Conservative or surgical management for that shoulder dislocation?

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doi:10.12788/jfp.0156

Applied Evidence

Conservative or surgical management for that shoulder dislocation?

J Fam Pract. 2021 March;70(2):80-82,84-85 | 10.12788/jfp.0156

By

Cayce Onks, DO, MS, ATC

Matthew Silvis, MD

Jayson Loeffert, DO

James Tucker, MD

Robert A. Gallo, MD

A number of factors—including patient age and risk for recurrence—influence treatment choices. Here’s a closer look at what to consider.

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PRACTICE RECOMMENDATIONS

› Start with conservative management of shoulder dislocation in patients older than 30 years and those with uncomplicated injuries. B

› Discourage strict immobilization; its utility is debated and it may not change outcomes. B

› Recommend a progressive rehabilitative program after the initial acute shoulder injury. B

› Consider surgical management for patients younger than 30 years who have complicated injuries with bone or cartilage loss, rotator cuff tears, or recurrent instability or for the highly physically active individual. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Lin K, James E, Spitzer E, et al. Pediatric and adolescent anterior shoulder instability: clinical management of first time dislocators. Curr Opin Pediatr. 2018;30:49-56.

2. Kavaja L, Lähdeoja T, Malmivaara A, et al. Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis. Br J Sports Med. 2018;52:1498-1506.

3. Brelin A, Dickens JF. Posterior shoulder instability. Sports Med Arthrosc Rev. 2017;25:136-143.

4. Galvin JW, Ernat JJ, Waterman BR, et al. The epidemiology and natural history of anterior shoulder dislocation. Curr Rev Musculoskelet Med. 2017;10:411-424.

5. Rozzi SL, Anderson JM, Doberstein ST, et al. National Athletic Trainers’ Association position statement: immediate management of appendicular joint dislocations. J Athl Train. 2018;53:1117-1128.

6. Hovelius L, Saeboe M. Arthropathy after primary anterior shoulder dislocation: 223 shoulders prospectively followed up for twenty-five years. J Shoulder Elbow Surg. 2009;18:339-347.

7. Polyzois I, Dattani R, Gupta R, et al. Traumatic first time shoulder dislocation: surgery vs non-operative treatment. Arch Bone Jt Surg. 2016;4:104-108.

8. Cox CL, Kuhn JE. Operative versus nonoperative treatment of acute shoulder dislocation in the athlete. Curr Sports Med Rep. 2008;7:263-268.

9. Kuhn JE. Treating the initial anterior shoulder dislocation—an evidence-based medicine approach. Sports Med Arthrosc Rev. 2006;14:192-198.

10. Smith TO. Immobilization following traumatic anterior glenohumeral joint dislocation: a literature review. Injury. 2006;37:228-237.

11. Liavaag S, Brox JI, Pripp AH, et al. Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence: a randomized controlled trial. J Bone Joint Surg Am. 2011;93:897-904.

12. Itoi E, Hatakeyama Y, Sato T, et al. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence: a randomized controlled trial. J Bone Joint Surg Am. 2007;89:2124-2131.

13. Miller BS, Sonnabend DH, Hatrick C, et al. Should acute anterior dislocations of the shoulder be immobilized in external rotation? A cadaveric study. J Shoulder Elbow Surg. 2004;13:589-592.

14. Hanchard NCA, Goodchild LM, Kottam L. Conservative management following closed reduction of traumatic anterior dislocation of the shoulder. Cochrane Database Syst Rev. 2014;(4):CD004962.

15. Cools AM, Borms D, Castelein B, et al. Evidence-based rehabilitation of athletes with glenohumeral instability. Knee Surg Sports Traumatol Arthrosc. 2016;24:382-389.

16. Lafuente JLA, Marco SM, Pequerul JMG. Controversies in the management of the first time shoulder dislocation. Open Orthop J. 2017;11:1001-1010.

