Raiyyan Tahsan

Raiyyan Tahsan
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TC(959).(05).Orthopedics Case No 37. Dislocation

Dislocation — সংজ্ঞা

Dislocation হলো কোনো joint-এর দুই হাড়ের articular surface স্বাভাবিক alignment থেকে সম্পূর্ণ আলাদা হয়ে যাওয়া। Partial হলে তাকে subluxation বলা হয়। এটি orthopedic emergency, কারণ nerve/artery/ligament/cartilage injury হতে পারে। তাই নিজে টেনে বসানোর চেষ্টা করা যাবে না; trained doctor দ্বারা reduction করতে হবে। MSD Manual dislocation injury-তে neurovascular injury—numbness, paresis, poor perfusion—তাৎক্ষণিক মূল্যায়নের কথা বলে।

Cause / Etiology — কারণগুলো

  1. Trauma / আঘাত
    • পড়ে যাওয়া, road traffic accident, sports injury, fight/assault।
    • Shoulder, elbow, finger, patella, hip dislocation বেশি দেখা যায়।
  2. Sports-related sudden force
    • Football, cricket fielding fall, wrestling, gymnastics, kabaddi।
    • হাত পেছনে/উপরে ঘুরে গেলে shoulder anterior dislocation common।
  3. Previous dislocation / recurrent instability
    • একবার dislocation হলে ligament/capsule/labrum ঢিলে বা ছিঁড়ে যেতে পারে, ফলে বারবার বের হওয়ার ঝুঁকি থাকে।
  4. Congenital বা connective tissue laxity
    • Ehlers–Danlos, hypermobility syndrome, congenital hip dysplasia।
  5. Seizure/electric shock
    • তীব্র muscle contraction থেকে posterior shoulder dislocation হতে পারে।
  6. Weak muscles / poor rehabilitation
    • reduction-এর পর physiotherapy না করলে joint unstable থাকে।

Symptoms — লক্ষণগুলো

  • হঠাৎ তীব্র ব্যথা — movement করলে ব্যথা বাড়ে।
  • Joint deformity — joint-এর shape অস্বাভাবিক দেখা যায়।
  • Swelling ও bruising — ligament/capsule injury থাকলে বেশি হয়।
  • Movement করতে না পারা — patient limb ধরে রাখে, নড়াতে চায় না।
  • Numbness/tingling — nerve injury যেমন shoulder dislocation-এ axillary nerve injury হতে পারে।
  • Cold/pale limb, pulse কমে যাওয়া — vascular injury; emergency.
  • Muscle spasm — reduction কঠিন করে।
  • Shoulder dislocation example: বাহু সামান্য abducted/external rotated, deltoid contour flat, severe pain; reduction হলে pain দ্রুত কমে যায়—AAOS shoulder dislocation treatment section-এ reduction-এর পর pain কমার কথা উল্লেখ আছে।

Clinical Diagnosis — Clinically কীভাবে diagnose করবেন

  1. History
    • Injury mechanism: fall? RTA? sports? seizure?
    • Time since injury, first-time নাকি recurrent?
    • Pain severity, numbness, weakness, cold hand/foot আছে কিনা।
  2. Inspection
    • deformity, swelling, bruising, open wound, limb position।
  3. Palpation
    • bony tenderness, joint gap, associated fracture suspicion।
  4. Range of motion
    • active movement সাধারণত করা যায় না; forceful passive movement করা যাবে না।
  5. Neurovascular examination — reduction-এর আগে ও পরে দুবার
    • Pulse: radial/dorsalis pedis/posterior tibial।
    • Capillary refill, limb temperature, color।
    • Sensation: numbness area।
    • Motor: finger/wrist/ankle movement।
    • Shoulder হলে axillary nerve: lateral deltoid “regimental badge” area sensation + deltoid contraction।
    • Knee dislocation হলে popliteal artery injury rule out করতে ABI/Doppler/CTA দরকার হতে পারে।

