THE EFFICACY OF EXTERNAL ROTATION METHOD FOR THE REDUCTION OF ACUTE ANTERIOR SHOULDER DISLOCATION WITH AND WITHOUT GREATER TUBEROSITY FRACTURE Affiliation

Introduc on Several methods of reduc on technique have been described for the anterior disloca on of shoulder but none technique is said to be ideal. The aim of this study was to show the efficacy of external rota on method which could be safe and painless method for the reduc on of the acute anterior shoulder disloca on with or without fracture of the greater tuberocity and to search the cause of failure of reduc on.


INTRODUCTION
Almost fi y percents of all joints disloca on presen ng in emergency department accounts for shoulder disloca on and most of them are anterior (90 to 98%).Some of them are associated with greater tuberocity fracture and Hill Sacs 1 compression defect.
There are several techniques which are being prac ced tradi onally for the reduc on of dislocated shoulder joint.Most of them are painful and some are complicated with [2][3][4] further traum The ideal choice of reduc on should be a.simple, painless and safe.External rota on method is considered as a new technique which has been claimed to 5 be safe, comfortable and reliable .
The effec veness of external rota on method in achieving reduc on of different type of anterior disloca on of shoulder has not been tested in this part of popula on.So the aim of this study was to assess the efficacy of external rota on method for successful reduc on of anterior shoulder disloca on.

METHODOLOGY
This was an prospec ve and cross-sec onal study conducted in Department of Emergency and Department of Orthopedic, Lumbini Zonal Hospital and Meditech Interna onal Hospital, Butwal .The dura on of study was June 2016 to Nov 2017.Ethical approval was obtained from the ins tu on before beginning of the study.Inform consent was taken from every pa ent included in the study.We treated total 50 cases of anterior shoulder disloca on by this method.All pa ents were treated by consultant orthopedic surgeon only and they were requested to use this method ini ally.The diagnosis was confirmed by clinical examina on and radiography in AP and axillary view.
All pa ents with acute anterior disloca on of the shoulder with or without greater tuberociy fracture were included in the study.Exclusion criteria were, pa ents with polytrauma, hemodynamic instability, disloca on associated with Neer three-part, four-part or head spli ng proximal humerus fracture, disloca on with severe glenoid fracture, pa ents with open growth plate and pa ents presen ng more than twenty four hour a er injury.
A proforma containing demographic, radiological, clinical, past history and therapeu c details were filled which contained name, age/sex, address, mechanism of injury, dura on of injury, side of disloca on, dominant side, type of disloca on+/-fracture, previous history of disloca on, any previous a empts for reduc on, need of premedica on before the procedure, me taken for reduc on, number of a empts, any alternate procedure used when this method was failed, Pain during reduc on was noted.The pa ent was asked to rate the amount of pain during the process of reduc on as none, mild, moderate, or severe, and these ra ngs were given a score on a 4-point scale with 1 indica ng 6 no pain and 4, severe pain and finally complica ons, such as axillary nerve injury, vascular injury and iatrogenic fracture were clearly documented.
Shoulder reduc on was a empted by external rota on 6 method using standard technique.Premedica on was given to pa ents who felt unbearable pain during reduc on maneuver for which 5 ml of 2% lignocaine injec on given intra-ar cular and waited for 5 minutes for its effect.Trac on was avoided.The reduc on was confirmed by clinical examina on, and neurovascular status of the limb was re assessed.The shoulder was immobilized by immobilizer in adduc on and internal rota on and sent for radiographs to confirm the reduc on.
Pa ents with successful reduc on were sent home with medica on and advised to follow up a er two weeks and those with unsuccessful reduc on were planned for reduc on under GA.

RESULTS
There were 54 pa ents who were treated for anterior disloca on during study period, 33 pa ents were from Lumbini Zonal Hospital and twenty one were from Meditech Hospital.Out of them only 50 pa ents were included in the study and 4 cases were excluded.In the exclusion group, first pa ent had open physis, second pa ent had associated poly trauma, third pa ent had anterior disloca on with proximal humerus fracture and fourth pa ent had associated lacerated arm which required debridement under GA.Commonest mechanism of injury was fall on an outstretched hand (74%).

Pain Index
Reduc on was achieved with this method in 30 disloca ons within two minutes and in 12 disloca ons within five minutes.Premedica on was not used in 36 reduc ons and this was used only when any a empt (procedure) without premedica on failed.We used 5 ml of 2% plain lignocaine intraar cularly and waited for 5 minutes.Premedica on was used in 14 cases out of them 6 pa ents had successful reduc on.Out of 36 successful reduc ons achieved without premedica on, 6 pa ents had no pain, 18 pa ents had mild pain, 8 pa ents had moderate pain and 4 pa ents had severe pain.Out of these four pa ents, who experienced severe pain during reduc on process, three pa ents had associated greater tuberocity fracture.Complica on was not noted in any cases in this study.

