Professional Documents
Culture Documents
dislocation (Protocol)
Theivendran K, Thakrar RR, Deshmukh SC, Dwan K
This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2014, Issue 3
http://www.thecochranelibrary.com
TABLE OF CONTENTS
HEADER . . . . . . . . . .
ABSTRACT . . . . . . . . .
BACKGROUND . . . . . . .
OBJECTIVES . . . . . . . .
METHODS . . . . . . . . .
ACKNOWLEDGEMENTS
. . .
REFERENCES . . . . . . . .
APPENDICES . . . . . . . .
CONTRIBUTIONS OF AUTHORS
DECLARATIONS OF INTEREST .
SOURCES OF SUPPORT . . . .
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[Intervention Protocol]
ABSTRACT
This is the protocol for a review and there is no abstract. The objectives are as follows:
To compare the effects of different methods of closed reduction of acute anterior shoulder dislocation.
BACKGROUND
Nordqvist 1995; Owens 2007; Simonet 1984). A Danish population-based study documenting shoulder dislocations over a fiveyear period found that the overall incidence rate was 17 in 100,000
per year (Kroner 1989). Kroner 1989 found that most anterior
shoulder dislocations happened in younger people during sporting activities. In older people, dislocations often result from a fall
from standing height. The general mechanism of injury is a fall
onto the outstretched arm in abduction (away from the body) with
external rotation; this results in levering the head of the humerus
anteriorly (in front) of the glenoid (socket) of the shoulder joint.
Another mechanism is a direct impact at the back of the shoulder,
which levers the humeral head out of the socket resulting in an
anterior shoulder dislocation.
Shoulder dislocations are related to a traumatic event in up to 96%
of cases (Rowe 1956). Dislocation can also occur in individuals
with generalised ligament laxity. One study found a 46% incidence
of ligament laxity in people who sustained a sports-related shoulder
dislocation (Akhtar 2010).
Subsequent to dislocation, the shoulder is less stable and more
Types of interventions
OBJECTIVES
To compare the effects of different methods of closed reduction
of acute anterior shoulder dislocation.
METHODS
Types of studies
Randomised controlled trials and quasi-randomised (using a
method of allocating participants to a treatment that is not strictly
random, e.g. by hospital number) controlled trials evaluating
closed reduction methods for acute anterior shoulder dislocation.
Primary outcomes
Types of participants
People who have an acute anterior shoulder dislocation that is considered suitable by the trial investigators for reduction by closed
methods (non-surgical procedure). This can be a primary or firsttime dislocation or a re-dislocation. Closed reduction can take
place in any setting. Ideally, the acute anterior shoulder dislocation
should have been confirmed by physical examination and radiography or other imaging technique. Where trials do not specify
their method of diagnosis or base their diagnosis on physical examination alone, we will consider the potential for misdiagnosis,
such as a missed proximal humeral fracture. We will exclude trials focusing on people with fracture-dislocations of the proximal
humerus.
Although we will not exclude trials including patients presenting
more that 24 hours after injury, we anticipate that most trials will
exclude these late presentations as they are generally treated in
theatre.
Secondary outcomes
Electronic searches
We will search the Cochrane Bone, Joint and Muscle Trauma
Group Specialised Register (to present), the Cochrane Central Register of Controlled Trials (in The Cochrane Library,
current issue), MEDLINE (1946 to present) and EMBASE
(1980 to present). We will also search the World Health
Organization International Clinical Trials Registry platform and
Current Controlled Trials to identify ongoing and recently completed trials. We will apply no restrictions based on language or
publication status.
In MEDLINE (Ovid Online), we will combine a subject-specific
strategy with a modified version of the of the Cochrane Highly
Sensitive Search Strategy for identifying randomised trials (sensitivity-maximising version) (Lefebvre 2011). Search strategies for
MEDLINE, The Cochrane Library and EMBASE can be found in
Appendix 1.
Searching other resources
We will check reference lists of articles. We will also attempt to
contact researchers in the field for information on existing or ongoing trials. We will search specific proceedings of shoulder and elbow surgery meetings and conferences from the following sources:
British Elbow and Shoulder Society (2001 onwards); American
Orthopaedic Trauma Association (1996 onwards); The Bone
and Joint Journal Orthopaedic Proceedings (2001 onwards) and
American Shoulder and Elbow Society (2005 onwards).
Selection of studies
Two review authors (KT and RT) will independently examine the
titles and abstracts of articles identified via the search for potentially eligible trials. After obtaining the full texts of these trials,
where possible, the same two authors will then independently perform study selection based on our inclusion criteria. Any disagreement will be discussed and, if necessary, a third author (SD) will
arbitrate. Where necessary, we will attempt to contact trial authors
for clarification of study methods.
