Results of applying author’s manual method for repositioning shoulder dislocation

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BACKGROUND

Among joint dislocations, shoulder dislocations (SDs) rank first in terms of incidence and account for more than 50% [1, 2]. This is due to the anatomical and physiological characteristics of SD, such as the large size of the shoulder joint, significant volume and variety of movements, relatively small plane of the articular surface of the scapula, large head of the humerus, weakness of the wall of the anterior-posterior joint capsule, etc. [1, 3, 4].

The reduction of the shoulder immediately after dislocation is a basic measure for the successful treatment of SD [5].

SD is verified annually in 17 cases per 100,000 of the population, with the maximum rates noted among men aged 21–30 years and women aged 61–80 years [6, 7]. The incidence of SD recurrence is approximately 50% of cases [8, 9].

In Russia and other countries, the incidence of SD continues to increase [10, 11]. Doctors describe and use dozens of techniques to reduce a dislocated shoulder. Specialists from many countries continue to discuss issues of diagnostics, treatment, and rehabilitation of patients with SD [12–14].

All shoulder reduction methods can be divided into conservative and surgical. Modern traumatology includes approximately 50 methods, which are associated with the maximum relaxation of the patient’s muscles. It cannot be achieved with severe pain; therefore, most methods involve preliminary anesthesia and muscle relaxation [1, 15, 16]. However, in recent years, studies have been conducted on SD reduction using manual techniques without anesthetics [17, 18]. This motivated authors to conduct a special study aimed at developing and testing the manual method of shoulder reduction without using anesthesia.

This study aimed to analyze the results of applying the author’s manual technique for SD reduction.

MATERIALS AND METHODS

The study was performed from 2013 to 2020 and included a consecutive sample. It included 1968 patients with primary SD, who presented to the trauma center of the N.I. Pirogov City Hospital No. 1 and were diagnosed with closed traumatic SD. The exclusion criterion was secondary SD. A method for treating patients with a closed SD has been patented [19].

This method provides osteopathic effect on the musculofascial region of the shoulder joint with the patient in the sitting position. For this purpose, soft tissue techniques of simultaneous traction and inhibition were used. Traction was performed on the injured arm of the patient, abducted by the hand to the side to a horizontal position, followed by abduction backward at an angle of 3°–15°. Inhibition was performed in the armpit of the injured arm. No more than three attempts were made. In the supine position, the injured arm was only abducted to the side.

For this treatment, the patient leaned back on the back of the chair in a sitting position, the legs were bent at an angle of approximately 90° in the hip and knee joints, the distance between the knees and feet ranged from 10 to 50 cm, the head was located evenly, with forward gaze, and the shoulders were down and relaxed. If the patient cannot sit, a lying position was taken on the edge of the couch or manipulation table, providing the doctor access to the injured limb.

The doctor stood on the side of the injured limb facing the patient. With the dorsal (opposite to the injured side) hand, the doctor captured the wrist joint area without squeezing the bone, muscle, and neurovascular structures of the patient’s forearm and hand and placed the fingertips of the ventral (homonymous to the damaged side) hand in the patient’s armpit under the head of the dislocated bone.

Following the correction technique, the doctor abducted the injured arm of the patient by the hand to the side to a horizontal position and performed traction of the limb (osteopathic technique) with its abduction back at an angle of 3°–15° rhythmically with 10–15 cycles per minute. Simultaneously with traction, with the fingers of the hand located in the armpit, the doctor performed inhibition (osteopathic technique) of the shoulder joint muscles. Traction and inhibition were performed for 5–15 seconds.

The doctor performed the independent return of the humeral head to a congruent position with the glenoid cavity of the scapula, simultaneously relaxing the muscles. Moreover, the doctor adducted the injured limb to the torso. With the patient in the supine position, the injured limb should only be abducted to the side.

A complicated dislocation is a contraindication to this technique. Absolute contraindications include damage to the blood vessels of the limb, damage to the limb nerves, and neglected dislocation. Relative contraindications include shoulder joint fractures and partial damage (compression and compremation) of the structures involved in limb innervation.

