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.

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For the nonathletic population, the timing of injury is less critical and surgery is typically recommended after conservative treatment has failed. In an athletic population, the timing of injury is a necessary consideration. An injury midseason may be “rehabbed” in hopes of returning to play. Individuals with injuries occurring at the end of a season, who are unable to regain desired function, and/or with peri-articular fractures or associated full-thickness rotator cuff tears may benefit from sooner surgical intervention.²¹

Arthroscopic techniques have become the mainstay of treatment and account for 71% of stabilization procedures performed.

Owens et al have described appropriate surgical indications and recommendations for an in-season athlete.²¹ In this particular algorithm, the authors suggest obtaining an MRI for decision making, but this is specific to in-season athletes wishing to return to play. In general, an MRI is not always indicated for patients who wish to receive conservative therapy but would be indicated for surgical considerations. The algorithm otherwise uses bone and soft-tissue injury, recurrent instability, and timing in the season to help determine management.²¹

Outcomes: Surgery has advantages …

Recurrence rates following surgical intervention are considerably lower than with conservative management, especially among young, active individuals. A recent systematic review by Donohue et al demonstrated recurrent instability rates following surgical intervention as low as 2.4%.²⁹ One study comparing the outcome of arthroscopic repair vs conservative management showed that the risk of postoperative instability was reduced by 20% compared to other treatments.⁷ Furthermore, early surgical fixation can improve quality of life, produce better functional outcomes, decrease time away from activity, increase patient satisfaction, and slow the development of glenohumeral osteoarthritis produced from recurrent instability.^2,7

Complications. Surgery does carry inherent risks of infection, anesthesia effects, surgical complications, and surgical failure. Recurrent instability is the most common complication following surgical shoulder stabilization. Rates of recurrent instability after surgical stabilization depend on patient age, activity level, and amount of bone loss: males younger than 18 years who participate in contact competitive sports and have significant bone loss are more likely to have recurrent dislocation after surgery.²³ The type of surgical procedure selected may decrease this risk.

While the open procedures decrease risk of postoperative instability, these surgeries can pose a significant risk of complications. Major complications for specific open techniques have been reported in up to 30% of patients³⁰ and are associated with lower levels of surgeon experience.³¹ While the healing of bones and ligaments is always a concern, 1 of the most feared complications following stabilization surgery is iatrogenic nerve injury. Because of the axillary nerve’s close proximity to the inferior glenoid, this nerve can be injured without meticulous care and can result in paralysis of the deltoid muscle. This injury poses a major impediment to normal shoulder function. Some procedures may cause nerve injuries in up to 10% of patients, although most injuries are transient.³²

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