DISCUSSION
Acute anterior shoulder disloca on is a very common disorder for orthopedic surgeon and emergency doctor.Older methods of reduc on used tradi onally are o en technically difficult, painful and me consuming.Addi onally, these methods frequently require two persons and some mes the injury can be exacerbated by these methods.Conversely, the described method of reduc on by external rota on is safe, reliable, can be performed rapidly 6 by a single physician and pa ent can tolerate it well.
This study showed that external rota on method is effec ve and reliable method for the closed reduc on of acute anterior disloca on of shoulder.This procedure was The beauty of this method is effec ve, reliable, safe, causing minimal discomfort to the pa ent and requiring only a 5 single physician to perform it.External rota on method is 8 more or less similar method described by the Kocher .In our study we kept the pa ent in supine posi on and arm was adducted, by keeping the elbow in right angle, forward flexion of the shoulder done by 20 degree.The difference in our technique is that we kept the shoulder in forward flexion in compared with the original technique of external 9.
rota on described by the Leidelmeyer The forward flexion of the shoulder was done to facilitate relaxa on of the anterior capsule and to prevent any bowstring ac on of the long head of biceps and the conjoint tendons.As described by the Jahir et al., "Gentle but sustained external rota on was used to neutralize the medially directed contrac on force of the subcapsularis and the pectoralis major muscle, which are the main obstacles to the lateral displacement of 10 humeral head." Trac on is commonly used in other reduc on method which is not used in this method.The disadvantage of trac on is that it increases the muscular spasm which could make the reduc on more difficult ,the procedure would be 11 painful and the reduc on couldn't be achieved.Medirik et 7 9 al. and Leidelmeyer advised the use of intravenous seda on in pa ents with first episode of disloca on; however in our series, 36 out of 42 reduc on was achieved without premedica on.Using other method, authors have 12,13 reported greater failure rate with subcoracoid disloca on 14 and sub glenoid disloca on unlike in our series where the rate of reduc on of subcoracoid and sub glenoid disloca on was similar.
We could not reduced eight disloca ons by this method.Out of 8 unreduced disloca ons, 5 were associated with displaced greater tuberocity fracture which signifies the ini al greater trauma of bone and so ssue.Hemarthrosis and marked muscle spasm may have contributed for the 14 unsuccessful reduc on.A study by Ceroni D et al. also recommended that, in sub glenoid disloca on associated with a fracture of greater tuberocity, the ini al reduc on should be under the general anesthesia to avoid the complica ons like iatrogenic fracture of anatomical neck of the of the humerus.We do agree with this recommenda on and our data also shows the same scenario.
We did not compare the external rota on method with any other method for efficacy, safety and pa ents comfort.In our study, all pa ents underwent external rota on method without any choice.There is possibility of selec on bias in this study because the physician preselected pa ents in whom they thought this method would be successful.The number of pa ent included in this study was very few and the dura on of study was for a short period.We did not encounter any short term complica on in our series which confirm the safety of this method.

CONCLUSION
The external rota on method is ra onal, simple, and rela vely pain free method to reduce an acute anterior disloca on of shoulder.It can be used successfully to reduce both subcoracoids and subglenoid disloca on without displaced greater tuberocity fracture.

RECOMMENDATION
The author suggests applying this method to treat every cases of acute anterior disloca on of shoulder.This method has been tested in many popula on in different area of the globe.This is effec ve, easy and reliable.

LIMITATION OF THE STUDY
We did not compare the external rota on method with any other method for efficacy, safety and pa ents comfort.In our study, all pa ents underwent external rota on method without any choice.There is possibility of selec on bias in this study because the physician preselected pa ents in whom they thought this method would be successful.We studied the limited number of pa ent for limited me.

Figure 1 :
Figure 1: Pain felt by the pa ents when premedica on was not used.

Figure 3 :
Figure 3: Pre and post reduc on X-Rays

Table 2 :
Reduc on achieved by using External Rota on method

Table 3 :
Rela on of successful reduc on and greater tuberocity fracture

Table 4 :
Need of premedica on Gnawali GP et al reproducible and easily acceptable by both pa ents and surgeons.We were able to achieve the closed reduc on in 84% of the pa ents which is almost similar to the rate 7 reported by Mirick et al. , who also used the same technique.