CORR Insights®: External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial

Early treatment of first-time anterior glenohumeral dislocations still elicits controversy and active investigation. In 2001, Itoi and colleagues [3] introduced the concept of bracing in external rotation with increased tension of the subscapularis resulting in a coaptation of the avulsed capsulolabral complex back to its bony bed, which allowed for healing in a reduced position. After showing proof of concept with an MRI study [3], this group moved forward with randomized trials comparing external rotation bracing for 3 weeks, with 3 weeks in a standard internal rotation sling [1, 2]. Their initial trial enrolled 40 patients with a mean age of 39 years (range 17 to 84 years) and found a significant reduction in recurrent dislocation in the external rotation group [1]. A subsequent trial included randomized 198 patients representing a slightly younger cohort (mean ages 35 and 37 years), and had similar findings [2]. The authors included a subgroup analysis, and found that their results also held true for patients younger than 30 years of age. Despite promising studies by this group in an Asian population, other investigators have not been able to reproduce these results [4, 5]. In an Israeli study [4] of 51 subjects with a mean age of 20 years (range 17 to 27 years), 78% of whom were soldiers, no decrease in recurrent dislocation was noted with external rotation bracing. Similarly disappointing results for recurrent dislocation were seen in a well-executed randomized controlled trial of 188 patients in Norway [5]. This study by Liavaag and colleagues [5] also enrolled a younger cohort, with a mean age of 26 years (range 16 to 40 years); they too failed to find differences in Western Ontario Shoulder Instability (WOSI) scores between groups as well as recurrent subluxation. They also included an age subgroup analysis, again, not showing any differences between groups. A recent meta-analysis [6] utilized pooled data from five randomized controlled trials and close to 500 patients, but did not demonstrate evidence of efficacy of external rotation bracing for reducing recurrent dislocation.