Conservative or surgical management for that shoulder dislocation?
A number of factors—including patient age and risk for recurrence—influence treatment choices. Here’s a closer look at what to consider.
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
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
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...
