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Evaluation of Patients Presenting to the Emergency Service with Shoulder Dislocation.

INTRODUCTION

Among major joint dislocations in the entire body, glenohumeral joint dislocation is the most common (1).

Anterior dislocations (95%), posterior dislocations (2-5%), and inferior dislocations (luxation erecta) secondary to arm hyper-abduction injury (0.5%) constitute the majority of shoulder dislocations (2-6).

Anterior dislocations occur mostly due to indirect trauma when the upper extremity is positioned in abduction, extension, and external rotation. Convulsion, direct impact to the back, and electric shock can also result in anterior shoulder dislocation. Posterior dislocations occur mostly due to indirect trauma when the upper extremity is positioned in adduction, flexion, and internal rotation (4, 7).

Inferior shoulder dislocation is very rare. It is mainly seen in older patients. Superior glenohumeral dislocation is a very rare presentation that is seen less frequently than inferior shoulder dislocations (4, 8).

After shoulder dislocation, patients tend not to move their arm due to muscle spasm and pain. In cases of anterior shoulder dislocation, the shoulder is typically in slight abduction and external rotation. Fullness in the posterior region of the shoulder joint is decreased, and the humeral head cannot be felt by palpating the posterior edge of the acromion. Since patients with posterior shoulder dislocation do not exhibit a marked deformity, they should be examined very carefully. The arm on the affected side is typically in adduction and internal rotation. The humeral head can be palpated on the posterior and coracoid process on the anterior. Pain is significantly severe in inferior shoulder dislocation. In a typical clinical presentation, the patient's arm is in 110[degrees]-160[degrees] abduction, the elbow is in flexion, the forearm is in pronation, and the hand is above the head level. This position can also be defined as the salute position. The humeral head can be palpated on the lateral chest wall and axilla. The humeral shaft is directed to the superior. Pain is significantly severe in superior shoulder dislocation. In a typical clinical presentation, the patient's arm is in adduction, and the upper extremity affected by the migration of humeral head to the superior is shortened. The humeral head can be palpated above the acromion. Neurologic pressure symptoms often coexist, and are alleviated after reduction (4, 7, 8).

Anteroposterior, scapular Y, and axillary graphs of the shoulder should be obtained in radiologic imaging. Direct graphs, especially in posterior dislocations, can sometimes be unhelpful. In this case, computerized tomography should be used (2, 4). Shoulder dislocation is treated by reduction with traction and counter-traction maneuvers under sedation and/or analgesia. The arm should be immobilized in a sling for 3-6 weeks after reduction. Severely painful shoulder dislocations should be treated under general anesthesia (4, 7).

The most commonly used and known methods are the Hippocratic technique and the Kocher technique. In addition, there is the Stimson technique, Milch technique, and combined techniques involving both these methods. The front flexion-adduction-external rotation (FAD rotation) method has also been commonly used in recent years (1, 7, 8).

Neurologic complications are common during the reduction of shoulder dislocation. However, the probability of these complications cannot be predicted before the reduction procedure. Apraxia is generally completely healed. Nerve laceration is significantly rare (less than 4% of cases). Axillary and suprascapular nerves carry the highest risk of laceration (1, 4, 7).

This study is an epidemiologic and demographic investigation of dislocated shoulder cases presenting to the emergency room of a public hospital.

METHODS

This study includes patients who presented to the emergency room of Sivas Numune Public Hospital with a dislocated shoulder between the dates 01/02/2015 and 01/01/2018. This hospital provides services for 1 million people on average, and the number of patients admitted to the emergency room per day is around 1200-1400. Ethics committee approval was received for this study. Ethical approval was obtained from the Non-interventional Clinical Research Ethical Committee of Cumhuriyet University (2017-20836).

Patients admitted to the emergency room and diagnosed with shoulder dislocation were informed about this study. Patient consents were obtained, and patient information was filled in previously prepared reports. Emergency medicine specialists and orthopedists treated patients, and evaluated their radiologic imaging. During treatment, the emergency trauma room was used. Patients with polytrauma, hemodynamic instability, and accompanying two- and more-part proximal humerus fracture were not included in the same group as patients with intraarticular fracture.

