Not so simple but sitting and joking method : a “New Technique” for Reducing Anterior Shoulder Dislocation : Matsumoto’s or Orthopedix’ “Joking Planche à Sida” ?

I just read one very good japanese article with great enthousiasm, because for many years in a 120 000 inhabitants French West Indian Community (Saint Claude, Basse Terre Guadeloupe), I obtained not 80 per cent but 100 per cent success with a method very close to this japanese one, but still much simpler !

I obtained 100 per cent because my own method is probably still simpler than Matsumoto’s: sitting patient, with axillary board fixed by the foot of the quiet patient sitting surgeon (talling same old joke about sex) and simply pulling arm axially gently AND permanently (both hands) sometime many minutes, with elbow maintained in flexion.

That’s it ! and NOT THIS…

Falls from skiing accidents, (snow)boarding injuries, car accidents and other traumatic events account for many first-time shoulder dislocations.

When the shoulder doesn’t pop back in place on its own, the patient ends up in the emergency department or doctor’s office for a reduction (put it back in the socket).

There are many ways to reduce the shoulder but most require anesthesia (and in 1983-1989 Basse Terre, anesthesiologists…) to put the patient asleep and relax the muscles or strong narcotic medications for pain.

In their clever report, surgeons from Japan propose a “new” method for reducing anterior (forward) shoulder dislocations.

Most shoulder dislocations are anterior so this approach would be useful in many cases, if not every case.

No medication or anesthesia is used.

The patient remained in the sitting position.

There were no complications from the technique such as fractures or nerve injury.

The sitting position used was more comfortable for patients who were already holding the dislocated arm with the other hand.

The patient was sitting in a chair facing the surgeon.

The surgeon took hold of the patient’s forearm very gently and (?) raised the arm straight forward 90 degrees.

The surgeon placed his other hand (?) on the patient’s chest wall against the front of the patient’s shoulder.

The (?) surgeon’s thumb was against the head of the humerus (upper arm bone).

Just by pulling on the patient’s arm with one (?) hand while applying pressure on the humeral head with the other hand, the humeral head slipped back into the socket.

If the patient tensed up, the surgeon just lowered the arm a little, waited for the pain to go away and the muscles to relax and started the procedure again.

The hand against the shoulder helped control the tilt of the shoulder socket.

My axillary board is probably much more stable and accurate…

The technique is done slowly and gently.

If the surgeon wasn’t able to successfully reduce the shoulder after several(?)  tries, the patient was placed supine (lying on his or her back).

A forward elevation maneuver was used instead.

The dislocated arm was placed overhead while the surgeon applied traction, gently rotating the arm outward until the head of the humerus slipped back into the socket.

Afterwards, everyone was given a sling to wear to support the arm during the acute phase of healing. X-rays were taken to confirm reduction.

Results of this technique were evaluated by reviewing the charts of patients later.

Data collected included previous history of shoulder dislocation, use of medications for reduction, type of reduction technique used, and before and after X-rays.

A total of 34 patients were treated for anterior shoulder dislocation with this “new” reduction method.

The surgeon accomplished the task alone while talking with the patient.

Combining the sitting position with a (simpler, straight, gentle, firm, axial) traction technique may be “new”… in Japan and may be has never been described before in medical journals !

Compared with other methods of shoulder reduction, this was simple, unique, drug-free, and successful.

It worked for almost 80 per cent of the patients.

The key to this technique is to work with patients who are already seated and self-supporting their arm.

Changing positions causes the shoulder to tense up and can be avoided with this method.

This method can be tried first before using drugs, mechanical force, or surgery.

There was no clear reason why a small number of patients could not be reduced with this method.

The success rate wasn’t quite as high as with some other methods, but the fact that no narcotics or interscalene block were needed was the added benefit.

Kazu Matsumoto, MD, PhD, et al. Anterior Dislocation of the Shoulder: A Simple and Sitting Method for Reduction. In Current Orthopaedic Practice. May/June 2009. Vol. 20. No. 3. Pp. 281-284.

Shoulder MR Arthrography

Although arthrography (the placement of contrast within a joint) generally increases the accuracy of MRI, on occasion the contrast can camouflage important findings.

Paralabral cyst

Axial image from the same patient identifies the paralabral cyst (red arrow) and the adjacent tear of the anterosuperior labrum (yellow arrow) :

Radial Nerve Palsy Associated with Humeral Shaft Fractures

Radial nerve palsy associated with radial shaft fracture is a common occurrence.

Approximately one in ten patients with a humeral shaft fractures will also have associated radial nerve palsy.

In an epidemiologic study of 1.4 million people, the overall incidence of radial nerve palsy in 401 humeral shaft fractures was 8.5%.1

In my own non operative orthopedic study, from 1983 to 1989 of 120 000 people, the overall incidence of radial nerve palsy in 40 humeral shaft fractures is also 8.5% (Basse-Terre, Saint-Claude, Camp Jacob General Hospital, unpublished data).

In a systematic literature review, Shao and investigators2 identified 532 radial nerve palsies in 4,517 radial shaft fractures; an 11.8% incidence of radial nerve palsy.

The management of radial nerve palsy associated with a humeral shaft fracture is a topic of debate.

Although it is known that the majority of these injuries are neuropraxias that will recover spontaneously, the indication and need for operative exploration has been disputed, with authors offering conflicting opinions.

While some surgeons have advocated different treatment algorithms for radial nerve palsies that occur secondary to a closed fracture reduction, others believe that the timing of the nerve palsy is irrelevant to the management decision.

Primary nerve palsies occur at the time of injury and are discovered during the patients initial evaluation.

