Strategic approach of first time dislocation of shoulder

Abstract

Anterior dislocation of glenohumeral joint is a common injury in shoulder. There is a bimodal age distribution in the presentation of first time shoulder dislocation. The first peak occurs in the second and third decade of life while the second peak appears in the sixth to seventh decade. The prognosis and treatment are different. A strategic approach is required for proper management of this common injury. For young patients suffering from first time anterior shoulder dislocation, the main concern is recurrent shoulder dislocation. The incidence is reported to range from 90 to 100% in patients presenting at or less than 20 years old. Damage to anterior inferior glenohumeral ligament complex is inevitable. There is a high incidence of Hill Sachs lesion. Anterior-inferior glenoid bone injury is as high as 20%. Majority of shoulder surgeons recommend early surgical intervention in terms of arthroscopic assisted Bankart repair in young patients suffering from first time anterior shoulder dislocation. This approach reduces the chance of development of “off-track” bipolar bone lesions with repeated recurrent dislocations. More aggressive surgical intervention (e.g. coracoid process transfer) will be required if significant glenoid bone loss is present. For older patients suffering from first time anterior shoulder dislocation, the risk of recurrent dislocation is low. However, it is notorious that there is a high chance of concomitant rotator cuff tear. After closed reduction and ruling out of associated humeral and glenoid fracture, an initial period of non-operative treatment is recommended. Prolonged immobilization should be avoided to minimize the chance of secondary frozen shoulder. It is important to examine the rotator cuff function three to six weeks after the initial injury. Presence of pseudoparalysis raises the suspicion of acute rotator cuff tear. Early surgical repair is recommended to preserve shoulder function. Persistent shoulder pain at four to six months should be investigated as potential symptomatic rotator cuff tear.