RESULTS

A total of 581 patients presenting to Sivas Numune Public Hospital and diagnosed with shoulder dislocation were included in the study.

The average age of patients was 43[+ or -]18.59 years, with the youngest patient aged 19 years, and the oldest 88 years. The study included 242 (41.7%) females and 339 (58.3%) male. A total of 537 (92.4%) patients had anterior, 32 (5.5%) patients had posterior, and 12 (2.1%) patients had inferior dislocations. In addition, bilateral shoulder dislocation was observed in 12 (2.1%) patients, and superior dislocation in none. A total of 497 (85.5%) of shoulder dislocation cases were associated with trauma, whereas 84 (14.5%) of the cases were due to spontaneous and low-energy events (coughing, sneezing etc.).

Reduction of dislocations was performed by FAD rotation in 183 patients, Cunningham in 164 patients, and both methods in 177 patients. One of the other methods, that is, Hippocratic, Kocher, or Stimson, was applied for dislocations that could not be reduced with the previously mentioned methods. The remaining 57 dislocations were reduced using these methods.

A total of 480 (82.6%) patients were sedated, and 101 (17.4%) patients were not sedated. A total of 23 (3.9%) patients were hospitalized, and 558 (86.1%) patients were discharged after a short monitoring period in the emergency room.

The average duration of hospital stay was 9.12[+ or -]5.50 days with the longest hospitalization period of 33 days.

In the first attempt, 455 (78.3%) dislocations were reduced, whereas in the second, 126 (21.7%) dislocations were reduced.

Furthermore, 473 (81.4%) cases presented with a dislocated shoulder for the first time, whereas 108 (18.6%) cases presented with recurrent shoulder dislocation to the emergency room (Table 1).

DISCUSSION

This study was conducted with data obtained from a public hospital that address a large population, and showed the incidence and demographic characteristics of shoulder dislocation cases. Sadly, there are not many extensive studies showing these characteristics of shoulder dislocation in Turkey. The studies conducted indicate that the prevalence of shoulder dislocation is higher throughout the world as compared to that in Turkey. For instance, studies conducted in the United States and Europe report rates that are three to four fold higher in comparison to the rates of the studies conducted in Turkey (9-12). This might stem from the sociodemographic structure of people living in this region. Another reason might be the fact that people living in Sivas and its vicinity choose a more sedentary lifestyle due to long and harsh winter conditions.

Leroux et al. (13) found that the average age of patients presenting to hospitals with shoulder dislocation was 37.39[+ or -]16.62 years, whereas Tas et al. (14) found it to be 37.2[+ or -]21.3 years, and Abbasi et al. (15) found it to be 31.63[+ or -]15.88 years in their studies encompassing Turkey. In our study, the average patient age was 43[+ or -]18.59 years. Sivas is a city that is not strong in terms of industry with especially limited employment opportunities and harsh winter conditions. The highest rate of immigration to another city in Turkey is seen in Sivas. In fact, most of the immigrants in Istanbul are from Sivas. The high average age of the patients with dislocated shoulders in our study is associated with the fact that the employed young population is low in Sivas.

The majority of cases in our study were males, whereas females constituted only 42%. In literature, males constitute the majority of shoulder dislocation cases (13-15). Our study is in compliance with the literature inthis respect.

In the study, 537 (92.4%) patients had anterior, 32 (5.5%) patients had posterior, and 12 (2.1%) patients had inferior dislocations. In addition, bilateral shoulder dislocation was observed in 12 (2.1%) patients, and superior dislocation in none. In this aspect, our study complies with other studies examining this subject (13-16).

The initial diagnosis and treatment of shoulder dislocation is performed in emergency departments throughout the world (17). Emergency medicine physicians should have sufficient knowledge for the initial diagnosis of shoulder dislocation. In Turkey, emergency medicine physicians in many clinics are sufficiently trained for diagnosing shoulder dislocation. In fact, in our study, almost all shoulder dislocations were diagnosed by emergency medicine physicians. Orthopedists provided support during the reduction operation.

