Editorial - Australian Medical Journal 179: 370-371, 6 Oct 2003 We got it wrong on shoulder dislocation. Don't use a sling. George AC Murrell, MBBS, DPhil  Sports Medicine and Shoulder Service, and Orthopaedic Research Institute St George Hospital Campus, University of New South Wales Sydney, Australia Making the external rotation splint: play movie (1.23 or 2.95 Mb) If you are having difficulty playing the video you may need to upgrade your version of QuickTime Player 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. A number of studies of non-operative treatment for anterior shoulder instability have been unable to show one treatment regime to be any better than another, and all have been unable to reduce the recurrence rate.3  Surgery has had better outcomes in terms of recurrence,7 and even for symptoms.  In a randomized clinical trial comparing sling immobilization versus arthroscopic surgery in first time shoulder dislocation, Kirkley et al6 showed a recurrence rate in the surgical group of 16% at 2 years versus 47% in the sling group. The patients who had not re-dislocated in the non-operative group also had worse functional scores than the surgical group. One answer for the poor outcomes in the non-operative treatment of dislocating shoulders may lie in the patho-anatomy of dislocated shoulders and the inability of non-operative methods to correct this pathology. When the shoulder dislocates the major damage is a disruption of the labrum and capsule from the anterior glenoid -- a Bankart lesion.1 The labrum constitutes the fibrocartilogenous rim of the glenoid and contributes to shoulder stability by elevating the glenoid edge and providing attachment of the glenohumeral ligaments.  Most surgical procedures aim to reattach the Bankart lesion to the fibrocartilogenous rim of the glenoid. It was thought that this lesion did not heal back to bone, and this was why the outcomes of non-operative treatment have been so poor, and why surgical reattachment has much better success rates. However, two teams of researchers, one in Japan5 and one in Australia2 have shown that by putting the arm in internal rotation -- how it is normally positioned in a sling -- the labral detachment is actually more pronounced (Figure 1a). When the arm is placed in external rotation, the labrum becomes re-apposed to the glenoid rim (Figure 1b). The first study5 involved magnetic resonance imaging of shoulders with recently dislocations in both internal and external rotation. The Bankart lesion was more marked in external rotation and became far less obvious in internal rotation.  The second study2 artificially created Bankart lesions in cadaver shoulders and measured the force transmitted to the glenoid rim in different arm positions. There was no contact force generated when the arm was internally rotated and maximal force when placed in 45 degrees of external rotation. Most recently Itoi et al.4 have shown in a randomized clinical trial that patients immobilized in 10 degrees of external rotation (Figure 2) for three weeks following anterior dislocation had a recurrence rate of 0/20, compared with 6/20 when immobilized in internal rotation at 13-15 months.   It seems like we got it wrong, and that if we are to treat anterior shoulder dislocation non-operatively, the arm should be positioned in external rotation (Figure 2), or at the very least -- do not use a sling!   Figure 1. Schematic of the capsulo-labral detachment - Bankart lesion (arrow) following anterior shoulder dislocation with the arm positioned in (a) internal rotation (ie as it would with the arm in a sling), and in (b) external rotation.   Figure 2. Illustration of a patient fitted with an external rotation splint (photo and movie kindly provided by Professor Itoi) .    References: Bankart ASB: The pathology and treatment of recurrent dislocation of the shoulder-joint. British Medical Journal 26: 23-9, 1938 Hatrick C, O'Leary S, Miller B, Goldberg J, Sonnabend D, Walsh W. Should acute anterior dislocation of the shoulder be treated in external rotation. in 48th Annual Meeting of the Orthopaedic Research Society. 2002. Dallas, Texas: poster 0830.  Hayes K, Callanan M, Walton J, Tzannes A, Paxinos A, Murrell GAC: Shoulder instability - management and rehabilitation. J Orthop Sports Phys Ther 32: 497-509, 2002 Itoi E, Hatakeyama Y, Kido T, Sato K, Minagawa H, Wakabayashi I, Kobayashi Y. A new method of immobilization after dislocation of the shoulder: A prospective randomized study. in American Shoulder and Elbow Surgeons Specialty Day Meeting. 2003. New Orleans, LA: American Shoulder and Elbow Surgeons, paper # 8  Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I, Sato K: Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging. J Bone Joint Surg Am 83-A: 661-7., 2001 Kirkley A, Griffin S, Richards C, Miniaci A, Mohtadi N: Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder. Arthroscopy 15: 507-14, 1999 Paxinos A, Walton J, Tzannes A, Callanan M, Hayes K, Murrell GAC: Advances in the management of traumatic anterior and atraumatic multidirectional shoulder instability. Sports Medicine 31: 819-28, 2001 Warning: No person should rely on the contents of this website without first obtaining advice from a qualified person. 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