Main causes of Shoulder Dislocations
Often, shoulder dislocations are caused by a violent injury. This may be a fall off a ladder, hit during a football game, car accident, or a slip and fall. During this injury the ball portion of the shoulder joint slips off the cup, known as the glenoid. When this happens, the labrum is torn. The labrum is a soft tissue structure that seals the joint and keeps the ball connected to the glenoid portion of the shoulder. Sometimes, a piece of bone may be broken off the glenoid portion of the joint in addition to a labral tear.
Initial Treatments
Usually a shoulder dislocation is first seen on the sidelines or in the emergency department. At either of these locations a reduction may be performed. A reduction is a maneuver that applies force and places the shoulder joint back into place. Sometimes this can be accomplished and sometimes this cannot be accomplished. If a reduction cannot be performed initially you may need to go under sedation to relax the muscles in order to reduce the joint. This would be performed in the emergency department or in the operating room. Once the shoulder joint is reduced, you will be placed into a sling. Once the shoulder is reduced and you are not in a sling, outpatient follow-up in the clinic can be performed safely.
Clinic visit
At your first clinic visit, x-rays will be taken to see if any damage has been done to the shoulder joint. You may have had shoulder x-rays in the emergency department, but x-rays will likely be repeated in the office as emergency room x-rays are sometimes of not the best quality to determine definitive treatment. Dr. Howard will take time to listen to your story, examine your injured arm, and recommend treatment options. Often, a MRI will be ordered, usually with contrast.
MRI
After your MRI has been completed, you will see Dr. Howard again in the office. At this visit a discussion will be had of your MR results, and what to do with those results. Often treatment is dictated by the MRI results, your age, and activity level. Scientific literature has shown that people less than 20-25 years of age with a shoulder dislocation are at very high risk of repeat dislocations, up to 90% chance of recurrence. As we age that risk starts to go down. Unfortunately, the risk of a traumatic rotator cuff tear starts to go up with age.
Treatment
Depending on what was found on the MRI, nonsurgical treatment or surgery may be discussed. For people under 20-25, often times surgery is indicated for labral tears or glenoid fractures. For people over 40 who have a rotator cuff tear, surgery is often recommended. For people from 20-25 years old to 40 years old, or people without labral tears or rotator cuff tears, nonsurgical treatment may be tried first. Nonsurgical treatment may consist of physical therapy, anti-inflammatories (NSAIDs), Tylenol, cortisone injections, rest, and other treatments. Often 4-6 weeks is needed to see results.
Surgery
If you have been diagnosed with a labral tear and surgery has been recommended, Dr. Howard will explained to you what will happen during the surgical procedure during your clinic visit. If you have a rotator cuff tear, please see the rotator cuff tear page for more details. Surgery to fix a labral tear is outpatient surgery. This means that you will come in and go home on the same day. Surgery is often performed at a outpatient surgery center. Outpatient surgery centers are often more affordable and have specialized equipment that general inpatient hospitals often do not have. After you check in to the surgery center, he will be taken back to the preoperative area. Here you will change into a gown and the nurses will confirm your procedure and start an IV in the arm. The anesthesiologist will speak to you regarding what is called a regional block. Regional blocks are local anesthesia which is injected around the nerves which makes the arm completely numb for up to 24 hours. Dr. Howard recommends this treatment unless there is a reason not to perform the block.
Dr. Howard will see you before the surgery and discuss any last-minute questions that you have. After this time you will go back to the operating room and the anesthesiologist and nurse anesthetist (a specialized anesthesia nurse) will put you to sleep using medications through the IV. After this time you will be positioned, sterilely prepared, and surgery will begin. Dr. Howard will use the arthroscope, a minimally invasive technique, to view the labral tear. Using specialized instruments, Dr. Howard will repair the labrum back down to the bone. If you have a fracture of the glenoid, sometimes this can be re-repaired using the arthroscope as well. Large fractures of the glenoid unfortunately sometimes have to be fixed with an open incision, but thankfully this is very rare. Usually, there are 3 or 4 incisions approximately 1 cm in length (0.40 inch) that are used to repair the labrum. These are closed with stitches and a sterile dressing is placed on top, and your arm will be placed into a specialized sling.
Latarjet Surgery
Unfortunately, some patients have major damage to their shoulder after a dislocation. Fractures such as glenoid fractures or Hill-Sachs fractures (a fracture on the humeral head) may prevent minimally invasive surgery such as labrum repair through the arthroscope. In these situations a Latarjet surgery is recommended. This surgery involves cutting a piece of bone from the scapula and moving it onto the glenoid. This is done through an open approach. This surgery is very successful at treating shoulder dislocations with bony fractures, or for dislocations after a labral repair.
Recovery
Recovery after a labral repair or Latarjet surgery is approximately 3 months. An initial phase of protecting the repair and increasing motion is followed by a strengthening phase and then a return to sport phase. Physical therapy is required after surgery. Initially physical therapy will be often, but as you recover and your knowledge of the physical therapy exercises increases, formal physical therapy is required less. Patients are still required to do their exercises as they transition to a home exercise program.
Outcomes
Outcomes after labral repair surgery are very successful. Over 85-90 percent of patients do very well and have no further dislocations. After a full recovery, patients are allowed to return to all activities as tolerated. Some patients may see a reduction in their end range of motion, and this is an expected outcome after surgery and protects the shoulder from dislocating again.
Nonsurgical treatment can be very successful in select patients. Nonsurgical patients, if selected correctly, can do just as well as surgical patients. Each patient is different and individual, and each injury is different even in the same patient.
Please call our office today and schedule an appointment with Dr. Howard if you have experienced a shoulder dislocation, 727-787-5577 (Palm Harbor) or 727-848-4249 (New Port Richey).