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X-ray of a 37-year-old corrections officer 2 weeks after a right shoulder dislocation
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Outlet x-ray of the patient
A 37-year-old man presents 2 weeks after a right shoulder dislocation. The injury resulted from a fall while skiing. He was taken to the bottom of the mountain by ski patrol and underwent reduction in the base clinic by a covering orthopedist. Magnetic resonance imaging taken 3 days previously showed a small Hill-Sachs lesion with no fracture, labral tearing, or Bankart lesions. The patient denies any history of shoulder pain or instability. He is right-handed and works as a corrections officer. He would prefer to avoid surgery if possible but is concerned about the risk for another dislocation.
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The patient sustained a traumatic anterior shoulder dislocation. Management of first-time shoulder dislocation is controversial and depends largely on patient age and activity level. Absolute indications for surgery after a first dislocation include large bony glenoid defects and associated injuries, including rotator cuff tears and displaced proximal humerus fracture.
Based on this patient’s magnetic resonance imaging findings, conservative treatment was recommended. Physical therapy was initiated to strengthen the dynamic stabilizers of the shoulder, including the rotator cuff and periscapular muscles. The shoulder should be immobilized in a sling for discomfort or until the patient is able to achieve full painless range of motion with therapy. Aggressive maneuvers should be avoided for the first 4 to 6 weeks after the injury, including no external rotation past neutral and no abduction past 90 degrees. Patients may return to full activity once strength and painless range of motion have returned, which occurs typically 6 to 8 weeks after the injury.1
Conservative treatment has failed if the patient continues to have recurrent instability, pain, and weakness. The overall recurrence rate following nonsurgical treatment is between 33% and 67% for all ages and activity levels and between 55% and 90% for young male athletes. The recurrent dislocation rate with nonsurgical treatment is much higher in younger and more active patients. Athletic teenagers have the highest recurrence rate at 80% to 90%. Risk for recurrence also increases when the dominant limb is involved. This patient’s risk for recurrent dislocation is increased to approximately 60% to 80% because of his right hand dominance and occupation. Recurrent instability can lead to shoulder arthritis in up to 40% of patients and should be addressed surgically. The severity of arthritis is correlated with the number of recurrent dislocations.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Youm T, Takemoto R, Park BKH. Acute management of shoulder dislocations. J Am Acad Orthop Surg. 2014;22(12):761-771.
- Abbasi D. Traumatic Anterior Shoulder Instability (TUBS). http://www.orthobullets.com/sports/3050/traumatic-anterior-shoulder-instability-tubs. Updated March 30, 2016. Accessed April 5, 2016.
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