Shoulder dislocation mainly occurs due to various types of trauma. Falls, car accidents, and sports injuries are some examples. A minority of shoulder dislocations occur due to epileptic seizures, mild strain, and contraction (4, 7). Tas et al. (14) found that shoulder dislocation injuries resulted from falls in 74.5%, simple trauma in 12.5%, motor vehicle accidents in 8.7%, physical assault in 2.9%, and epileptic seizures in only 1.4% of cases. Abbasi et al. (15) classified causes of shoulder dislocation as traumatic and a traumatic, and reported that traumatic causes were encountered more frequently with 63.8%. The most common traumatic causes included fights and falls, whereas the majority of atraumatic causes occurred during sleep and arm movement (15). In our study, 497 (85.5%) of shoulder dislocation cases were associated with trauma, whereas 84 (14.5%) of the cases were due to spontaneous and low-energy (coughing, sneezing etc.) events.

There are many conventional methods for the reduction of shoulder dislocation. The most commonly used methods are the Hippocratic technique and the Kocher technique. In addition, there is the Stimson technique, Milch technique, or combined techniques involving both these methods; the Cunningham technique and the FAD rotation method (7, 16). Reduction was performed by FAD rotation in 183 patients, Cunningham in 164 patients, and both methods in 177 patients. The Hippocratic, Kocher or Stimson method was applied for 57 dislocations that could not be reduced through the previously mentioned methods.

In a study conducted in Turkey, it was stated that FADR rotation method is a simple, nontraumatic, and effective method that requires only one practitioner to reduce shoulder dislocations. It was suggested that the method can be easily applied by orthopedic assistants and emergency physicians since it is practical and has a low learning curve (16).

Gul et al. (16) did not sedate their patients during the reduction procedure, in which they used the FAD rotation method, because there was not much pain. Tas et al. (14), on the other hand, sedated all their patients during the reduction procedure. In Canada, all patients were sedated during the reduction of shoulder dislocations in a study investigating younger cases (13). In our study, 480 (82.6%) patients were sedated during reduction, whereas sedation was not needed in 101 (17.4%) patients. Sedation was performed by emergency physicians in the emergency room.

The average duration of hospital stay was 9.12[+ or -]5.50 days with the longest hospitalization period of 33 days. A total of 455 dislocations were reduced in the first attempt, whereas 126 dislocations were reduced in the second attempt.

Furthermore, 473 (81.4%) cases presented with a dislocated shoulder for the first time, whereas 108 (18.6%) cases presented with recurrent shoulder dislocation to the emergency room. Considering the studies conducted in Turkey, Gul et al. (16) reported that recurrent shoulder dislocation was seen in 28.1% of the cases, whereas Tas et al. (14) reported the same in 17.3% of the cases. Our study is similar to the ones in the literature.

CONCLUSION

Shoulder dislocation cases are commonly seen in emergency rooms. The incidence of shoulder dislocation is around 4.09% in Public Hospital. It is more commonly seen in males, and the most frequently seen type is anterior dislocation. This condition concernsindividuals of all age groups, and develops mainly due to trauma. Although there are many methods for treating shoulder dislocation, a majority of shoulder dislocations were reduced using mainly FAD rotation and Cunningham methods in our study. Despite the fact that shoulder dislocations can be diagnosed and treated easily in emergency rooms, prevention of shoulder dislocations can only be achieved by means of preventive measures and informative meetings.

Ethics Committee Approval: Ethics committee approval was received for this study from the Ethics Committee of Cumhuriyet University (2017-20836).

Informed Consent: Written informed consent was obtained from patients who participated in this study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - A.C., S.H.E.; Design - M.E., S.H.E.; Supervision - B.A., S.Z.; Resources -A.C., i.K.; Materials - A.C., i.K.; Data Collection and/or Processing - A.C., S.H.E.; Analysis and/or Interpretation - S.H.E.; Literature Search - S.H.E.; Writing Manuscript - S.H.E., A.C., i.K.; Critical Review - S.H.E., A.C.

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES

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(2.) Cave EF, Burke JF, Boyd RJ. Trauma management. Chicago: Year Book Medical Publishers, 1974; 437.