Data extraction and management
Two review authors (KT and RT) will independently extract data
from each included trial using a piloted data extraction form. We
will resolve any differences in data extraction by consensus, and
by referring back to the original article. When necessary, we will
seek information from the study authors. Disagreement will be
allocation con-
outcome assessment;
blinding of
selective
reporting and other bias. We will attempt to locate trial registrations of included trials in trial registries; this will include the UK
National Research Register (NRR) Archive, where appropriate.
We will consider two sources of other bias: that from major imbalances in baseline characteristics (age, time from injury, primary
or recurrent dislocations) and additional performance bias arising
from differences in the level of experience of the care providers
with the methods of reduction under test.
We will judge each of these domains as being at low risk of bias,
high risk of bias or unclear risk of bias (either lack of information
or uncertainty over the potential for bias). Disagreement will be
resolved by discussion and, where necessary, in consultation with
a third review author (SD).
Assessment of heterogeneity
We will assess clinical heterogeneity within all comparisons of all
included trials. We will assess statistical heterogeneity by visual
inspection of graphs (e.g. forest plots) and calculation of the I
statistic, which provides an estimate of the percentage of variability
due to heterogeneity rather than to chance alone. We will judge
there to be considerable heterogeneity if the I estimate is 75%
or more (Higgins 2003; Higgins 2011).
Data synthesis
When considered appropriate, we will pool results of comparable
groups of trials using both fixed-effect and random-effects models. The choice of the model to report will be guided by careful
consideration of the extent of heterogeneity and whether it can be
explained, in addition to other factors, such as the number and
size of included studies. We will use 95% CIs throughout. We will
consider not pooling data where there is considerable heterogeneity (I > 75%) that cannot be explained by the diversity of methodological or clinical features among trials. Where it is inappropriate
to pool data, we will still present trial data in the analyses or tables
for illustrative purposes and will report these in the text.
ACKNOWLEDGEMENTS
We would like to thank Lindsey Elstub for general helpful advice
and support. We are also grateful to Joanne Elliott for advice on
developing the search strategies. We would like to thank Keith Hill
and Kash Khan for their feedback at editorial and external review.
We would like to thank Laura MacDonald and Helen Handoll for
continued support and final revision of the protocol.
REFERENCES
Additional references
Akhtar 2010
Akhtar MA, Robinson CM. Generalised ligament laxity and
shoulder dislocations after sports injuries (abstract). British
Journal of Sports Medicine 2010;44:i3.
Chong 2006
Chong M, Karataglis D, Learmonth D. Survey of the
management of acute traumatic first-time anterior shoulder
dislocation among trauma clinicians in the UK. Annals of
the Royal College of Surgeons of England 2006;88(5):4548.
[PUBMED: 17002849]
Cunningham 2003
Cunningham N. A new drug free technique for reducing
anterior shoulder dislocations. Emergency Medicine 2003;15
(5-6):5214. [PUBMED: 14992071]
Dawson 1999
Dawson J, Fitzpatrick R, Carr A. The assessment of
shoulder instability. The development and validation of a
questionnaire. Journal of Bone and Joint Surgery. British
Volume 1999;81(3):4206. [PUBMED: 10872358]
DePalma 1973
DePalma AF, Flannery GF. Acute anterior dislocation of
the shoulder. Journal of Sports Medicine 1973;1(2):615.
[PUBMED: 4806591]
Eachempati 2004
Eachempati KK, Dua A, Malhotra R, Bhan S, Bera JR. The
external rotation method for reduction of acute anterior
dislocations and fracture-dislocations of the shoulder.
Journal of Bone and Joint Surgery. American Volume 2004;86
(11):24314. [PUBMED: 15523014]
Handoll 2004
Handoll HHG, Almaiyah MA. Surgical versus non-surgical
treatment for acute anterior shoulder dislocation. Cochrane
Database of Systematic Reviews 2004, Issue 1. [DOI:
10.1002/14651858.CD004325.pub2]
Handoll 2006
Handoll HHG, Hanchard NCA, Goodchild LM, Feary J.
Conservative management following closed reduction of
traumatic anterior dislocation of the shoulder. Cochrane
Database of Systematic Reviews 2006, Issue 1. [DOI:
10.1002/14651858.CD004962.pub2]
Higgins 2003
Higgins JP, Thompson SG, Deeks JJ, Altman DG.
