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Closed reduction methods for acute anterior shoulder

dislocation (Protocol)
Theivendran K, Thakrar RR, Deshmukh SC, Dwan K

This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2014, Issue 3
http://www.thecochranelibrary.com

Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

TABLE OF CONTENTS
HEADER . . . . . . . . . .
ABSTRACT . . . . . . . . .
BACKGROUND . . . . . . .
OBJECTIVES . . . . . . . .
METHODS . . . . . . . . .
ACKNOWLEDGEMENTS
. . .
REFERENCES . . . . . . . .
APPENDICES . . . . . . . .
CONTRIBUTIONS OF AUTHORS
DECLARATIONS OF INTEREST .
SOURCES OF SUPPORT . . . .

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Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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[Intervention Protocol]

Closed reduction methods for acute anterior shoulder


dislocation
Kanthan Theivendran1,2 , Raj R Thakrar2 , Subodh C Deshmukh2 , Kerry Dwan3
1 Department of Trauma and Orthopaedics, University Hospital Birmingham NHS Foundation

Trust, Birmingham, UK. 2 Department


of Trauma and Orthopaedics, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK. 3 Department of Biostatistics,
University of Liverpool, Liverpool, UK
Contact address: Kanthan Theivendran, k.theivendran@nhs.net. kanthan79@gmail.com.

Editorial group: Cochrane Bone, Joint and Muscle Trauma Group.


Publication status and date: New, published in Issue 3, 2014.
Citation: Theivendran K, Thakrar RR, Deshmukh SC, Dwan K. Closed reduction methods for acute anterior shoulder dislocation.
Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD011051. DOI: 10.1002/14651858.CD011051.
Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT
This is the protocol for a review and there is no abstract. The objectives are as follows:
To compare the effects of different methods of closed reduction of acute anterior shoulder dislocation.

BACKGROUND

Description of the condition


Anterior glenohumeral dislocation of the shoulder joint describes
the forward-directed displacement of the humeral head (top end
of the upper arm bone) out of the socket (glenoid) of the shoulder
joint. Usually people present with complete dislocation or they describe symptoms of instability, where the humeral head can move
into a partially dislocated (subluxed) position but often spontaneously returns to its original position.
Although shoulder dislocation can occur in other directions, anterior glenohumeral dislocations are the most common, comprising
between 85% to 98% of all shoulder dislocations (DePalma 1973;
Rowe 1963). In contrast, posterior shoulder dislocations, which
involve backward-directed displacement, make up only 2% to 3%
of all glenohumeral dislocations (Rowe 1963).
Shoulder dislocations occur with a reported incidence ranging
from 8.2 to 23.9 per 100,000 persons per year (Kazar 1969;

Nordqvist 1995; Owens 2007; Simonet 1984). A Danish population-based study documenting shoulder dislocations over a fiveyear period found that the overall incidence rate was 17 in 100,000
per year (Kroner 1989). Kroner 1989 found that most anterior
shoulder dislocations happened in younger people during sporting activities. In older people, dislocations often result from a fall
from standing height. The general mechanism of injury is a fall
onto the outstretched arm in abduction (away from the body) with
external rotation; this results in levering the head of the humerus
anteriorly (in front) of the glenoid (socket) of the shoulder joint.
Another mechanism is a direct impact at the back of the shoulder,
which levers the humeral head out of the socket resulting in an
anterior shoulder dislocation.
Shoulder dislocations are related to a traumatic event in up to 96%
of cases (Rowe 1956). Dislocation can also occur in individuals
with generalised ligament laxity. One study found a 46% incidence
of ligament laxity in people who sustained a sports-related shoulder
dislocation (Akhtar 2010).
Subsequent to dislocation, the shoulder is less stable and more

Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

susceptible to re-dislocation. Prospective and retrospective studies


of the natural history of initial (primary) shoulder dislocations
suggest that recurrence depends primarily on age and activity level.
Hovelius 2008 reported on 227 study participants with primary
anterior shoulder dislocation who were managed non-operatively
and found the rate of recurrence lower in people over 30 years
(27%) compared with under 23 years (72%). In a prospective
study of 252 participants with anterior dislocations, a recurrence
rate of 87% was found in people aged 15 to 20 years (Robinson
2006).
The goal of treatment after anterior shoulder dislocation is to restore pain-free, functional range of movement whilst maintaining
shoulder stability. This is usually achieved by non-surgical means,
starting with closed reduction, where the humeral head (ball) is
manoeuvred back onto the glenoid (socket). This is followed by
a period of three to six weeks of immobilisation in a sling, and
subsequent structured physiotherapy exercises. Surgical intervention is generally reserved for recurrence or instability (Handoll
2004; Handoll 2006). Most closed reductions are performed in
the emergency department using intravenous analgesia with sedation (Chong 2006), although other forms of analgesia such as
intra-articular injections and inhaled nitrous oxide have also been
used. Closed shoulder reduction can be also performed without
any analgesia (OConnor 2006).

Description of the intervention


Many techniques have been described for reduction of anterior
shoulder dislocations. In perhaps the oldest, the Hippocratic technique, longitudinal traction was applied on the dislocated upper
extremity with counterforce against the humeral head in the axilla (arm pit). Typically, a ball of the physicians heel was used for
countertraction. However, given the numerous accounts of neurovascular complications and traumatic injuries, this technique is
uncommon nowadays. An example of a less forceful method is
the Milch technique, where the shoulder is gently abducted and
externally rotated with one of the physicians hands placed over
the humeral head; the physician then gently pushes the humeral
head back onto the glenoid while the arm is in full abduction.
Janecki 1982 reported that there were no neurovascular injuries or
fracture complications encountered in a series of 50 consecutive
anterior dislocations reduced with this technique.
Overall, closed reduction methods generally involve one or more
manoeuvres to relocate the humeral head back into place. These
can be classified according to their principal mode of action.
Traction-countertraction methods are exemplified by the Hippocratic (Mattick 2000) and Stimson (Stimson 1900) techniques
whereby longitudinal force is applied whilst providing an opposite
counteractive force. Other examples of methods using tractioncountertraction are Manes (Manes 1980), Eskimo (Poulsen 1988)
and Snowbird (Westin 1995). More modern techniques have been
described, including the FARES (Fast, Reliable and Safe) method,

where traction is applied with vertical oscillating movements of


the arm whilst increasing abduction (Sayegh 2009).
Leverage manoeuvres are exemplified by the Kocher technique
(Kocher 1870), which involves external rotation followed adduction and internal rotation of the shoulder, and the Milch technique
(Milch 1938), which uses abduction and external rotation over the
patients head. Other examples are Cunningham (Cunningham
2003), Eachempati (Eachempati 2004) and Spaso (Ugras 2008).
Other techniques include scapular manipulation (McNamara
1993), where the scapula is rotated manually in order for the
humeral head to fall back into place while the arm is kept in traction.