(3.) Becker R, Weyand F. Rare, bilateral posterior shoulder dislocation: a case report. Unfallchir 1990; 93: 66-8.

(4.) Rockwood CA, Wirth MA. Subluxations and dislocations about the glenohumeral joint. In: Rockwood CA, Green DP, Bucholz RW, et al, eds. Fractures in Adults. Philadelphia: Lippincott-Raven; 1996: 1193-339.

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(10.) Kroner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg 1989; 108: 288-90. [CrossRef]

(11.) Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 1995; 4: 107-12. [CrossRef]

(12.) Liavaag S, Svenningsen S, Reikeras O, Enger M, Fjalestad T, Pripp AH, et al. The epidemiology of shoulder dislocations in Oslo. Scand J Med Sci Sports 2011; 21: e334-40. [CrossRef]

(13.) Leroux T, Wasserstein D, Veillette C, Khoshbin A, Henry P, Chahal J, et al. Epidemiology of primary anterior shoulder dislocation requiring closed reduction in Ontario, Canada. Am J Sports Med 2014; 42: 442-50. [CrossRef]

(14.) TaS M, Canbora MK, Kose O, Egerci OF, Gem M. Demographic and clinical characteristics of traumatic shoulder dislocations in an urban city of Turkey: a retrospective analysis of 208 cases. Acta Orthop Traumatol Turc 2013; 47: 147-52. [CrossRef]

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(16.) Gul M, Yavuz U, Sokucu S, cetinkaya E, Arikan Y, Kabukcuoglu YS. Flexion-adduction-external rotation method for shoulder dislocations. Acta Orthop Traumatol Turc 2014; 48: 164-8. [CrossRef]

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How to cite:

CoSkun A, Eren M, Korkmaz i, Al B, Zengin S, Eren SH. Evaluation of Patients Presenting to the Emergency Service with Shoulder Dislocation. Eur J Ther 2018; 24(4): 241-4.

Abuzer Coskun (1) [iD], Mehmet Eren (2) [iD] , Ilhan Korkmaz (3) [iD] , Behcet Al (4) [iD], Suat Zengin (4) [iD] , Sevki Hakan Eren (4) [iD]

(1) Emergency Service, Sivas State Hospital, Sivas, Turkey

(2) Clinic of Orthopedics, Yenimahalle State Hospital, Ankara, Turkey

(3) Department of Emergency Medicine, Cumhuriyet University School of Medicine, Sivas, Turkey

(4) Department of Emergency Medicine, Gaziantep University School of Medicine, Gaziantep, Turkey

ORCID IDs of the authors: A.C. 0000-0003-4824-7021; M.E. 0000-0002-3303-0092; i.K. 0000-0001-5182-3136; B.A. 0000-0001-8743-8731; S.Z. 0000-0003-1196-6380; S.H.E. 0000-0003-1686-7234.

Corresponding Author: Sevki Hakan Eren E-mail: shakaneren@hotmail.com

Received: 28.02.2018 * Accepted: 02.04.2018

DOI: 10.5152/EurJTher.2018.530
Table1. Demographic information of shoulder dislocation

Demographic Variable             Case cohort           %
Age (year)
Mean                                43[+ or -]18.59
Range                              69
Min-Max                            19-88
Sex
Male                              339                58.3
Female                            242                41.7
Shoulder dislocation type
Anterior                          537                92.4
Posterior                          32                 5.5
Inferior                           12                 2.1
Bilateral                          12                 2.1
Injury mechanism
Traumatic                         497                85.5
Nontraumatic                       84                14.5
Method
FAD                               183                31.5
Cunningham                        164                28.2
FAD+Cunningham                    177                30.5
Others                             57                 9.8
Sedation
Yes                               480                82.6
No                                101                17.4
Type of dislocation occurred
Primary                           473                81.4
Recurrent                         108                18.6
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Title Annotation:Original Research
Author:Coskun, Abuzer; Eren, Mehmet; Korkmaz, Ilhan; Al, Behcet; Zengin, Suat; Eren, Sevki Hakan
Publication:European Journal of Therapeutics
Article Type:Report
Date:Dec 1, 2018
Words:2857
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