparison of Scapular Manipulation With External Rotation
Method of Reduction of Acute Anterior Shoulder Dislocation for
Sedation Requirements and Success Rates

1
Subarna Adhikari, MBBS, DiMM, MS *;
2
Pranawa Koirala, MBBS, DiMM, DMEM, MD ; Dinesh Kafle, MBBS, MS 3

ABSTRACT
Background: Anterior shoulder dislocation is a common The use of procedural sedation and anesthesia in reducing a
sports­related musculoskeletal injury. Various methods have shoulder dislocation is a common practice but it carries some
been described for reduction of the dislocation. A method that inherent risks of respiratory depression and cardiovascular
requires less sedation without compromising the success rate compromise. It requires monitoring and extra staff. 18–20
is likely to be highly useful in austere and prehospital settings.
This study compares scapular manipulation with external ro­ Various studies have compared different methods of reduction
tation method for requirement of sedation and success rates. of shoulder dislocations. 7,10,11,21–24 No study to date, to our
Methods: Forty­six patients with anterior shoulder dislocation knowledge, has compared the SMM with the ERM. The aim
were allocated alternatively to reduction using either scapular of this prospective study was to compare clinical outcomes of
manipulation (SMM) or external rotation (ERM) techniques. the two methods in the emergency department (ED) without
The groups were compared for sedation requirements, pain anesthesia. The main outcomes were reduction success rates,
scores, and success rates. Results: Reductions using SMM had requirement of sedation, and pain scores during reduction.
fewer requirements for sedation (13% versus 39%; p < .05)
and higher first­pass success rates (87% versus 61%; p < .05) Methods
as compared with ERM for anterior shoulder dislocation re­
duction. The numeric rating score of pain during reduction The study was done between January 2014 and March 2015
procedures was less in SMM (mean, 1.65 [standard deviation, in the ED of Tribhuvan University Teaching Hospital, Kath­
1.6]) than in ERM group (mean, 4.30 [standard deviation, mandu, Nepal, which is an urban tertiary care hospital with
1.8]; p < .01). Conclusion: The SMM required less sedation 1,000 beds. The ED has a total of 60 beds and receives ap­
and had higher first­pass success rates than ERM for reduction proximately 110–125 patients daily. The study was approved
of anterior shoulder dislocation. The SMM is thus likely to be by the Tribhuvan University Institute of Medicine Institutional
of advantage in resource­limited austere settings. Review Board on December 17, 2014, and was conducted in
accordance with the latest version of the Helsinki Declaration.
Keywords: shoulder reduction, scapular manipulation, exter- All patients were informed about the study and signed an in­
nal rotation formed consent form prior to enrollment.

All patients presenting with clinical and radiographic features of
Introduction anterior shoulder dislocation (on standard anteroposterior and
lateral views) during the study period and not meeting exclu­
Shoulder dislocations are common in wilderness and outdoor sion criteria were allocated either into the SMM group or the
settings. Closed reduction in the acute prehospital setting helps ERM group alternatively on the basis of presentation. Patients
1
avoid potential complications and difficulty in reduction that who had associated multiple injuries or dislocations with frac­
can be caused by delay. Techniques of closed reduction in­ tures other than greater tuberosity fracture of the humerus, and
2,3
volve manipulation of the humeral head back into the glenoid patients with duration of dislocation >24 hours were excluded
cavity by using either traction, leverage, or scapular manipula­ from the study, because of the known difficulties in reducing
tion. 4–11 The external rotation method (ERM) is described as a such dislocations and the possibility of requiring sedation on the
simple, safe, well tolerated, and reliable technique. 8,12,13 In the first attempt. Patients with severe cardiovascular or pulmonary
scapular manipulation method (SMM), the scapula is moved disease (American Society of Anesthesiologists grade III and IV)
so that the glenoid rotates down to meet the humeral head. 14,15 were excluded from the study because of the departmental policy
It is claimed to be simple, effective, relatively painless, without to sedate such patients for the procedure by an anesthesiologist
complication, often requiring no sedation or analgesia, and for better control over the patient’s cardiopulmonary physiology.
with a success rate >90%. 10,16,17 SMM has been described as an
ideal method to use in the wilderness setting because of safety Neurovascular status of the injured limb was documented
and tolerability by patients. 2 before and after the reduction. Patients were included in the

*Correspondence to: House No. 43.1, Annapurna Marga, Ward No. 17, Pokhara­Lekhnath Municipality, Kaski district, Province No 4, Nepal;
or justsubun@gmail.com
1 Dr Adhikari is at the Department of Orthopedics, Kaski Sewa Hospital Travel Medicine Center, Pokhara­Lekhnath Municipality, Kaski District,
3
Nepal. Dr Koirala is at the Department of Emergency Medicine, Virginia Tech Carilion Roanoke Memorial Hospital, Roanoke, VA. Dr Kafle
2
is at the Department of Orthopedics and Trauma Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal.
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