How the intervention might work


The aim of closed reduction of acute anterior shoulder dislocation is to restore (reduce) the normal anatomical position of the
humeral head joint surface with the joint surface of the glenoid.
The repositioning of the humeral head back onto the glenoid of
the shoulder joint should restore pain-free movement and function of the arm. The method or manipulative technique to achieve
this reduction without operative (surgical) intervention should be
quick, effective and simple to perform and should require minimal
force, analgesia and assistance from other people (such as for applying traction). The technique should not damage the shoulder
joint structures (e.g. labrum, humeral head) or the surrounding
nerves or vessels. The obstacles to relocating the humeral head
are both static barriers, principally the glenoid rim, and dynamic
forces from muscles that continue to pull on the displaced humeral
head. Reduction methods represent different ways of circumventing these barriers, set in the context of the above aims.
The rates of success and complications following closed reduction
vary according to the method used (Miller 2002; Riebel 1991). Although most anterior shoulder dislocations can be easily reduced
in the emergency department, some dislocations still require more
than one method and in 5% to 10% of cases reduction can only be
achieved under general anaesthesia in the operating room (Riebel
1991; Ufberg 2004). On the whole the type of reduction technique performed is generally based on the individual physicians
experience and the method he or she was trained in.
A failure to reduce a dislocated shoulder successfully within the
first 24 hours carries the risk that it will be difficult to achieve a
stable closed reduction (Hovelius 1996). Late reduction may cause
muscle spasm along with possible engaging dislocation. This is
where after dislocation the shoulder is locked in a dislocated position with the posterior humeral head impacted onto the anterior
rim of the glenoid (an engaging Hills Sachs lesion). In this situation it may be impossible to reduce the dislocation in the emergency care setting and open reduction in theatre may be required.

Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Why it is important to do this review

Types of interventions

Closed reduction is the primary treatment for most cases of


acute anterior shoulder dislocation, which is a fairly common and
painful injury that can occur at any age. It is important to identify
and summarise the current evidence from randomised controlled
trials in order to determine the most effective and safe method of
closed reduction that also has the best long-term outcome, including the lowest rate of subsequent recurrence.

Various methods (manipulative manoeuvres) of closed reduction


of anterior shoulder dislocation have been described. We aim to
compare different methods of putting the shoulder joint back into
its normal position (reduction) without the need for surgery. We
will group reduction techniques according to their principal mode
of action: traction-countertraction, leverage and scapular manipulation.
We plan the following comparisons based on the principal modes
of action.
Leverage versus traction-countertraction
Scapular manipulation versus traction-countertraction
Scapular manipulation versus leverage

OBJECTIVES
To compare the effects of different methods of closed reduction
of acute anterior shoulder dislocation.

When comparing techniques with similar modes of action, the


control comparison will be the older or more established of the
methods used.

METHODS

Types of outcome measures

Criteria for considering studies for this review

Types of studies
Randomised controlled trials and quasi-randomised (using a
method of allocating participants to a treatment that is not strictly
random, e.g. by hospital number) controlled trials evaluating
closed reduction methods for acute anterior shoulder dislocation.

Primary outcomes

Reduction success. We will define this as a successful


reduction after up to two attempts with the same technique,
without requiring a major change in analgesia or anaesthesia. We
will collect other definitions of reduction success used by study
authors under the secondary outcome reduction failure.
Pain scores (visual analogue scale) measured during the
procedure.
Complications: for example, early complications can
include fractures of the proximal humerus and nerve injuries;
complete failure requiring general anaesthesia, surgery or both.

Types of participants
People who have an acute anterior shoulder dislocation that is considered suitable by the trial investigators for reduction by closed
methods (non-surgical procedure). This can be a primary or firsttime dislocation or a re-dislocation. Closed reduction can take
place in any setting. Ideally, the acute anterior shoulder dislocation
should have been confirmed by physical examination and radiography or other imaging technique. Where trials do not specify
their method of diagnosis or base their diagnosis on physical examination alone, we will consider the potential for misdiagnosis,
such as a missed proximal humeral fracture. We will exclude trials focusing on people with fracture-dislocations of the proximal
humerus.
Although we will not exclude trials including patients presenting
more that 24 hours after injury, we anticipate that most trials will
exclude these late presentations as they are generally treated in
theatre.

Secondary outcomes

Reduction failure (lack of success) as defined by study


authors. This could include a change in technique, more than
two attempts at reduction and complete failure.
Patient satisfaction with intervention.
Number of attempts at reduction.
Subsequent recurrence of dislocation, preferably assessed at
one year or more.
Long-term shoulder function assessed using validated
patient-reported outcome measures such as the Oxford Shoulder
Instability Score (Dawson 1999) and Western Ontario Shoulder
Instability Score (WOSI) (Kirkley 1998), preferably assessed at
one year.
Duration of reduction procedure (time taken to put the
shoulder back into joint from start of closed reduction
procedure).

Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Search methods for identification of studies

resolved by discussion and, where necessary, in consultation with


a third review author (SD).

Electronic searches
We will search the Cochrane Bone, Joint and Muscle Trauma
Group Specialised Register (to present), the Cochrane Central Register of Controlled Trials (in The Cochrane Library,
current issue), MEDLINE (1946 to present) and EMBASE
(1980 to present). We will also search the World Health
Organization International Clinical Trials Registry platform and
Current Controlled Trials to identify ongoing and recently completed trials. We will apply no restrictions based on language or
publication status.
In MEDLINE (Ovid Online), we will combine a subject-specific
strategy with a modified version of the of the Cochrane Highly
Sensitive Search Strategy for identifying randomised trials (sensitivity-maximising version) (Lefebvre 2011). Search strategies for
MEDLINE, The Cochrane Library and EMBASE can be found in
Appendix 1.
Searching other resources
We will check reference lists of articles. We will also attempt to
contact researchers in the field for information on existing or ongoing trials. We will search specific proceedings of shoulder and elbow surgery meetings and conferences from the following sources:
British Elbow and Shoulder Society (2001 onwards); American
Orthopaedic Trauma Association (1996 onwards); The Bone
and Joint Journal Orthopaedic Proceedings (2001 onwards) and
American Shoulder and Elbow Society (2005 onwards).

Data collection and analysis

Selection of studies
Two review authors (KT and RT) will independently examine the
titles and abstracts of articles identified via the search for potentially eligible trials. After obtaining the full texts of these trials,
where possible, the same two authors will then independently perform study selection based on our inclusion criteria. Any disagreement will be discussed and, if necessary, a third author (SD) will
arbitrate. Where necessary, we will attempt to contact trial authors
for clarification of study methods.
Data extraction and management
Two review authors (KT and RT) will independently extract data
from each included trial using a piloted data extraction form. We
will resolve any differences in data extraction by consensus, and
by referring back to the original article. When necessary, we will
seek information from the study authors. Disagreement will be

Assessment of risk of bias in included studies


Two review authors (RT and KD) will independently assess the
risk of bias of the included studies using The Cochrane Collaborations Risk of bias tool (Higgins 2011). We will assess the following domains: random sequence generation;
cealment;

allocation con-

blinding of participants and personnel;

outcome assessment;

completeness of outcome data;

blinding of
selective

reporting and other bias. We will attempt to locate trial registrations of included trials in trial registries; this will include the UK
National Research Register (NRR) Archive, where appropriate.
We will consider two sources of other bias: that from major imbalances in baseline characteristics (age, time from injury, primary
or recurrent dislocations) and additional performance bias arising
from differences in the level of experience of the care providers
with the methods of reduction under test.
We will judge each of these domains as being at low risk of bias,
high risk of bias or unclear risk of bias (either lack of information
or uncertainty over the potential for bias). Disagreement will be
resolved by discussion and, where necessary, in consultation with
a third review author (SD).

Measures of treatment effect


We will calculate risk ratios (RR) with 95% confidence intervals
(CI) for dichotomous outcomes (such as reduction success) and
mean differences with 95% CIs for continuous outcomes (such
as pain measured with a visual analogue scale). When pooling
continuous outcome data, we will use mean differences and 95%
CIs where similar scales are used to measure the same outcome
and standardised mean differences (SMD) and 95% CIs where
different scales are used to measure the same outcome.

Unit of analysis issues


We anticipate that the units of randomisation and analysis in the
included trials will be the individual participant. Exceptionally,
people may present with bilateral dislocations, which may be randomised to a single procedure for each limb. Therefore, a trial including people with bilateral dislocations may present results for
limbs rather than individuals. We will ignore this type of discrepancy between the unit of analysis and randomisation if we assess it
as being unlikely to change the trial results. Where we pool data,
we will perform a sensitivity analysis to examine the effects of excluding incorrectly reported trials from the analysis.

Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Dealing with missing data


Where appropriate, we will perform intention-to-treat analyses in
which all randomised participants are analysed in the groups to
which they were originally assigned. We will attempt to contact
authors of primary studies to request missing data from trials such
as means, standard deviations or number of events. Where standard deviations from continuous data have not been reported, we
will calculate standard deviations, if possible, from standard errors, P values or confidence intervals, using the methods outlined
in the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2011). If we are unable to do this, we will not impute
standard deviations from similar studies.

Assessment of heterogeneity
We will assess clinical heterogeneity within all comparisons of all
included trials. We will assess statistical heterogeneity by visual
inspection of graphs (e.g. forest plots) and calculation of the I
statistic, which provides an estimate of the percentage of variability
due to heterogeneity rather than to chance alone. We will judge
there to be considerable heterogeneity if the I estimate is 75%
or more (Higgins 2003; Higgins 2011).

Assessment of reporting biases


We will investigate the possibility of publication bias by constructing a funnel plot if there are data from more than 10 trials.

participants with first time versus recurrent dislocation;


age range: less than 30 years, older than 30 years (Hovelius
2008);
athletes versus non-athletes;
the use/type of anaesthesia/sedation (including sedation,
intra-articular anaesthetic and intravenous analgesia).
The age ranges have been chosen to reflect those reported in an
important long-term study by Hovelius 2008, highlighting the
higher chances of recurrence of dislocation in the younger age
category.
We will investigate whether the results of subgroups are significantly different by inspecting the overlap of confidence intervals
and performing the test for subgroup differences available in Review Manager 5.2 (RevMan 2012).
Sensitivity analysis
Where possible, we plan to conduct sensitivity analyses examining
various aspects of trial and review methodology. These will include
examining the effects of:
excluding trials at high or unclear risk of bias, such as
selection bias arising from the lack of allocation concealment;
excluding trials only reported in conference abstracts;
excluding trials with unit of analyses problems related to the
inclusion of participants with bilateral dislocations;
the choice of statistical model for pooling (fixed-effect
versus random-effects);
missing data.

Data synthesis
When considered appropriate, we will pool results of comparable
groups of trials using both fixed-effect and random-effects models. The choice of the model to report will be guided by careful
consideration of the extent of heterogeneity and whether it can be
explained, in addition to other factors, such as the number and
size of included studies. We will use 95% CIs throughout. We will
consider not pooling data where there is considerable heterogeneity (I > 75%) that cannot be explained by the diversity of methodological or clinical features among trials. Where it is inappropriate
to pool data, we will still present trial data in the analyses or tables
for illustrative purposes and will report these in the text.

Subgroup analysis and investigation of heterogeneity


Where data allow, we will analyse variations of similar techniques
or methods of reduction.
If possible, and where relevant, we will conduct the following
subgroup analyses:

Assessing the quality of the evidence


We will use the GRADE approach to assess the quality of evidence
related to each of the primary outcomes listed in Types of outcome
measures (Higgins 2011; see section 12.2). Where there are sufficient data, we will summarise the results for the main comparisons described in Types of interventions in Summary of findings
tables.

ACKNOWLEDGEMENTS
We would like to thank Lindsey Elstub for general helpful advice
and support. We are also grateful to Joanne Elliott for advice on
developing the search strategies. We would like to thank Keith Hill
and Kash Khan for their feedback at editorial and external review.
We would like to thank Laura MacDonald and Helen Handoll for
continued support and final revision of the protocol.

Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Indicates the major publication for the study

Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

APPENDICES

Appendix 1. Search strategies

The Cochrane Library (Wiley Online Library)


#1 MeSH descriptor: [Shoulder Dislocation] this term only
#2 ((shoulder* or glenohumeral) near/3 (dislocat* or sublux* or lux*)):ti,ab,kw (Word variations have been searched)
#3 #1 or #2
#4 closed or conservativ* or nonoperativ* or non operativ*:ti,ab,kw (Word variations have been searched)
#5 reduc* or maneuv* or manoeuvr* or manipulat* or reposition* or traction or counter traction or countertraction or TCT or leverage
or direct pressure*:ti,ab,kw (Word variations have been searched)
#6 Hippocratic or Stimson or Kocher or Milch or FARES or Spaso or Eskimo or Manes or Cunningham or Eachempati or Snowbird:
ti,ab,kw (Word variations have been searched)
#7 #4 or #5 or #6
#8 #3 and #7

MEDLINE (Ovid Online)


1 Shoulder Dislocation/
2 ((shoulder* or glenohumeral) adj3 (dislocat* or sublux* or lux*)).tw.
3 1 or 2
4 (closed or conservativ* or nonoperativ* or non operativ*).tw.
5 (reduc* or man?euv* or manipulat* or reposition* or traction or counter traction or countertraction or TCT or leverage or direct
pressure*).tw.
6 (Hippocratic or Stimson or Kocher or Milch or FARES or Spaso or Eskimo or Manes or Cunningham or Eachempati or Snowbird).tw.
7 4 or 5 or 6
8 3 and 7
9 Randomized controlled trial.pt.
10 Controlled clinical trial.pt.
11 randomized.ab.
12 placebo.ab.
13 randomly.ab.
14 trial.ab.
15 groups.ab.
16 or/9-15
17 exp Animals/ not Humans/
18 16 not 17
19 8 and 18

EMBASE (Ovid Online)


1 Shoulder Dislocation/
2 ((shoulder* or glenohumeral) adj3 (dislocat* or sublux* or lux*)).tw.
3 1 or 2
4 (closed or conservativ* or nonoperativ* or non operativ*).tw.
5 (reduc* or man?euv* or manipulat* or reposition* or traction or counter traction or countertraction or TCT or leverage or direct
pressure*).tw.
6 (Hippocratic or Stimson or Kocher or Milch or FARES or Spaso or Eskimo or Manes or Cunningham or Eachempati or Snowbird).tw.
7 4 or 5 or 6
8 3 and 7
Closed reduction methods for acute anterior shoulder dislocation (Protocol)
Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

9 Randomized controlled trial/


10 Clinical trial/
11 Controlled clinical trial/
12 Randomization/
13 Single blind procedure/
14 Double blind procedure/
15 Crossover procedure/
16 Placebo/
17 Prospective study/
18 ((clinical or controlled or comparative or placebo or prospective* or randomi#ed) adj3 (trial or study)).tw.
19 (random* adj7 (allocat* or allot* or assign* or basis* or divid* or order*)).tw.
20 ((singl* or doubl* or trebl* or tripl*) adj7 (blind* or mask*)).tw.
21 (cross?over* or (cross adj1 over*)).tw.
22 ((allocat* or allot* or assign* or divid*) adj3 (condition* or experiment* or intervention* or treatment* or therap* or control* or
group*)).tw.
23 RCT.tw.
24 or/9-23
25 Case Study/ or Abstract Report/ or Letter/
26 24 not 25
27 8 and 26

CONTRIBUTIONS OF AUTHORS
KT: conceiving the review, designing and writing the protocol. KT is also the guarantor of the review
RT: providing general advice on drafts of the protocol
SD: providing general advice on drafts of the protocol
KD: providing general advice on drafts of the protocol

DECLARATIONS OF INTEREST
Kanthan Theivendran: none known
Raj R Thakrar: none known
Subodh C Deshmukh: none known
Kerry Dwan: none known

SOURCES OF SUPPORT

Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Internal sources
Royal Orthopaedic Hospital, Birmingham, UK.
University Hospital Birmingham, UK.

External sources
No sources of support supplied

Closed reduction methods for acute anterior shoulder dislocation (Protocol)


Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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