Dear editor:
A shoulder dislocation is a common diagnosis at the emergency department, showing an incidence of 23.9 per 100,000 person-years. In the current diagnostic work-up, a radiograph is often used to confirm the dislocation. As radiographs are associated with radiation exposure, the ultrasound has been proposed as an alternative. Therefore, the study by Entezari et al is of great importance in evaluating the applicability of the ultrasound. However, the authors suggest that the ultrasound can be used as an alternative to the radiograph. In our opinion, an important advantage of the radiograph has not been discussed and we question some decisions that were made in terms of methodology. Therefore, we think that this study has to be seen in the light of these remarks

van den Bekerom, Michel P.J.

van der Woude, Henk-Jan

Verweij, Lukas P.E.

English

Advanced Journal of Emergency medicine

Conventional Radiograph Is Still Advised in the Diagnostic Work-up of a Shoulder Dislocation; a Letter to the Editor

Frontiers in Emergency Medicine (E-Journal)

ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e66 Verweij et al     1 Copyright © 2020 Tehran University of Medical Sciences  This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).  Letter to the Editor DOI: 10.22114/ajem.v0i0.346 Conventional Radiograph Is Still Advised in the Diagnostic Work-up of a Shoulder Dislocation; a Letter to the Editor  Lukas P.E. Verweij1*, Henk-Jan van der Woude2, Michel P.J. van den Bekerom3  1. Department of Orthopedic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Movement Sciences (AMS), Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, The Netherlands. 2. Department of Radiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands. 3. Department of Orthopedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.  *Corresponding author: Lukas P.E. Verweij; Email: l.p.verweij@amsterdamumc.nl Published online: 2020-02-20  Dear editor: A shoulder dislocation is a common diagnosis at the emergency department, showing an incidence of 23.9 per 100,000 person-years (1). In the current diagnostic work-up, a radiograph is often used to confirm the dislocation. As radiographs are associated with radiation exposure, the ultrasound has been proposed as an alternative (2). Therefore, the study by Entezari et al is of great importance in evaluating the applicability of the ultrasound (3). However, the authors suggest that the ultrasound can be used as an alternative to the radiograph. In our opinion, an important advantage of the radiograph has not been discussed and we question some decisions that were made in terms of methodology. Therefore, we think that this study has to be seen in the light of these remarks.  An anterior shoulder dislocation can be accompanied by glenohumeral bone defects, such as glenoid bone loss, greater tuberosity fractures or Hill-Sachs lesions (4). Griffith et al showed that glenoid bone loss is present in up to 41% and a Hill-Sachs lesion is present in up to 81% after primary anterior dislocation (5). Glenohumeral bone defects are meaningful, as they can be decisive in advising patients to be treated with a bone augmentation procedure to prevent further damage to the glenohumeral joint (6). In addition, especially for large glenohumeral bone defects, a radiograph can be used to determine if a CT scan or MRI is indicated to evaluate the defects (4). An AP radiograph, trans scapular radiograph or axial radiograph of adequate quality can identify these defects through absence of the sclerotic line or presence of an impression fracture of the posterolateral side of the humeral head, following an anterior dislocation (4, 7). However, Gottlieb et al showed that post-reduction radiographs did not identify new fractures in addition to the pre-reduction radiograph (8). Ultrasound might be able to determine if the shoulder is dislocated, but it is unclear if ultrasound is able to detect these defects. As additional radiographs do not seem to identify additional fractures after reduction, a single radiograph might be valuable after dislocation or reduction. That being said, a radiograph might be valuable in detecting large bone defects, but a CT scan remains the gold standard. The aim of this review states that the authors wanted to evaluate the efficacy of ultrasound in diagnosis of shoulder dislocation and confirmation of shoulder reduction. However, as only one primary outcome is shown in table 2, it seems like the results have been pooled for some studies. The sensitivity and specificity has been determined of either diagnosis before reduction, diagnosis after reduction or diagnosis before and after reduction. We question the validity of the sensitivity and specificity, as diagnosing dislocation and reduction successfully might not be the same thing. The definition of a positive test is not reached through the same or a similar image, therefore the groups are different and pooling them seems impossible. Furthermore, the authors did not distinguish between anterior, posterior and inferior dislocation. Not only do posterior and anterior dislocations show clear distinctions in terms of presentation and clinical findings, they show different images in terms of radiology as well (9). Therefore, the shoulder dislocation directions should be analyzed separately. ACKNOWLEDGEMENT None. AUTHOR CONTRIBUTION The author passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e66 Verweij et al     2 Copyright © 2020 Tehran University of Medical Sciences  This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).  CONFLICT OF INTEREST None declared. FUNDING None declared. REFERENCES 1. Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010;92(3):542-9. 2. Gottlieb M, Holladay D, Peksa GD. Point-of-care ultrasound for the diagnosis of shoulder dislocation: A systematic review and meta-analysis. Am J Emerg Med. 2019;37(4):757-61. 3. Entezari P, Jalili M, Seyedhosseini J, Doosti-Irani A, Mirfazaelian H. Accuracy of Ultrasonography in Diagnosis of Shoulder Dislocation: A Systematic Review. Adv J Emerg Med. 2020;4(1):e9. 4. Auffarth A, Mayer M, Kofler B, Hitzl W, Bogner R, Moroder P, et al. The interobserver reliability in diagnosing osseous lesions after first-time anterior shoulder dislocation comparing plain radiographs with computed tomography scans. J Shoulder Elbow Surg. 2013;22(11):1507-13. 5. Griffith JF, Antonio GE, Yung PS, Wong EM, Yu AB, Ahuja AT, et al. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR Am J Roentgenol. 2008;190(5):1247-54. 6. Provencher MT, Bhatia S, Ghodadra NS, Grumet RC, Bach BR, Jr., Dewing CB, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am. 2010;92 Suppl 2:133-51. 7. Jankauskas L, Rudiger HA, Pfirrmann CW, Jost B, Gerber C. Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: a diagnostic sign for an osseous defect of the anterior glenoid rim. J Shoulder Elbow Surg. 2010;19(1):151-6. 8. Gottlieb M, Nakitende D, Krass L, Basu A, Christian E, Bailitz J. Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation. West J Emerg Med. 2016;17(1):35-8. 9. Bernhardson AS, Murphy CP, Aman ZS, LaPrade RF, Provencher MT. A Prospective Analysis of Patients With Anterior Versus Posterior Shoulder Instability: A Matched Cohort Examination and Surgical Outcome Analysis of 200 Patients. Am J Sports Med. 2019;47(3):682-7.  

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Conventional Radiograph Is Still Advised in the Diagnostic Work-up of a Shoulder Dislocation; a Letter to the Editor

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