title: Immobilization in External Rotation Versus Internal Rotation After Primary Anterior Shoulder Dislocation: A Meta-analysis of Randomized Controlled Trials.
abstract: BACKGROUND
  The recurrence rate after primary anterior shoulder dislocation is high, especially in young, active individuals. Recent studies have suggested external rotation immobilization as a method to reduce the rate of recurrent shoulder dislocation in comparison to traditional sling immobilization.
  
  
  OBJECTIVE
  To assess and summarize evidence from randomized controlled trials on the effect of internal rotation versus external rotation immobilization on the rate of recurrence after primary anterior shoulder dislocation.
  
  
  METHODS
  Meta-analysis.
  
  
  METHODS
  PubMed, MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and abstracts from recent proceedings were searched for eligible studies. Two reviewers selected studies for inclusion, assessed methodological quality, and extracted data.
  
  
  RESULTS
  Six randomized controlled trials (632 patients) were included in this review. Demographic and prognostic variables measured at baseline were similar in the pooled groups. The average age was 30.1 years in the pooled external rotation group and 30.3 years in the pooled internal rotation group. Two studies found that external rotation immobilization reduced the rate of recurrence after initial anterior shoulder dislocation compared with conventional internal rotation immobilization, whereas 4 studies failed to find a significant difference between the 2 groups. This meta-analysis suggested no overall significant difference in the rate of recurrence among patients treated with internal rotation versus external rotation immobilization (risk ratio, 0.69; 95% CI, 0.42-1.14; P = .15). There was no significant difference in the rate of compliance between internal and external rotation immobilization (P = .43). The Western Ontario Shoulder Instability Index scores were pooled across 3 studies, and there was no significant difference between the 2 groups (P = .54).
  
  
  CONCLUSIONS
  Immobilization in external rotation is not significantly more effective in reducing the recurrence rate after primary anterior shoulder dislocation than immobilization in internal rotation. Additionally, this review suggests that there is minimal difference in patients' perceptions of their health-related quality of life after immobilization in internal versus external rotation.
authors.affiliation: Division of Orthopaedic Surgery, University of Toronto, St Michael's Hospital, Toronto, Ontario, Canada db_whelan@hotmail.com.
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Whelan
authors.affiliation: Division of Orthopaedic Surgery, University of Toronto, St Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Stephanie N
authors.initials: SN
authors.lastname: Kletke
authors.affiliation: Division of Orthopaedic Surgery, University of Toronto, St Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Schemitsch
authors.affiliation: Department of Orthopaedic Surgery, Women's College Hospital, Toronto, Ontario, Canada.
authors.forename: Jaskarndip
authors.initials: J
authors.lastname: Chahal
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001915:Braces; D002648:Child; D005260:Female; D006801:Humans; D007103:Immobilization / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012107:Research Design; D012399:Rotation; D055502:Secondary Prevention / Q000379:methods; D012720:Severity of Illness Index; D012783:Shoulder Dislocation / Q000628:therapy*; D016896:Treatment Outcome; D055815:Young Adult
keywords: external rotation; immobilization; nonoperative treatment; shoulder dislocation