17. Dickens JF, Owens BD, Cameron KL, et al. Return to play and recurrent instability after in-season anterior shoulder instability: a prospective multicenter study. Am J Sports Med. 2014;42:2842-2850.

18. Conti M, Garofalo R, Castagna A, et al. Dynamic brace is a good option to treat first anterior shoulder dislocation in season. Musculoskelet Surg. 2017;101(suppl 2):169-173.

19. Shanley E, Thigpen C, Brooks J, et al. Return to sport as an outcome measure for shoulder instability. Am J Sports Med. 2019;47:1062-1067.

20. Gombera MM, Sekiya JK. Rotator cuff tear and glenohumeral instability. Clin Orthop Relat Res. 2014;472:2448-2456.

21. Owens BD, Dickens JF, Kilcoyne KG, et al. Management of mid-season traumatic anterior shoulder instability in athletes. J Am Acad Orthop Surg. 2012;20:518-526.

22. Ozturk BY, Maak TG, Fabricant P, et al. Return to sports after arthroscopic anterior stabilization in patients aged younger than 25 years. Arthroscopy. 2013;29:1922-1931.

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24. Kao J-T, Chang C-L, Su W-R, et al. Incidence of recurrence after shoulder dislocation: a nationwide database study. J Shoulder Elbow Surg. 2018;27:1519-1525.

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The shoulder, or glenohumeral joint, is the most commonly dislocated large joint; dislocation occurs at a rate of 23.9 per 100,000 person/years.^1,2 There are 2 types of dislocation: traumatic anterior dislocation, which accounts for roughly 90% of dislocations, and posterior dislocation (10%).³ Anterior dislocation typically occurs when the patient’s shoulder is forcefully abducted and externally rotated.

The diagnosis is made after review of the history and mechanism of injury and performance of a complete physical exam with imaging studies—the most critical component of diagnosis.⁴ Standard radiographs (anteroposterior, axillary, and scapular Y) can confirm the presence of a dislocation; once the diagnosis is confirmed, closed reduction of the joint should be performed.¹ (Methods of reduction are beyond the scope of this article but have been recently reviewed.⁵)

Risk for recurrence drives management choices

Following an initial shoulder dislocation, the risk of recurrence is high.^6,7 Rates vary based on age, pathology after dislocation, activity level, type of immobilization, and whether surgery was performed. Overall, age is the strongest predictor of recurrence: 72% of patients ages 12 to 22 years, 56% of those ages 23 to 29 years, and 27% of those older than 30 years experience recurrence.⁶ Patients who have recurrent dislocations are at risk for arthropathy, fear of instability, and worsening surgical outcomes.⁶

Reducing the risk of a recurrent shoulder dislocation has been the focus of intense study. Proponents of surgical stabilization argue that surgery—rather than a trial of conservative treatment—is best when you consider the high risk of recurrence in young athletes (the population primarily studied), the soft-tissue and bony damage caused by recurrent instability, and the predictable improvement in quality of life following surgery.

In a recent systematic review and meta-analysis, there was evidence that, for first-time traumatic shoulder dislocations, early surgery led to fewer repeat shoulder dislocations (number needed to treat [NNT] = 2-4.7). However, a significant number of patients primarily treated nonoperatively did not experience a repeat shoulder dislocation within 2 years.²

The conflicting results from randomized trials comparing operative intervention to conservative management have led surgeons and physicians in other specialties to take different approaches to the management of shoulder dislocation.² In this review, we aim to summarize considerations for conservative vs surgical management and provide clinical guidance for primary care physicians.

When to try conservative management

Although the initial treatment after a traumatic anterior shoulder dislocation has been debated, a recent meta-analysis of randomized controlled trials showed that at least half of first-time dislocations are successfully treated with conservative management.² Management can include immobilization for comfort and/or physical therapy. Age will play a role, as mentioned earlier; in general, patients older than 30 have a significant decrease in recurrence rate and are good candidates for conservative therapy.⁶ It should be noted that much of the research with regard to management of shoulder dislocations has been done in an athletic population.

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