Step-by-step evaluation and treatment of shoulder dislocation
Tailor management decisions by taking into account the patient’s age, the direction of instability, functional demands, risk of recurrence, and associated injuries.
PRACTICE RECOMMENDATIONS
› Refer first-time dislocation in patients younger than 20 years or who have a displaced fracture to an orthopedic surgeon. A
› Order magnetic resonance imaging (MRI) for all patients with a suspected rotator cuff tear. A
› Send patients with weakness of the rotator cuff—but no tear on MRI—for evaluation by electromyography and nerve-conduction studies. A
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
Patients with negative findings on MRI and nerve-conduction studies should be offered physical therapy. Patients with recurrent anterior shoulder dislocation should be referred to an orthopedic surgeon for surgical repair. Frequently, improper or delayed treatment with chronic instability results in degenerative arthropathy of the joint22 (FIGURE 10).
Posterior and multidirectional instability can typically be treated conservatively; however, whereas posterior dislocation typically must be immobilized for 3 to 6 weeks post reduction, multidirectional instability does not require immobilization. Instead, physical therapy should start as soon as possible. In these cases, recurrent dislocation or subluxation that persists after conservative treatment should be referred for possible surgical intervention.5
Instability with associated fracture
Fracture concomitant with dislocation most commonly involves the humeral neck, humeral head, greater tuberosity, or the glenoid itself.2 Clinical variables that predict a fracture associated with shoulder dislocation include23:
- first episode of dislocation
- age ≥ 40 years
- fall from higher than 1 flight of stairs
- fight or assault
- motor vehicle crash.
A computed tomography scan with 3-dimensional reconstruction can help characterize associated fracture accurately—including location, size, and displacement—and can play an important role in treatment planning and prognosis in these complicated injuries. Displaced fracture should be referred to an orthopedic surgeon. Nondisplaced fracture of the humeral head or greater tuberosity (FIGURE 11) poses less risk of complications and can be treated conservatively with 6 weeks in an arm sling, followed by physical therapy.24
Summing up
Management of shoulder dislocation must, first, be tailored to the individual and, second, account for several interactive factors—including age, direction of instability, functional demands, risk of recurrence, and associated injuries. In many patients, conservative treatment produces a favorable long-term outcome. Particularly in young, active patients with anterior shoulder instability, most surgeons consider open or arthroscopic reconstruction to be the treatment of choice.2,18
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