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

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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.

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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.

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A common approach to the care of a patient after a glenohumeral joint dislocation is to place the patient’s shoulder in a sling for comfort, with permitted pain-free isometric exercise along with passive and assisted elevation up to 100°.¹⁶ This is followed by a nonaggressive rehabilitation protocol for 2 months until full recovery, which includes progressive range of motion, strength, proprioception, and return to functional activities.¹⁶

An increasing number of dislocations portends a poor outcome with nonoperative treatment.

More aggressive return-to-play protocols with accelerated timelines and functional progression have been studied, including in a multicenter observational study that followed 45 contact intercollegiate athletes prospectively after in-season anterior glenohumeral instability. Thirty-three of 45 (73%) athletes returned to sport for either all or part of the season after a median 5 days lost from competition, with 12 athletes (27%) successfully completing the season without recurrence. Athletes with a subluxation event were 5.3 times more likely to return to sport during the same season, compared with those with dislocations.¹⁷

Dynamic bracing may also allow for a safe and quicker return to sport in athletes¹⁸ but recently was shown to not impact recurrent dislocation risk.¹⁹

Return to play should be based on subjective assessment as well as objective measurements of range of motion, strength, and dynamic function.¹⁵ Patients who continue to have significant weakness and pain at 2 to 3 weeks post injury despite physical therapy should be re-evaluated with an MRI for concomitant rotator cuff tears and need for surgical referral.²⁰

When to consider surgical intervention

In a recent meta-analysis, recurrent dislocation and instability occurred at a rate of 52.9% following nonsurgical treatment.² The decision to perform surgical intervention is typically made following failure of conservative management. Other considerations include age, gender, bone loss, and cartilage defect.^21,22 Age younger than 30 years, participation in competition, contact sports, and male gender have been associated with an increased risk of recurrence.^23-25 For this reason, obtaining an MRI at time of first dislocation can help facilitate surgical decisions if the patient is at high risk for surgical need.²⁶

Continue to: An increasing number...