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.

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.

23. Balg F, Boileau P. The instability severity index score. A simple preoperative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89:1470-1477.

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.

25. Porcillini G, Campi F, Pegreffi F, et al. Predisposing factors for recurrent shoulder dislocation after arthroscopic treatment. J Bone Joint Surg Am. 2009;91:2537-2542.

26. Magee T. 3T MRI of the shoulder: is MR arthrography necessary? AJR Am J Roentgenol. 2009;192:86-92.

27. Green MR, Christensen KP. Arthroscopic versus open Bankart procedures: a comparison of early morbidity and complications. Arthroscopy. 1993;9:371-374.

28. Khatri K, Arora H, Chaudhary S, et al. Meta-analysis of randomized controlled trials involving anterior shoulder instability. Open Orthop J. 2018;12:411-418.

29. Donohue MA, Owens BD, Dickens JF. Return to play following anterior shoulder dislocations and stabilization surgery. Clin Sports Med. 2016;35:545-561.

30. Griesser MJ, Harris JD, McCoy BW, et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review. J Shoulder Elbow Surg. 2013;22:286-292.

31. Ekhtiari S, Horner NS, Bedi A, et al. The learning curve for the Latarjet procedure: a systematic review. Orthop J Sports Med. 2018;6:2325967118786930.

32. Shah AA, Butler RB, Romanowski J, et al. Short-term complications of the Latarjet procedure. J Bone Joint Surg Am. 2012;94:495-501.

Immobilization may benefit some

Recent evidence has determined that the duration of immobilization in internal rotation does not impact recurrent instability.^8,9 In patients older than 30, the rate of repeat dislocation is lower, and early mobilization after 1 week is advocated to avoid joint stiffness and minimize the risk of adhesive capsulitis.¹⁰

Arm position during immobilization remains controversial.¹¹ In a classic study by Itoi et al, immobilization for 3 weeks in internal rotation vs 10° of external rotation was associated with a recurrence rate of 42% vs 26%, respectively.¹² In this study, immobilization in 10° of external rotation was especially beneficial for patients ages 30 years or younger.¹²

At least half of first-time dislocations are successfully treated with conservative management.

Cadaveric and magnetic resonance imaging (MRI) studies have shown external rotation may improve the odds of labral tear healing by positioning the damaged and intact parts of the glenoid labrum in closer proximity.¹³ While this is theoretically plausible, a recent Cochrane review found insufficient evidence to determine whether immobilization in external rotation has any benefits beyond those offered by internal rotation.¹⁴ A recent systematic review and meta-analysis found that immobilization in external rotation vs internal rotation after a first-time traumatic shoulder dislocation did not change outcomes.² With that said, most would prefer to immobilize in the internal rotation position for ease.

More research is needed. A Cochrane review highlighted the need for continued research.¹⁴ Additionally, most of the available randomized controlled trials to date have consisted of young men, with the majority of dislocations related to sports activities. Women, nonathletes, and older patients have been understudied to date; extrapolating current research to those groups of patients may not be appropriate and should be a focus for future research.²

Physical therapy: The conservative standard of care

Rehabilitation after glenohumeral joint dislocation is the current standard of care in conservative management to reduce the risk for repeat dislocation.¹⁵ Depending on the specific characteristics of the instability pattern, the approach may be adapted to the patient. A recent review focused on the following 4 key points: (1) restoration of rotator cuff strength, focusing on the eccentric capacity of the external rotators, (2) normalization of rotational range of motion with particular focus on internal range of motion, (3) optimization of the flexibility and muscle performance of the scapular muscles, and (4) increasing the functional sport-specific load on the shoulder girdle.

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