Investigations — Specific test

  1. X-ray — first-line
    • Before reduction: dislocation direction + associated fracture দেখতে।
    • After reduction: joint ঠিকভাবে বসেছে কিনা confirm করতে।
    • Shoulder: AP view + scapular Y/axillary view।
    • Elbow: AP + lateral।
    • Hip: AP pelvis + lateral/cross-table lateral।
    • Finger/toe: AP + lateral + oblique।
  2. CT scan
    • fracture-dislocation, intra-articular fragment, acetabular fracture, complex elbow/hip injury সন্দেহে।
  3. MRI
    • Labral tear/Bankart lesion, Hill-Sachs lesion, rotator cuff tear, ligament injury, recurrent instability evaluation।
    • First-time anterior shoulder dislocation-এর পর persistent pain/instability থাকলে MRI useful; review evidence MRI/orthopedic referral-এর কথা বলে।
  4. Doppler ultrasound / CT angiography
    • pulse কম, cold limb, expanding hematoma, knee dislocation, vascular compromise সন্দেহে।
  5. Nerve conduction study / EMG
    • reduction-এর পর persistent nerve deficit থাকলে পরে করা হয়।

Differential Diagnosis

  • Fracture near joint
  • Severe sprain / ligament tear
  • Tendon rupture
  • Subluxation
  • Septic arthritis — fever, hot swollen joint
  • Hemarthrosis
  • Soft tissue contusion
  • Compartment syndrome — pain out of proportion, tense swelling, paresthesia, pallor, pulselessness

Complications — জটিলতা

  1. Nerve injury
    • Shoulder: axillary nerve; elbow: ulnar/median/radial nerve; hip: sciatic nerve।
  2. Vascular injury
    • Knee dislocation-এ popliteal artery injury limb-threatening হতে পারে।
    • Pulse না থাকলে emergency vascular assessment।
  3. Associated fracture
    • Greater tuberosity fracture, glenoid fracture, acetabular fracture, radial head/coronoid fracture।
  4. Recurrent dislocation
    • Young athlete/first-time anterior shoulder dislocation-এ recurrence risk বেশি; immobilization + rehab গুরুত্বপূর্ণ। Literature review-এ first-time traumatic anterior shoulder dislocation management-এ reduction, immobilization ও rehabilitation মূল বিষয় হিসেবে উল্লেখ আছে।
  5. Joint stiffness
    • দীর্ঘ immobilization বা physiotherapy না করলে।
  6. Avascular necrosis
    • বিশেষ করে hip dislocation দেরিতে reduced হলে femoral head AVN ঝুঁকি।
  7. Post-traumatic arthritis
    • cartilage damage বা recurrent instability থাকলে।
  8. Compartment syndrome
    • severe swelling/vascular compromise হলে emergency fasciotomy লাগতে পারে।

Treatment / Management

A. Immediate first aid

  • Joint নাড়াচাড়া কমান।
  • নিজে reduction করবেন না।
  • Splint/sling দিয়ে immobilize করুন।
  • Ice pack 15–20 মিনিট করে দিন।
  • Finger ring/bracelet খুলে ফেলুন swelling হওয়ার আগে।
  • Numbness, pulse কম, cold limb, open wound, severe deformity থাকলে emergency department.

B. Definitive management

  1. Analgesia + muscle relaxation
    • Pain control দিলে muscle spasm কমে, reduction সহজ হয়।
  2. Closed reduction
    • Trained doctor/orthopedic surgeon করবেন।
    • Shoulder reduction technique একাধিক আছে; MSD/Merck shoulder reduction overview অনুযায়ী anterior shoulder dislocation-এ axial traction/external rotation ভিত্তিক বিভিন্ন technique ব্যবহৃত হয়, একটাই “perfect” technique নেই।
  3. Post-reduction check
    • Pain কমেছে কিনা।
    • Neurovascular exam repeat।
    • Post-reduction X-ray।
  4. Immobilization
    • Shoulder হলে sling; elbow/finger/hip/knee অনুযায়ী splint/brace।
    • AAOS reduction-এর পর sling immobilization ও rehabilitation-এর কথা বলে।
  5. Rehabilitation / physiotherapy
    • Pain কমলে ROM exercise → strengthening → proprioception → sport-specific return।
    • Shoulder first-time anterior dislocation-এ commonly 1–3 weeks sling + several months rehab recommended হয়েছে।
  6. Surgery indications
    • Open dislocation
    • Irreducible dislocation
    • Fracture-dislocation
    • Vascular injury
    • Persistent nerve compression
    • Recurrent dislocation
    • Young athlete with Bankart/labral tear
    • Hip/knee complex instability

