Immobilization of a Dislocated Shoulder in External Rotation.

Basic information about the shoulder joint.
The normal functioning shoulder is a marvel of motion and muscular activity. People normally think of the shoulder as a simple joint in which the upper arm bone (humerus) joins the shoulder socket. In reality the structure is very complex. The shoulder joint is designed to allow an extremely wide range of motions that include:

• Moving forward and backwards.
• Rotating in a circular motion.

• Hinging out, up and away from the body.

Unfortunately, all this motion is at the expense of the strength of the joint. The joint is not a true ball and socket type joint like the hip in that the ball (rounded portion of the upper humerus) is larger than the socket (the dish-shaped part of the outer edge of the shoulder blade). This relationship, of the ball to the socket, resembles a golf ball sitting on a golf tee. That is the reason the shoulder joint is easily injured.

The bones of the shoulder are held in place by muscles, tendons, and ligaments. Tendons are tough cords of tissue that attach the shoulder muscles to bone and assist the muscles in moving the shoulder. Ligaments attach shoulder bones to each other, providing stability.

Given that the joint is not stabilized by tight ligaments, and that the glenoid socket provides support to the humeral head through an angle of only around 30 degrees, it is amazing the joint stays together at all. The reason that the shoulder joint is normally stable is that muscles around the joint keep the ball in place. These muscles, however, are not ideally positioned for strength.

Shoulder dislocations.
Because the shoulder is the most moveable joint in the body, it may become unstable if injured. As noted above, it is easily subjected to injury because the ball of the upper arm is considerably larger that the socket which holds it. Shoulder problems arise from disruption of tendons and ligaments, as a result of injury, and/or from over or under use.

Dislocation of the shoulder joint is frequent and occurs when the humeral ball slips out of the glenoid socket. The most common cause of a shoulder dislocation is a fall. A dislocation can also occur when the arm is moved into an awkward position by a violent action, such as a football tackle. The x-rays below demonstrate a healthy shoulder joint on the left and a dislocated shoulder on the right. The first treatment for shoulder dislocation is to "reduce" or manipulate the ball back into the socket. The shoulder and arm are then immobilized to allow for healing of the torn capsule and ligaments.

Ref #1: Ito E., Hatakeyama Y, Kido T, et al. A new method of immobilization after dislocation of the shoulder: A prospective randomized study. AAOS annual meeting, New Orleans, 2003. (in press, J Shoulder Elb Surg, Vol 12, No.5, 2003). Ref #2: Itoi E., Sashi R., Minagawa H, et al. Position of immobilization after dislocation of the glenohumeral joint: A study with use of magnetic resonance imaging. J Bone Joint Surg, 83A: 661-7, 2001)

One of the real benefits of an external rotation sling is that you do not have to put the patient in a bulky type of apparatus, as used in some surgical procedures. This is very nice for the physician, physical therapists and the patient.

The UltraSling® ER. The UltraSling® ER is a sling designed to immobilize the shoulder in external rotation. The sling has attached to it a foam pad which rests against the hip. This places the shoulder in external rotation. A strap goes over the healthy shoulder to help secure the sling in this position. It comes in a right and left version, three sizes, S, M, L and 15 or 30 degree rotation. Quick release buckles make it fast and easy to put on and off.

The uncomfortable metal immobilizers of the past for external rotation were not comfortable or convenient. They were physicians friendly in that they did immobilize the shoulder, but patients would often not reliably wear them. The UltraSling® ER is more patient friendly and easy to use. It comes with an exercise ball to keep the muscles working. It is extremely important to continue working the muscles of the elbow, wrist and hand. Patients, who require shoulder immobilization, will use and enjoy this sling.

Other advantages to External Rotation Bracing:

• Encourages effective healing with external rotation.
• Helps prevent post-operative internal rotation contractures (loss of motion).
• Promotes underarm air exchange to reduce the risk of secondary infections.
• Easy open front panel encourages forearm exercises.

• Breathable extra padded fabric for greater comfort.

Where, Who and When should External Rotation Bracing be used?
Emergency room physicians, athletic trainers, coaches, family physicians, and paramedics need to know about the benefits of immobilization in external rotation for first time shoulder dislocations. The UltraSling® ER should be considered as the first option to treating any youngster who dislocates a shoulder on the playground, ski slopes or football games. It should be available for immediate shoulder immobilization by athletic trainers, emergency room physicians and paramedics. The unfortunate truth is physicians have been taught immobilization should be internal rotation. This internal rotation concept is proven wrong. A lot of education, on the part of emergency rooms physicians, family physicians, athletic trainers, paramedics and the general public, is necessary to explain times have changed. With external rotation immobilization, there is hope for patients, especially children that they will not dislocate again.

Physicians who treat young athletes with shoulder injuries need to know the benefits of an external rotation brace. This should be their first choice for treatment. Hopefully we can keep young athletes out of the operating room and back into activities with minimum amount of complications.

The UltraSling® ER should be used for the patient who has a dislocated shoulder, whether it is a first dislocator, or a subsequent dislocation. A great deal of interest is developing in using it after shoulder surgeries, especially rotator cuff repairs.
 

Putting on the UltraSling® ER. Step 1 - Unfasten the Velcro straps at the forearm and wrist, on the outside position of the sling. Have the patient insert the bad arm into the sling, resting the cushion on their hip. Place their bad arm as far back into the sling as possible. Put the thumb strap between the thumb and index finger. Re-attach both the forearm and wrist straps on the top of the sling to secure the bad arm/shoulder. Step 2 - Align the cushion, on the injured side, at waist level with the ball away from the body. Place the pillow so the line on the top is parallel to the front of the body or to the nearest wall or table. This alignment line, on the top of the product, is what allows the arm to be placed into external rotation. Step 3 - Bring the waist strap around from the back of the cushion, to attach to the front buckle. Adjust the strap for proper fit. Step 4 - Unfasten the shoulder strap buckle at the front of the cushion. Using the good arm, reach behind the body placing the arm through the shoulder strap. This motion is similar to putting on a backpack. The wide strap is on the collarbone (clavicle) and the thin foam pad is in the under arm area. Step 5 - Re-attach the shoulder strap to the front buckle on the front of the cushion. Step 6 - Adjust all the straps for adequate stabilization and placement of the external pad. These straps will not have to be re-adjusted later if it is done properly this first time.

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