A distinctive characteristic of the proposed method of humeral reduction is the restoration of the congruence of the humeral articular surfaces without force impact and anesthetic support. This method

• avoids the risks of humeral fractures, damage to the cartilaginous surfaces of the articular cavity of the scapula and humeral head, and damage to the vessels and nerves of the shoulder joint;
• provides the possibility of treating patients with SD as outpatients; and
• reduces the cost and duration of treatment for patients with SD.

Patients were randomly distributed into two groups. Humeral reduction was performed in an outpatient setting in group 1 (n = 1552) using traditional methods with local anesthesia, and in group 2 (n = 416), manual techniques were used without local anesthesia.

Table 1 presents the distribution of groups 1 and 2 patients by sex and age, and Table 2 presents the dislocation type.

 

Table 1. Distribution of the patients with shoulder dislocation by sex and age using traditional methods (1) and manual techniques (2)

Таблица 1. Распределение пациентов с вывихом плеча по полу и возрасту в группах лечения традиционными методами (1) и с использованием мануальных техник (2)

Age, years	Group 1 (n = 1552)				Group 2 (n = 416)
	men		women		men		women
	n	proportion (%)	n	proportion (%)	n	proportion (%)	n	proportion (%)
18–29	145	9.3	16	1.0	18	4.3	6	1.4
30–44	240	15.5	44	2.8	58	13.9	41	9.9
45–59	198	12.8	117	7.5	63	15.1	9	2.2
60–74	224	14.4	197	12.7	54	13.0	48	11.5
75–89	193	12.4	149	9.6	71	17.1	41	9.9
>90	13	0.8	16	1.0	4	1.0	3	0.7
Total	1013	65.3	539	34.7	268	64.4	148	35.6

 

Table 2. Distribution of the patients with shoulder dislocation by dislocation type using traditional methods (1) and manual techniques (2)

Таблица 2. Распределение пациентов с вывихом плечевого сустава по виду вывиха в группах лечения традиционными методами (1) и с использованием мануальных техник (2)

Type of dislocation	Group 1 (n = 1552)				Group 2 (n = 416)
	men		women		men		women
	n	proportion (%)	n	proportion (%)	n	proportion (%)	n	proportion (%)
Anterior	915	59.0	466	30.0	236	56.7	134	32.2
Inferior	73	4.7	67	4.3	26	6.3	12	2.9
Posterior	25	1.6	6	0.4	6	1.4	2	0.5
Total	1013	65.3	539	34.7	236	56.7	134	32.2

 

No significant difference was found between groups 1 and 2 by sex, age, and dislocation type.

RESULTS AND DISCUSSION

Patients diagnosed with closed traumatic SD in Sevastopol are treated in the Traumatology Center and Department of Traumatology and Orthopedics of the N.I. Pirogov City Hospital No. 1. Cases of humeral reduction in other medical institutions of the city are rare, and their indicators are not considered in this study.

Humeral reduction on an outpatient setting was performed in 1159 (58.9%) patients, of which 809 (41.1%) patients were hospitalized due to SD and received inpatient treatment (Table 3).

 

Table 3. Conditions of medical care provision for patients with shoulder dislocation

Таблица 3. Условия оказания медицинской помощи пациентам с вывихом плеча

Humeral reduction	Number of cases,n (%)
Outpatient ·             Using osteopathic techniques ·             Traditional methods (using local anesthesia)	1159 (58.9) 352 (17.9) 807 (41.0)
Inpatient (using general anesthesia) ·             After unsuccessful application of osteopathic methods ·             As a result of inefficiency of traditional methods	809 (41.1) 64 (3.3) 745 (37.8)
Total	1968 (100)

 

The author’s osteopathic technique for providing emergency care was used in 416 of 1968 patients. In 85% (n = 352) of the cases, the dislocation was reduced on an outpatient basis using osteopathic techniques without anesthesia. Moreover, 64 (15%) patients were hospitalized. In 1552 patients, traditional methods of SD reduction were used under local anesthesia, which enabled SD reduction in 807 (52%) patients. The remaining 745 (48%) patients were hospitalized for surgery under general anesthesia.