Pharmacological Management — Bangladesh prescription logic

Important: নিচের ডোজ adult general dose. CKD, liver disease, peptic ulcer, anticoagulant, asthma, pregnancy, elderly, child—ডোজ/medicine বদলাবে। NSAID একসাথে দুইটা দেবেন না। MedEx নিজেও registered doctor-এর পরামর্শে ওষুধ সেবনের সতর্কতা দেয়।

1. Paracetamol

  • Generic name: Paracetamol / Acetaminophen
  • Therapeutic category: Non-opioid analgesic, antipyretic
  • Pharmacological class: Para-aminophenol derivative
  • Dose: 500–1000 mg PO 6–8 hourly PRN; max usually 3–4 g/day; liver disease/alcohol use থাকলে কম।
  • Duration: 3–5 days or as needed.
  • কেন ব্যবহার হয়: Mild–moderate pain, fever, NSAID contraindication থাকলে safer option।
  • Side effects: nausea, rash; overdose হলে severe hepatotoxicity।
  • Interaction: alcohol, warfarin long-term use, other paracetamol-containing cold/pain medicine।
  • Bangladesh available brand: Napa 500 mg, Ace 500 mg, Fevac 500 mg, Fevimol 500 mg, G-Paracetamol 500 mg, Napa Extend 665 mg, Napa One 1000 mg. MedEx-এ Napa 500 mg ও Ace 500 mg paracetamol হিসেবে pain/fever/bodyache/sprain indication সহ listed আছে।

2. Ibuprofen

  • Generic name: Ibuprofen
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; propionic acid derivative
  • Dose: 400 mg PO 8 hourly after meal; max OTC 1200 mg/day; physician supervision ছাড়া high dose নয়।
  • Duration: 3–5 days.
  • কেন ব্যবহার হয়: Pain + swelling/inflammation কমাতে।
  • Side effects: dyspepsia, gastric ulcer/bleeding, renal impairment, BP rise, bronchospasm in NSAID-sensitive asthma।
  • Interaction: warfarin/DOAC, aspirin, steroid, SSRI/SNRI, ACEi/ARB + diuretic, other NSAID।
  • Bangladesh brand: Serviprofen 400 mg, Siflam 400 mg, Trufen 400 mg, Uniflam 400 mg. MedEx ibuprofen 200–400 mg 6-hour interval PRN ও max 1200 mg/day information দেয়, এবং 400 mg brands listed আছে।

3. Naproxen Sodium

  • Generic name: Naproxen Sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; propionic acid derivative
  • Dose: 250–500 mg PO twice daily after meal.
  • Duration: 3–5 days.
  • কেন ব্যবহার হয়: Longer acting NSAID; joint pain + inflammation।
  • Side effects: gastritis, ulcer/bleeding, renal injury, edema, BP rise।
  • Interaction: same NSAID interactions; anticoagulant/steroid/other NSAID avoid।
  • Bangladesh brand: Naid 250/500 mg, Naproxen 500 mg, Napdas 500 mg, Napasin 250 mg. MedEx Naproxen Sodium 500 mg products and Naid 250/500 mg brands listed আছে।

4. Diclofenac Sodium

  • Generic name: Diclofenac Sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative
  • Dose: 50 mg PO 8–12 hourly after meal; max 150 mg/day. IM 75 mg may be used in ED/clinic, but repeated unsupervised injection avoid.
  • Duration: 2–5 days; shortest effective course.
  • কেন ব্যবহার হয়: Acute traumatic pain ও inflammation কমাতে।
  • Side effects: gastritis, GI bleed, renal injury, edema, BP rise, liver enzyme elevation; CV risk।
  • Interaction: anticoagulant, aspirin, steroid, ACEi/ARB/diuretic, lithium/methotrexate।
  • Bangladesh brand: Diloren 50 mg, Diloren SR 100 mg, G-Diclofenac 50 mg, G-Diclofenac IM 75 mg/3 ml, Voltalin suppository 50 mg, Diclofen gel 1%. MedEx diclofenac sodium brand list-এ এসব strengths/forms আছে।