Approximately 10% to 20% of nerve palsies develop during the course of treatment, commonly noted more often (Basse-Terre)  following an open than a closed reduction, and are termed secondary nerve palsies.3

Complete motor loss is present in 50% to 68% (large majority in Basse Terre) of cases of radial nerve palsy, while the others are only partial motor loss or sensory loss.3

Systematic Literature Review

While some of the studies reported solely on patients with radial nerve palsies, 21 of the studies included the denominator of total radial palsy and shaft fractures.

In these studies, there were 532 radial nerve palsies in 4517 radial shaft fractures; an 11.8% incidence of radial nerve palsy.

Based on the studies that described the fracture location, the highest incidence of radial nerve palsy occurred for fractures in the distal third.

The incidence of palsies was significantly lower for fractures located in the proximal third, then in the middle or distal third.

Table 1. Incidence of radial nerve palsy based on fracture location.

Fracture location	Incidence	# Palsies/# Total fractures
Proximal third	1.8%	1/57
Middle third	15.2%	27/178
Distal third	23.6%	37/157

Transverse and spiral fracture patterns were significantly (P < .001) more likely to be associated with a radial nerve palsy than oblique or comminuted fractures .

Table 2. Incidence of radial nerve palsy based on fracture pattern.

Fracture pattern	Incidence	# Palsies/# Total fractures
Transverse	21.2%	47/222
Spiral	19.8%	19/96
Oblique	8.4%	15/179
Comminuted	6.8%	26/382

They reported no statistical difference in the incidence of radial nerve palsy in open vs closed fractures.²

Table 3. Incidence of radial nerve palsy based in open versus closed fractures.

Fracture Type	Incidence	# Palsies/# Total fractures
Open	18.2%	51/280
Closed	14.8%	137/929

In this literature review, which included a total of 1045 radial nerve palsies, the overall recovery rate was 88.1% (921/1045).

No significant difference in the recovery rate between primary (occurring at the time of injury) and secondary (occurring after the injury, or as a result of a closed reduction) nerve palsies was reported.

The mean time to the onset of recovery, reported in only five studies that included 101 patients, was 7.3 weeks (range: 2 weeks to 6.6 months).

The mean time to full recovery, reported in only five studies that included 110 patients, was 6.1 months (range: 3.4 months to 12 months).

Table 4. Recovery rate of radial nerve palsies.

Type of palsy	Recovery rate	# Recovery/# Total palsies
Overall rate	88.1%	921/1045
Primary	88.6%	632/713
Secondary	93.1%	121/130

Timing of EMG, nerve exploration, and/or tendon transfers

Controversy exists over the recommended timing for surgical exploration of radial nerve palsies.

Debate also exists over whether nerve repair or tendon transfers are the best treatment option for a transacted or permanently injured radial nerve.

Most surgeons suggest obtaining an initial electromyogram at 6 weeks following the injury if there has been no return of radial nerve function.

Thomsen and Dahlin8 recommend an electrodiagnostic examination at 5 to 6 weeks after injury and nerve repair and reconstruction within 2 months, not later than 3 months, after injury.

Ekholm and colleagues1 recommends exploration at 4 to 6 months if there is no resolution following a primary radial nerve palsy.

However for patients with indications for earlier operative fixation (eg, multiple trauma, open fractures, segmental or bilateral fractures, floating elbow, and nonunions), they advocated exploration of the nerve at the time of internal fixation.

Others note that the first sign of nerve recovery may be delayed as long as 6 months following injury.5

Ring and investigators5 suggest basing the timing of operative treatment on the patients willingness to continue wearing a radial nerve brace.

For patients wanting to be brace-free and satisfied with a hand that opens but does not have independent extension, they suggest tendon transfers at 6 months.

For patients who are comfortable wearing a brace, they recommend waiting until 12 months to see if they are one of the patients whose recovery is delayed in nature.

Nerve exploration may be considered in select patients (eg, patients with multiple nerve injuries in whom tendon transfer is not an option) at 6 months.

Verga and colleagues9 reported that in the absence of functional recovery, delayed surgical treatment (neurolysis or nerve grafts) performed 3 to 4 months after primary orthopedic treatment can be useful in achieving good functional recovery and subjectively satisfying results.

My experience is one of conservative treatment with early bracing both of the fracture (Sarmiento functional brace) and of the palsy.

References

1. Ekholm R, Adami J, Tidemark J, et al. Fractures of the shaft of the humerus: An epidemiologic study of 401 fractures. J Bone Joint Surg Br. 2006; 88:1469-1473.

2. Shao YC, Harwood P, Grotz MRW, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br. 2005; 87:1647-1652.

3. DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006; 31:655-663.

4. Foster RJ, Swiontkowski MF, Bach AW, Sack JT. Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am. 1993; 81:121-124.

5. Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am. 2004; 29:144-147.

6. Shah JJ, Bhatti NA. Radial nerve paralysis associated with fractures of the humerus. A review of 62 cases. Clin Orthop Relat Res. 1983; 172:171-176.

7. Holstein A, Lewis GM. Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg Am. 1963; 45:1382-1388.

8. Thomsen NO, Dahlin LB. Injury to the radial nerve caused by fracture of the humeral shaft: Timing and neurobiological aspects related to treatment and diagnosis. Scand J Plast Reconstr Surg Hand Surg. 2007; 41:153-157.

9. Verga M, Peri Di Caprio A, Bocchiotti MA, Battistella F, Bruschi S, Petrolati M. Delayed treatment of persistent radial nerve paralysis associated with fractures of the middle third of humerus: Review and evaluation of the long-term results of 52 cases. J Hand Surg Eur. 2007; 32:529-533.