Measuring inconsistency in meta-analyses. BMJ 2003;327
(7414):55760. [PUBMED: 12958120]
Higgins 2011
Higgins JPT, Green S (editors). Cochrane Handbook
for Systematic Reviews of Interventions. Version 5.1.0
[updated March 2011]. The Cochrane Collaboration,
2011. Available from www.cochrane-handbook.org.
Hovelius 1996
Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin
R, Thorling J. Primary anterior dislocation of the shoulder
Milch 1938
Milch H. Treatment of dislocation of the shoulder. Surgery
1938;3:73240.
Miller 2002
Miller SL, Cleeman E, Auerbach J, Flatow EL. Comparison
of intra-articular lidocaine and intravenous sedation
for reduction of shoulder dislocations: a randomized,
prospective study. Journal of Bone and Joint Surgery.
American Volume 2002;84(12):21359. [PUBMED:
12473699]
Rowe 1956
Rowe CR. Prognosis in dislocations of the shoulder. Journal
of Bone and Joint Surgery. American Volume 1956;38(5):
95777. [PUBMED: 13367074]
Nordqvist 1995
Nordqvist A, Petersson CJ. Incidence and causes of shoulder
girdle injuries in an urban population. Journal of Shoulder &
Elbow Surgery 1995;4(2):10712. [PUBMED: 7600160]
OConnor 2006
OConnor DR, Schwarze D, Fragomen AT, Perdomo M.
Painless reduction of acute anterior shoulder dislocations
without anesthesia. Orthopedics 2006;29(6):52832.
[PUBMED: 16786945]
Owens 2007
Owens BD, Duffey ML, Nelson BJ, DeBerardino
TM, Taylor DC, Mountcastle SB. The incidence and
characteristics of shoulder instability at the United States
Military Academy. American Journal of Sports Medicine
2007;35(7):116873. [PUBMED: 17581976]
Poulsen 1988
Poulsen SR. Reduction of acute shoulder dislocations
using the Eskimo technique: a study of 23 consecutive
cases. Journal of Trauma 1988;28(9):13823. [PUBMED:
3418764]
RevMan 2012
The Nordic Cochrane Centre, The Cochrane Collaboration.
Review Manager (RevMan). 5.2. Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2012.
Riebel 1991
Riebel GD, McCabe JB. Anterior shoulder dislocation:
a review of reduction techniques. American Journal
of Emergency Medicine 1991;9(2):1808. [PUBMED:
1994950]
Robinson 2006
Robinson CM, Howes J, Murdoch H, Will E, Graham C.
Functional outcome and risk of recurrent instability after
Rowe 1963
Rowe CR. Anterior dislocations of the shoulder: prognosis
and treatment. Surgical Clinics of North America 1963;43:
160914. [PUBMED: 14090208]
Sayegh 2009
Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME,
Kirkos JM, Kapetanos GA. Reduction of acute anterior
dislocations: a prospective randomized study comparing a
new technique with the Hippocratic and Kocher methods.
Journal of Bone and Joint Surgery. American Volume 2009;91
(12):277582. [PUBMED: 19952238]
Simonet 1984
Simonet WT, Melton LJ 3rd, Cofield RH, Ilstrup DM.
Incidence of anterior shoulder dislocation in Olmsted
County, Minnesota. Clinical Orthopaedics and Related
Research 1984;186:18691. [PUBMED: 6723141]
Stimson 1900
Stimson LA. An easy method of reducing dislocations of the
shoulder and hip. Medical Record 1900;57:3567.
Ufberg 2004
Ufberg JW, Vilke GM, Chan TC, Harrigan RA. Anterior
shoulder dislocations: beyond traction-countertraction.
Journal of Emergency Medicine 2004;27(3):3016.
[PUBMED: 15388222]
Ugras 2008
Ugras AA, Mahirogullari M, Kural C, Erturk AH, Cakmak
S. Reduction of anterior shoulder dislocations by Spaso
technique: clinical results. Journal of Emergency Medicine
2008;34(4):3837. [PUBMED: 18226873]
Westin 1995
Westin CD, Gill EA, Noyes ME, Hubbard M. Anterior
shoulder dislocation. A simple and rapid method for
reduction. American Journal of Sports Medicine 1995;23(3):
36971. [PUBMED: 7661270]
APPENDICES
CONTRIBUTIONS OF AUTHORS
KT: conceiving the review, designing and writing the protocol. KT is also the guarantor of the review
RT: providing general advice on drafts of the protocol
SD: providing general advice on drafts of the protocol
KD: providing general advice on drafts of the protocol
DECLARATIONS OF INTEREST
Kanthan Theivendran: none known
Raj R Thakrar: none known
Subodh C Deshmukh: none known
Kerry Dwan: none known
SOURCES OF SUPPORT
Internal sources
Royal Orthopaedic Hospital, Birmingham, UK.
University Hospital Birmingham, UK.
External sources
No sources of support supplied
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