Orthopedic Surgeons Offer Insights Into First-Time Shoulder DislocationYoung athletes are twice as likely to dislocate the shoulder compared to the general population. What's the best way to approach this problem? When is surgery needed? These are just two of the many questions answered in this update on first-time shoulder dislocations.
The authors did not study a specific group of patients. Instead, they reviewed current information on pathoanatomy (what happens in the shoulder) and etiology (causes of dislocation). The need for a quick and accurate diagnosis that leads to a plan of care is established. The benefits of imaging studies are presented. And options for both conservative (nonoperative) care and surgical management are presented. Here's a closer look at each of these topics.
Most first time shoulder dislocations are anterior (forward direction). The structures around the shoulder (e.g., ligaments, capsule, muscles) are designed to prevent dislocations. But with enough force and with the shoulder in just the right position, these safeguards can be overcome.
Younger patients are more likely to end up with a labral tear. Injury in older adults is more common because of degenerative changes of the rotator cuff associated with aging. The labrum is a tough rim of cartilage around the shoulder socket. The rotator cuff is a group of four muscles and tendons that surround the shoulder. Both of these anatomical structures help hold the shoulder stable and in place. A torn anterior-inferior (front/lower) labrum and joint capsule is called a Bankart lesion. Bankart lesions are very common in all anterior shoulder dislocations.
Most young athletes with their first shoulder dislocation are examined either on the field at the time of the injury or some time later in the emergency department. Some experts advise having an X-ray before trying to reduce the shoulder. Reduce means to put the shoulder back in the socket. Usually, the person is in so much pain, a closed (without surgery) reduction seems like the right thing to do. But there could be other injuries that need attention and that could be made worse by a closed reduction.
X-rays confirm the direction and severity of the dislocation. Any bone fractures present will show up on an X-ray. Other clinical tests may be performed to assess nerve, blood vessel, and soft tissue structures. If more details are needed, a CT scan and/or MRI may be ordered. MRIs with a dye injected into the joint can show the location and size of a labral tear.
Once the exam is completed, the surgeon can decide on the best plan of care for that patient. Reducing the dislocation is the first step. Sometmes this can be done without surgery. A special method called the Stimson technique can be used. A numbing agent is injected into the joint. Once the patient is pain free, he or she lies face down on an examining table. The injured arm hangs over the edge of the table. A weight tied to the forearm can pull the head of the humerus down, so it can pop back in the socket. In other cases, the patient may be anesthetized before closed (or open) reduction can be done.
Reducing the dislocation isn't the end of it. The shoulder must be protected while the soft tissues are healing. If surgery isn't needed to repair capsular tears, fractures, or a detached labrum, then immobilization in a sling for six weeks is still standard. This approach is more common with older,less active adults. Sports athletes who are at greater risk of recurrent dislocations may need arthroscopic repair.
When it's early in the sports season, some athletes may opt for a modified treatment approach. A short period of immoblization, followed by an early program of range-of-motion exercises can ge them back in the game. in this approach, there is still a risk of recurrent dislocation(s), especially when the athlete is involved in collision or contact sports. And with each injury, the chances of more soft tissue damage are much greater.
Research is ongoing to find ways to prevent a second dislocation. Immobilizing the shoulder in a position of external (outward) rotation (instead of the traditional internal rotation with the arm across the abdomen) works much better. This is a fairly new discovery. Continued improvements over the years in surgical technique have helped reduce the number of recurrent dislocations. Debate continues about the best timing for the surgery.
Early repair may be best -- before the damaged soft tissues stretch out and deform. As orthopedic surgeons, the authors describe their preferred arthroscopic surgical techniques and postoperative care for acute, first-time anterior shoulder dislocations. A procedure called the Bankart repair is done within two weeks' time of the original injury. Post-operative rehab takes place in four phases. This model is based on animal studies showing how and when tendon-to-bone healing takes place.
Early movement is important to prevent scarring. Resistance must be avoided at first to prevent disruption of the healing site. Phase one takes place during the first six weeks. The focus is on reducing pain and increasing motion. During phase two (six to 12 weeks), full motion is restored before the strenghtening phase (12 to 20 weeks) can begin. In the final phase, the athlete is prepared for a return-to-sport with sports-specific exercises. This phase must be completed before contact sports are allowed again (usually between five to six months after surgery).
There is plenty of evidence that the approach to first-time anterior shoulder dislocations described in this article produces good results. Fewer recurrent dislocations and greater patient satisfaction have been reported. These are just guidelines. The surgeon must still make treatment decisions on an individual basis taking into consideration the patient's age, type of sports involvement, and timing of the injury (preseason, during season, end of season).
Robert Y. Wang, MD, FRCSC, et al. The Recognition and Treatment of First-Time Shoulder Dislocation in Active Individuals. In The Journal of Orthopaedic & Sports Physical Therapy. February 2009. Vol. 39. No. 1. Pp. 118-123.
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