External Rotation Brace Evidence

Lennard Funk
Consultant Shoulder & Upper Limb Surgeon
Manchester, UK

For several thousand years, even before Hippocrates used his hot poker, dislocated shoulders have been treated in a sling with the arm internally rotated. In spite of, and perhaps because of, using the same treatment for so long, there is little information that it does any good.

The labrum acts as a Chuck Block, increasing the concavity of the glenoid and preventing translation of the Humeral Head. Thus it stops the head sliding or rolling off the glenoid.

Itoi felt that following an anterior dislocation of the shoulder the labrum would lie medially in internal rotation and reduce on external rotation. This theory was based on previous studies already in the literature.

Bonutti, J Comput Assist Tomogr. 1993

  • the tense subscapularis kept the capsule in contact with the underlying bone structures in external rotation, whereas in internal rotation the subscapularis became redundant and the labrum and the capsule folded into the joint
  • Full Abstract Here  

Perugia et al, JSES, 1996

  • 112 shoulders
  • First time anterior dislocations
  • Two groups
    • Grp 1 - Desault bandage for three weeks
    • Grp 2 - shoulder spica 600 abduction.
  • At 4.2 years, the recurrence rate was:
    • Grp 1 - 74%
    • Grp 2 - 21% 

Itoi et al. JBJS(Am) 1999 - Cadaveric study.

  • Ten thawed fresh-frozen cadaveric shoulders with all of the muscles removed.
  • A simulated Bankart lesion was created.
  • Linear transducers attached to the anteroinferior and inferior portions of the Bankart lesion
  • The opening and closing of the lesion were recorded with the arm in:
     0, 30, 45, and 60 degrees of elevation in the coronal and sagittal planes
    as well as with the arm in rotation from full internal to full external rotation in 10-degree increments.
  • The best coapted positions were:
    • Adduction + full internal rotation to 30 degrees of external rotation.
    • 30 degrees of flexion or abduction, neutral and internal rotation

Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I Sato K (2001) - Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging - Journal of Bone & Joint Surgery 83A: 661-7

  • 19 patients with shoulder dislocations.
  • MRI
  • Arm held at the side of the trunk and positioned
    • internal rotation (mean, 29 degrees)
    • external rotation (mean, 35 degrees)
    • The effect of an external rotation position (Itoi et al 2001)

Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I, Kobayashi M (2003) - A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. - Journal of Shoulder & Elbow Surgery 12: 413-5 2003

  • 40 patients with initial shoulder dislocations.
  • Randomised into:
    • internal rotation (IR) sling
    • external rotation (ER) splint (10 degrees)
  • 15.5 month Follow-up
  • Recurrence rate:
    • 30% in the IR group
    • 0% in the ER group

Latest Unpublished Results form Itoi - October 2004

  • Prospective multicenter randomised study from January 2000
  • 110 patients
  • Age range 17-80 (mean 40 yrs )
  • Anterior dislocation of the shoulder without fractures
  • 83 initial dislocations + 27 recurrent dislocations
  • Randomised to immobilization in either internal rotation (IR group, 51 shoulders) or external rotation (ER group, 59 shoulders) for 3 weeks.
  • Mean  follow-up = 20 months.
  • Average immobilization period = 15.9 ± 8.1 days in the IR group and 16.9 ± 7.1 days in the ER group.
  • Recurrence rate = 18/51 (35%) in the IR group and 11/59 (19%) in the ER group.
  • For those less than 29 years of age, recurrence rate was 48% in the IR group and 24% in the ER group.
  • In the IR group no significant difference between those immobilized for 3 weeks and those immobilized for less than 3 weeks (29% vs 45%, p=0.24)
  • In the ER group, there was a significant difference (8.7% vs 54%, p=0.0002).
  • For all patients splinted for at least 3 weeks, there was a significant difference in the recurrence rate between the IR and ER groups (p=0.0196).
  • Conclusion: Immobilization in external rotation after shoulder dislocation is better than the conventional immobilization in internal rotation in terms of reducing recurrent dislocations.

See the full Presentation HERE

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