5. Aceclofenac

  • Generic name: Aceclofenac
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; diclofenac analogue
  • Dose: 100 mg PO twice daily after meal.
  • Duration: 3–5 days.
  • কেন ব্যবহার হয়: Trauma-related pain, musculoskeletal inflammation।
  • Side effects/interaction: NSAID class adverse effects—GI bleed, renal injury, BP rise; anticoagulant/steroid/other NSAID avoid।
  • Bangladesh brand: Flexi 100 mg, Flexi SR 200 mg, Avenac 100 mg, Biofenac 100 mg, Ceclofen 100 mg, Celofen 100 mg, Labenac 100 mg. MedEx aceclofenac trauma/lumbago/pain inflammation indication এবং 100 mg brand list দেয়।

6. Ketorolac Tromethamine

  • Generic name: Ketorolac Tromethamine
  • Therapeutic category: Potent non-opioid analgesic
  • Pharmacological class: NSAID
  • Dose: 10 mg PO 6 hourly PRN; IM/IV 30 mg in adult may be used under medical supervision.
  • Duration: Maximum total 5 days; chronic painে নয়।
  • কেন ব্যবহার হয়: Severe acute pain, opioid-level analgesia দরকার হলে short-term।
  • Side effects: high GI bleed risk, renal injury, platelet inhibition, bronchospasm।
  • Interaction: other NSAID, anticoagulant, steroid, SSRI/SNRI, ACEi/ARB/diuretic।
  • Bangladesh brand: Torax 10 mg, Torax 30 mg injection, Rolac 10 mg, Ketorin 10 mg/30 mg/ml, Ketonic 30 mg/ml, Ketovalor 30 mg/ml, Roket 30 mg/ml. MedEx ketorolac short-term moderate–severe acute pain indication এবং multiple 10 mg/30 mg/ml brands listed করে।

7. Tramadol

  • Generic name: Tramadol Hydrochloride
  • Therapeutic category: Opioid analgesic
  • Pharmacological class: Centrally acting synthetic opioid; μ-opioid agonist + serotonin/noradrenaline reuptake inhibition
  • Dose: 50 mg PO/IM/IV 6 hourly PRN; max 400 mg/day in adults; elderly/renal/liver diseaseে কম।
  • Duration: 1–3 days, severe pain হলে only short course.
  • কেন ব্যবহার হয়: NSAID/paracetamol যথেষ্ট না হলে moderate–severe acute pain।
  • Side effects: nausea, vomiting, dizziness, drowsiness, constipation, respiratory depression, dependence, seizure, serotonin syndrome।
  • Interaction: alcohol, benzodiazepine, sleeping pill, SSRI/SNRI/TCA/MAOI, antipsychotic, other opioid।
  • Bangladesh brand: Anadol 100 mg/2 ml injection, Tramadol 50 mg preparations, sustained-release 100 mg forms; NapaDol 325 mg+37.5 mg contains paracetamol + tramadol. MedEx tramadol brand list includes 50 mg, 100 mg and 100 mg/2 ml forms; MedEx describes tramadol as centrally acting synthetic analgesic.

8. Tizanidine

  • Generic name: Tizanidine Hydrochloride
  • Therapeutic category: Muscle relaxant
  • Pharmacological class: Central α2-adrenergic agonist
  • Dose: 2 mg at night or 2 mg 2–3 times/day; titrate carefully.
  • Duration: 2–5 days for acute spasm, if needed.
  • কেন ব্যবহার হয়: Reduction-এর আগে/পরে painful muscle spasm কমাতে; routine না, selected cases।
  • Side effects: drowsiness, dizziness, hypotension, dry mouth, weakness, liver enzyme elevation।
  • Interaction: ciprofloxacin/fluvoxamine contraindicated, alcohol, benzodiazepine, opioid, antihypertensive।
  • Bangladesh brand: Relentus 2 mg, Sirdalud 2 mg. MedEx tizanidine painful muscle spasm indication এবং 2 mg brands listed করে।

9. PPI — NSAID gastric protection

  • Generic name: Omeprazole / Esomeprazole
  • Therapeutic category: Anti-ulcerant
  • Pharmacological class: Proton pump inhibitor
  • Dose: Omeprazole 20 mg once daily before breakfast, or Esomeprazole 20 mg once daily.
  • Duration: NSAID চলাকালীন 3–7 days; high GI riskে clinician decision.
  • কেন ব্যবহার হয়: NSAID-induced gastritis/ulcer risk কমাতে, especially ulcer history/elderly/steroid/anticoagulant use।
  • Side effects: headache, diarrhea/constipation, abdominal pain; long-termে B12/Mg deficiency, infection risk।
  • Interaction: clopidogrel with omeprazole caution, warfarin, methotrexate high dose।
  • Bangladesh brand: Losectil 20 mg, Losectil MUPS 20 mg, Omenix 20 mg, Omegut 20 mg, Maxpro 20 mg. MedEx omeprazole/esomeprazole brands and NSAID-induced ulcer/GERD-related indications list করে।

