This article was selected for presentation at the "Best of the Best" session at the 2015 BOA Annual Conference.

1. Does External Rotation Bracing for
Anterior Shoulder Dislocation Actually
Result in Reduction of the Labrum? A
systematic review
Robert W Jordan [1], Adnan Saithna [2], Jason Old [2], Peter
MacDonald [2]
1 - University Hospitals Coventry & Warwickshire
2 - Pan Am Clinic, Winnipeg

2. Introduction
 17-100% recurrence rate following primary anterior shoulder dislocation
 Higher rates in younger patients, contact sports or associated injuries
 Recurrence significantly lower following anatomic Bankart repair
 Despite this, surgery for first time dislocations is controversial
 Typically a sling with the arm adducted and internally rotated (IR)
 More recently external rotation (ER) bracing has been investigated

3. Introduction
 Original cadaveric work of Itoi et al suggested ER could improve labral reduction
 Results from clinical studies have been conflicting
 A recent systematic review concluded that current evidence does not support
the use of ER
 Possible reasons for this disparity include:
 Poor compliance
 Varying patient populations
 Differing degrees and durations of bracing
 However achieving labral reduction in ER has not been extensively studied

4. Aim
To perform a systematic review
assessing the ability of ER bracing to
reduce the labrum in patients with
anterior shoulder instability

5. Methods
 Online databases Medline, EMBASE and the Cochrane Controlled
Trial Register searched
 Eligibility of studies assessed independently by two authors
 Inclusion
 Traumatic anterior shoulder dislocation
 ER compared to IR splinting
 Study reported either labral position or Bankart reduction

6. Flow diagram of the review process
 Of the six studies included
 Five assessed labral reduction on MRI
 One assessed labral reduction arthroscopically
COCHRANE
N = 26
EMBASE
N = 38
MEDLINE
N = 27
Combined search
N = 62
29 Duplicates
Title review
N = 26
36 excluded
Abstract review
N = 15
11 Excluded

7. Assessment of labral reduction on MR
 Five studies, n=162 shoulders
 Four in acute patients and all reported an improvement in labral reduction in ER
 Itoi et al. (n=19) demonstrated statistically significant improvement in separation,
displacement and co-aptation of the anterior capsule but required 35 degrees ER
 Siegler et al. (n=16) reduction improved in all in ER but only 31% completely reduced
 Seybold et al. (n=34) reported a statistically significant reduction in displacement and
separation after ER (p<0.005)
 Chetouani et al. (n=15) reported that 40% had improved labral reduction in 30 degrees of ER
 One study reported labral reduction after bracing
 Liavaag et al. (n=55) performed an RCT comparing 15 degrees ER and IR for 3 weeks. MRI
demonstrated that ER bracing successful in reducing 21% to 65% of labrum (p=0.04)
 However the timing of the MR arthrogram varied between 21 and 385 days

8. Assessment of labral reduction arthroscopically
 Hart et al. (n=25) arthroscopically diagnosed Bankart lesion after a primary
traumatic dislocation
 Under anaesthesia the shoulder was put in full adduction and internal rotation
and then 30 degrees of abduction and 60 degrees of ER
 Best reduction was achieved in both external rotation and abduction
 84% were anatomic and 8% partial reduction
 However 30 degrees of abduction and 60 degrees of ER is unlikely to be
tolerated by patients for a prolonged period

9. Discussion
 MRI studies have shown that positioning the shoulder in ER improves the
position of the labrum in a Bankart lesion
 However a statistically significant difference in labral reduction does not
necessarily represent a clinically important difference.
 Only two studies report the rate of anatomic reduction at 35%
 We postulate that failed reduction may be a potential explanation for the
conflicting outcomes with ER bracing in the literature
 Extreme positions of ER improve reduction but this is really only of
academic interest due to poor compliance
 The degree of reduction required to confer a clinical benefit remains
unknown

10. Future developments
 The authors propose that targeting cases where ER leads to complete
reduction may lead to improved clinical results
 An acute MRI may
 Identify best candidates for ER bracing
 Allow creation of an individualised treatment plan coupling comfort with a
position that achieves anatomic or near-anatomic reduction
 However this would require performing an MR scan on all first-time shoulder
dislocations and may not be feasible
 Future studies should clarify the relationship between
 anatomic reduction and healing
 anatomic reduction and clinical outcome

11. Conclusion
 This systematic review demonstrates that ER bracing does not reliably result
in anatomical reduction of the labrum
 In fact, MRI studies demonstrate that this is only achieved in approximately
35% of cases, even when using extreme degrees of ER
 The results of this review suggest that failure to reduce the labrum may be a
potential explanation for the conflicting outcomes from clinical studies