An investigation comparing the Oxford Chair technique with the traditional methods of glenohumeral dislocation reduction currently implemented

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Abstract

This paper reports on the findings of a quantitative, retrospective service evaluation. It compared a new, conscious, sedation-free technique to reduce anterior glenohumeral dislocations with the traditional methods of reduction (TMR) currently implemented.

Objectives

The first objective for this study was to examine whether a new method, used at an Emergency Department (ED) in the south of England, of glenohumeral dislocation reduction, called the Oxford Chair Technique (OCT) can reduce anterior glenohumeral dislocations and to compare the success rates of reduction with the TMR. Secondary objectives examined how the OCT compared, using four set factors, against the TMR currently used. The fundamental comparisons being analysed was in terms of time taken for treatments.

Methods

A retrospective service evaluation was performed using data collected from the Patient Administration System (PAS) software and the Picture Archiving and Communications System (PACS) on patients who presented to an ED in the South of England with an anterior glenohumeral dislocation between March 2005 and August 2006.

Results

Of the 61 cases in which the OCT was used over the sampling period, 38 attempts to reduce the dislocation were successful, with 23 being unsuccessful. An overall success rate of 62% was obtained with the OCT. There were no complications reported with the OCT.

Statistically significant differences were found with the mean time from arrival to discharge (OCT 141 v. TMR 254 min, p < 0.001); mean time between the first diagnostic X-ray and post reduction X-ray (OCT 70 v. TMR 102 min, p < 0.003) and the mean time between the post reduction X-ray and discharge (OCT 51 v. TMR 119 min, p < 0.001).

No patients treated with the OCT required conscious sedation compared to 90% of patients treated with TMR (p < 0.001). Only 38% of patients treated with the OCT had morphine administered compared to 90% of patients treated with TMR (p < 0.001).

Conclusions

Overall, the success rate for reduction using the OCT was good in view of this being a new treatment to the ED. While the OCT had a lower success rate of reduction compared to TMR, when reduction was successful using the OCT, there were overwhelming time-saving benefits to the patient with subsequent logistical benefits to the ED. The use of conscious sedation and morphine was also significantly less for the OCT group compared to TMR.

Introduction

Nationally and internationally there is currently no uniform agreement on the method of reduction for anterior glenohumeral dislocations. A vast array of methods are used, often not evidence based and with little scientific theory behind their use.

Anterior glenohumeral dislocations classically occur with a combination of abduction, external rotation and extension. A fall on to the outstretched arm transmitting the force to the glenohumeral joint is a typical mechanism. The vast majority of dislocations are anterior (97%) and the remaining and posterior (Ceroni et al., 2000).

Intra-venous benzodiazepines and opiates ensure good analgesia and muscle relaxation and have been described as the gold standard of treatment for the reduction of glenohumeral dislocations (Gleeson, 1998). Despite this, many studies using a variety of techniques have shown the standard use of drugs to be unnecessary (Cunningham, 2005, Ceroni et al., 1997, Canales et al., 1989, Garnavos, 1992, Baykal et al., 2005, Yuen et al., 2001). A recent study retrospectively looking at the management of 308 patients with an anterior glenohumeral dislocation found that only 7.9% of patients required conscious sedation or anaesthesia for a successful reduction (Chalidis et al., 2007). It is recommended that conscious sedated patients require electrocardiograph and pulse oximetry monitoring with resuscitation equipment nearby and two doctors in attendance (The Royal College of Anaesthetists, 2001); one of whom is trained in advanced resuscitation and airway management and under the direct care of, or supervision of, a Registrar or Consultant in Emergency Medicine. Patients also require one on one nursing care. However, there are disadvantages to this procedure including inadequate relaxation and analgesia, procedural failure, postoperative apnoea and delayed recovery (Kosnick et al., 1999). Delays for reduction can occur in busy Emergency Departments (EDs) with resuscitation rooms already occupied. Patients are then monitored and observed until fully awake and alert after conscious sedation and reduction.

The title Emergency Nurse Practitioner (ENP) has been used widely in nursing and medical journals and in media and government reports whereupon a respected brand identity has been established. Expanding scope of practice for the ENP formed part of the NHS Plan (Department of Health (DOH) 2000) and in the later document Reforming Emergency Care (DOH, 2001). Crouch and Brookes (2004) stated that ENPs are already involved in independent assessment, diagnoses and management of increasingly complex problems. However, despite their advanced practice role, ENPs are currently unable to manage patients with glenohumeral dislocations due to the drugs required for conscious sedation and analgesia. Despite this, it is argued that most dislocations can be reduced in the ED by simple methods (Chung, 2004). Daya (2002) stated that these methods can be simple, quick, effective, atraumatic, require little assistance or medication and cause no additional injury to the shoulder joint, musculo-skeletal or neurovascular structures.

Section snippets

Techniques of reduction

A multitude of different reduction manoeuvres have been described in the literature. For the purpose of this study these methods are defined as “Traditional Methods of Reduction”. These techniques of TMR may require conscious sedation. Riebal and McCabe (1991) classified the various methods of reduction into four basic categories: traction, leverage, scapular manipulation and combined manoevres.

The OCT is a technique of glenohumeral dislocation reduction which does not require conscious

Methodology

A quantitative retrospective service evaluation (SE) was undertaken.

Results

Thirty-eight attempts with the OCT to reduce the dislocation were successful, with 23 being unsuccessful. All other patients (including patients who were unsuccessfully treated with the OCT) included in this study had their dislocation reduced using TMR. This gave an overall success rate of 62% with the OCT. All patients treated with TMR were successful.

A summary of the results for the five objectives are shown in Table 2, Table 3, Table 4.

The range of times from arrival to discharge for the

Discussion

The variation in success rates of reduction seen with the OCT compared to TMR may be explained by two factors. Firstly, the OCT was a new technique being introduced to the ED where this study was undertaken. As such, many of the first attempts of reduction using the OCT were performed by inexperienced practitioners. This may explain the relatively low success rate especially when compared with the 77.8% rate of reduction success in the Black and Hormbrey (2001) study where the OCT is a well

Conclusion

The aim of this retrospective service evaluation was to test, analyse and discuss five research hypotheses comparing the OCT of glenohumeral dislocation reduction with the TMR currently in place. The fundamental comparisons being analysed were in terms of time taken for treatments.

The five research hypotheses have shown evidence to the time saving benefits of the OCT when the reduction is successful compared to the TMR currently in place. The success rates for reduction, however, are lower than

Conflict of interest statement

Nil.

Funding

None declared.

Acknowledgements

I am grateful to Geraldine Lee, from La Trobe University Melbourne, for assistance in the layout of this article. I am also grateful to Mark Mulle, The Director of The Research and Development Support Unit at Southampton University Hospital Trust. His patience and expertise in assisting me with the statistical analyses of this project was invaluable. Finally, I am grateful to Mr. Phil Hormbrey from the ED at The John Radcliffe Hospital in Oxford. The OCT is ultimately his vision.

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