10. Lidocaine — ED reduction analgesia

  • Generic name: Lidocaine Hydrochloride injection
  • Therapeutic category: Local anesthetic
  • Pharmacological class: Amide local anesthetic
  • Dose: Intra-articular shoulder reductionে commonly 1% lidocaine 10–20 ml used by trained clinician; max dose calculate করতে হয়।
  • Duration: Single procedural use.
  • কেন ব্যবহার হয়: Sedation এড়াতে বা কমাতে joint pain numb করে reduction সহজ করা।
  • Side effects: local anesthetic systemic toxicity—perioral numbness, tinnitus, seizure, arrhythmia; allergy rare।
  • Interaction: antiarrhythmics, beta-blocker/cimetidine may increase level।
  • Bangladesh brand: Chemocain 2%, G-Lidocaine 2%, Jasocaine 1–2%, Locaine 2%, Lidocaine 2%. MedEx lidocaine injection local anesthetic use এবং Bangladesh brands listed করে।

11. Procedural sedation drugs — hospital only

এসব drug home prescription নয়; monitoring, oxygen, airway support, resuscitation facility ছাড়া দেওয়া যাবে না।

  • Midazolam
    • Class: Benzodiazepine sedative/anxiolytic
    • Use: Reduction-এর সময় anxiety/sedation।
    • Brand: Hypnofast 5 mg/5 ml, 15 mg/3 ml injection; Midalam/Midolam 7.5 mg tablet। MedEx midazolam sedation before procedures indication দেয়।
    • Risk: respiratory depression, hypotension, amnesia; opioid/alcohol interaction dangerous।
  • Propofol
    • Class: IV general anesthetic/sedative
    • Use: ED procedural sedation by trained physician/anesthetist।
    • Brand: Pofol 200 mg/20 ml, Propofol 200 mg/20 ml, Propofol MCT 200 mg/20 ml. MedEx propofol short-acting IV general anesthetic with rapid onset হিসেবে describes করে।
    • Risk: apnea, hypotension; airway support mandatory।
  • Ketamine
    • Class: Dissociative anesthetic; NMDA antagonist
    • Use: painful procedure/trauma setting; maintains airway reflex relatively better but monitoring essential। StatPearls ketamine brief procedures/general anesthetic indication উল্লেখ করে।
    • Risk: emergence reaction, hypersalivation, vomiting, hypertension, hallucination।
  • Fentanyl
    • Class: Potent opioid analgesic
    • Use: severe procedural pain, monitored setting only। CDC/NIOSH fentanyl analgesic/anesthetic property উল্লেখ করে।
    • Risk: respiratory depression, chest wall rigidity, dependence; benzodiazepine/alcohol interaction dangerous।

Bangladesh doctors usually prescribe কীভাবে — practical list

  1. Mild pain after reduction
    • Paracetamol 500 mg 1 tab 6–8 hourly PRN ± ice + sling.
  2. Pain + swelling বেশি
    • Paracetamol + one NSAID: Ibuprofen / Naproxen / Diclofenac / Aceclofenac short course.
    • একসাথে Ibuprofen + Diclofenac + Naproxen দেওয়া উচিত নয়।
  3. Severe acute pain
    • ED/clinic: Ketorolac IM/IV short-term or Tramadol short course.
    • Opioid হলে driving, alcohol, sedative avoid।
  4. Muscle spasm
    • Tizanidine short course, mainly night dose; drowsiness warning।
  5. Gastric risk
    • NSAID-এর সাথে Omeprazole/Esomeprazole।
  6. Reduction procedure
    • Lidocaine intra-articular / nerve block / procedural sedation—hospital protocol অনুযায়ী।
  7. Antibiotic
    • Closed dislocation-এ routine antibiotic লাগে না।
    • Open wound, open dislocation, surgery হলে antibiotic + tetanus prophylaxis দরকার।