Most traumatologists consider the duration from the moment of injury to the shoulder reduction as the main factor of the efficiency of treatment of patients with SD, as the dislocated segment must be reduced immediately after diagnostics. According to most experts, pain relief is mandatory when reducing a dislocated shoulder. Anesthesia can be either general or local. Some authors prefer general anesthesia [20]. Other researchers consider local anesthesia a priority with the administration of 1% procaine (novocaine) or another anesthetic at a dose of 20–40 mL into the joint cavity [21, 22]. Some specialists recommend using conduction anesthesia [23, 24].

Many authors consider humeral reduction without anesthesia as erroneous [25–27]. These researchers suggest communicating with the patient before SD reduction to calm him/her down, determine behavior at the stages of reduction, and achieve the maximum relaxation of the muscles. Humeral reduction is started only after anesthesia is achieved [25, 28]. Despite the vast majority of such works, publications began to appear with the opposite exact view, which included recommendations to reduce SD without anesthesia. For example, in 2016, Stafylakis et al. determined that 18% of patients with SD can be treated without using anesthesia [29]. The number of such studies has been increasing in recent years [30–32].

CONCLUSION

Comparison of traditional methods and the author’s manual technique of SD reduction in outpatient emergency care demonstrates a higher (1.6 times) efficiency of the latter because it provides sufficient care in the outpatient clinic without requiring inpatient care. In addition, manual techniques are used without anesthesia; therefore, the elimination of uncomplicated SD on an outpatient basis using this technique can reduce significantly the treatment cost.

Thus, the efficiency of the author’s manual technique for SD exceeds significantly the efficiency of inpatient treatment, as well as standard examination and reduction of the shoulder under local anesthesia on an outpatient basis.

ADDITIONAL INFORMATION

Funding. The study had no external funding.

Conflict of interest. The authors declare no conflict of interest.

Ethics approval. The research was approved by the Ethics Committee of the I.I. Mechnikov NWSMU and conducted in accordance with the ethical standards set out in the Helsinki Declaration. All patients received informational consent to conduct the study.

Author contributions. M.A. Slabospitskii — selection of clinical material, collection, and analysis of literature sources; D.E. Mokhov — collection and analysis of literature sources and text writing; A.N. Tkachenko — ideological concept of the work and article editing.

All authors made significant contributions to the study and article preparation and have read and approved the final version before its publication.

ДОПОЛНИТЕЛЬНАЯ ИНФОРМАЦИЯ

Источник финансирования. Исследование не имело финансового обеспечения или спонсорской поддержки.

Конфликт интересов. Авторы декларируют отсутствие явных и потенциальных конфликтов интересов, связанных с публикацией настоящей статьи.

Этика исследования. Исследования были одобрены этическим комитетом СЗГМУ им. И.И. Мечникова и проводились в соответствии с этическими стандартами, изложенными в Хельсинкской декларации. У всех пациентов получено информационное согласие на проведение исследования.

Вклад авторов. М.А. Слабоспицкий — подбор клинического материала, сбор и анализ источников литературы; Д.Е. Мохов — сбор и анализ источников литературы, написание текста; А.Н. Ткаченко — идеологическая концепция работы, редактирование статьи.

Все авторы внесли существенный вклад в проведение исследования и подготовку статьи, прочли и одобрили финальную версию перед публикацией.

About the authors

Maksim A. Slabospitskii

City Hospital No. 1 by N.I. Pirogov

Email: maxim-slabospitsky@rambler.ru
ORCID iD: 0000-0001-6102-3503
SPIN-code: 9756-5222
Russian Federation, Sevastopol

Dmitrii Ye. Mokhov

North-Western State Medical University named after I.I. Mechnikov

Email: dmitrii.mohov@szgmu.ru
ORCID iD: 0000-0002-8588-1577
SPIN-code: 8834-9914

MD, Dr. Sci. (Med.)

Russian Federation, Saint Petersburg

Aleksandr N. Tkachenko

North-Western State Medical University named after I.I. Mechnikov

Author for correspondence.
Email: altkachenko@mail.ru
ORCID iD: 0000-0003-4585-5160
SPIN-code: 2658-0405
Scopus Author ID: 57194971668
ResearcherId: O-3606-2014

MD, Dr. Sci. (Med.), Professor

Russian Federation, Saint Petersburg

References

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