Prevention — কীভাবে প্রতিরোধ করবেন

  • খেলাধুলার আগে warm-up ও stretching।
  • Shoulder/hip/knee stabilizing muscle strengthening।
  • Previous dislocation হলে proper physiotherapy শেষ না করে sports-এ ফেরা যাবে না।
  • Contact sports-এ protective gear।
  • Fall prevention: slippery floor avoid, elderlyদের balance training, vision correction।
  • Hypermobility থাকলে risky extreme movement avoid।
  • Recurrent dislocation হলে orthopedic follow-up; Bankart/labral repair লাগতে পারে।
  • Reduction-এর পর sling খুলে নিজের মতো heavy work শুরু করা যাবে না।

Overview / Summary

Dislocation হলো joint surface সম্পূর্ণ সরে যাওয়া। Diagnosis মূলত clinical, কিন্তু X-ray pre- and post-reduction জরুরি। Management হলো pain control → closed reduction → neurovascular re-check → immobilization → rehabilitation। Complication হিসেবে nerve/vascular injury, fracture, recurrent dislocation, stiffness, AVN এবং arthritis হতে পারে। শুধু painkiller দিয়ে dislocation cure হয় না।

Actionable Plan / Steps

  1. Suspected dislocation হলে limb immobilize করুন, ice দিন, ring খুলুন।
  2. Pulse, sensation, movement check করুন।
  3. Emergency X-ray করে fracture-dislocation rule out করুন।
  4. Trained clinician দ্বারা reduction করুন।
  5. Reduction-এর পর আবার neurovascular exam + X-ray করুন।
  6. Sling/splint দিয়ে immobilize করুন।
  7. 3–7 days pain plan: paracetamol ± one NSAID; GI risk থাকলে PPI।
  8. 1–3 weeks follow-up; physiotherapy শুরু করুন।
  9. Numbness, pulse কম, cold limb, uncontrolled pain, recurrent instability হলে urgent orthopedic referral।

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Apley & Solomon’s System of Orthopaedics and Trauma, 10th ed. Chapters: Joint injuries, shoulder instability/dislocation.
  2. Rockwood and Green’s Fractures in Adults, 9th ed. Sections: Glenohumeral dislocation, elbow/hip/knee dislocation.
  3. Campbell’s Operative Orthopaedics, 14th ed. Sections: Shoulder instability, traumatic dislocation, operative indications.
  4. Davidson’s Principles and Practice of Medicine, 24th ed. Emergency/trauma assessment principles.
  5. Harrison’s Principles of Internal Medicine, 21st ed. Approach to emergency and systemic complications; orthopedic detail is better covered by Apley/Rockwood/Campbell.

Guidelines / Clinical resources

  1. MSD Manual Professional: Overview of Dislocations; neurovascular examination and compartment syndrome warning.
  2. AAOS OrthoInfo: Shoulder Dislocation—reduction, sling immobilization, rehabilitation.
  3. NICE CKS: Shoulder pain—instability disorders, post-reduction management based on BESS/BOA guidance.
  4. Emergency Care BC: Shoulder dislocation clinical summary, immobilization and recurrence evidence.
  5. MedEx Bangladesh: Bangladesh available medicine brands and generic information for paracetamol, NSAIDs, tramadol, lidocaine, PPIs and sedatives.

Peer-reviewed / DOI

  1. Wang SI. Management of the First-time Traumatic Anterior Shoulder Dislocation. Clin Shoulder Elbow. 2018;21(3):169–175. DOI: 10.5397/cise.2018.21.3.169.
  2. Hasebroock AW et al. Management of primary anterior shoulder dislocations: a narrative review. Sports Medicine – Open. 2019. DOI: 10.1186/s40798-019-0203-2.
  3. Cutts S et al. Anterior shoulder dislocation. Ann R Coll Surg Engl. 2009;91:2–7. DOI: 10.1308/003588409X359123.
  4. Whelan DB et al. External rotation immobilization for primary shoulder dislocation: a randomized controlled trial. Clin Orthop Relat Res. 2014;472:2380–2386. DOI: 10.1007/s11999-013-3432-6.

Md.Rafiqul Islam Lipu,Date:-06-06-2026 Friday ,Time:-12-09-49 Pm

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