First-time traumatic anterior shoulder dislocations in young patients

Issue: BCMJ, vol. 58 , No. 7 , September 2016 , Pages 399-400 WorkSafeBC

Traumatic anterior shoulder dislocations are a relatively common injury, with an incidence rate near 24 per 100 000 person-years.[1] The injury is 2 to 5 times more common in males, with almost half occurring before the age of 30. Between 1990 and 2015, WorkSafeBC saw nearly 6000 shoulder dislocations, with 27.8% occurring in patients age 25 or younger. Surgery has often been reserved for cases of recurrence, but the literature suggests that young patients may benefit from primary surgical stabilization sooner rather than later.

The primary concern with shoulder dislocations in young patients—after acute management—is recurrence. Recurrence rates for young patients range from 54% to 100%.[2-14] The upper limit of what constitutes a “young patient” varies slightly from paper to paper, but it is usually considered to be between the ages of 20 and 25. Recurrence rates decrease as the patient ages; the older the patient, the lower the risk of recurrence—to the point where the recurrence rate is around 6% in patients over 40 years old.[4]

The concern with recurrence is twofold: increased risk of arthropathy, and bony loss necessitating a more invasive surgical stabilization procedure. Radiographic evaluation for degenerative changes at 25 years following initial injury found a prevalence rate of 56%, as compared to approximately 20% in the general population.[15] Shoulders with no recurrence were found to have less arthropathy than those that became stable over time or were persistently unstable. Patients whose shoulders were surgically stabilized had no difference in terms of moderate or severe degenerative changes compared to solitary dislocators.[15] The second recurrence concern, bony loss, involves both the glenoid and humeral head. Hill-Sach’s lesions—a compression fracture of the posterosuperolateral humeral head—are estimated to occur in 40% to 90% of all primary dislocations and near 100% of recurrent dislocations.[16,17] Sufficient glenoid wear can necessitate a more invasive and complex bony procedure (such as a Latarjet), or can lead to failure of a soft-tissue procedure (such as a Bankart repair) if not recognized. Glenoid insufficiency has been reported in up to 40% of primary dislocations and up to 90% of patients with recurrent shoulder instability.[16,18,19] A quantitative study on glenoid bone loss found an exponential relationship between the degree of anterior glenoid flattening and the number of dislocations.[18]

Because of the high incidence of recurrence in young, first-time traumatic shoulder dislocators, as well as the detrimental effects of recurrence, there is a movement toward primary surgical stabilization. Studies have shown a marked reduction in the recurrence rate when this group of patients is treated with a primary repair compared to conservative management using immobilization techniques.[20-23] There is also evidence for surgically stabilized shoulders having a lower rate of arthropathy, as compared to shoulders with recurrent instability.[15,24] In fact, as mentioned earlier, a 25-year prospective study found stabilized shoulders to have no significant difference from solitary dislocations in terms of moderate/severe arthropathy, but had appreciably less than shoulders with recurrent instability.[15]

Historically primary traumatic anterior shoulder dislocations have been treated conservatively, and surgical stabilization has often been reserved for cases of recurrence. The data suggest that the cohort of young patients with high-demand activities or occupations may be better served with primary surgical stabilization. As such, patients under age 25 with a first-time traumatic shoulder dislocation should be referred to an orthopaedic shoulder specialist for a discussion regarding the risks and options. Patients under age 20 are the most likely to benefit from primary stabilization.

For further information or assistance

If you have questions or require assistance with a worker patient, especially one who is less than 25 years of age, with a traumatic anterior shoulder dislocation, please contact a medical advisor in your nearest WorkSafeBC office.
—Derek Smith, MD, FRCS(C)
WorkSafeBC Orthopaedic Specialist Advisor

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.


References

1.    Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am 2010;92:542-549.

2.    Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med 1994;22:589-594.

3.    Hovelius L, Eriksson K, Fredin H, et al. Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment. J Bone Joint Surg Am 1983;65:343-349.

4.    te Slaa RL, Wijffels MP, Brand R, Marti RK. The prognosis following acute primary glenohumeral dislocation. J Bone Joint Surg Br 2004;86:58-64.

5.    Larrain MV, Botto GJ, Montenegro HJ, Mauas DM. Arthroscopic repair of acute traumatic anterior shoulder dislocation in young athletes. Arthroscopy 2001;17:373-377.

6.    Rhee YG, Cho NS, Cho SH. Traumatic anterior dislocation of the shoulder: Factors affecting the progress of the traumatic anterior dislocation. Clin Orthop Surg 2009;1:188-193.

7.    Wheeler JH, Ryan JB, Arciero RA, Molinari RN. Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy 1989;5:213-217.

8.    Lill H, Verheyden P, Korner J, et al. Conservative treatment after first traumatic shoulder dislocation. Chirurg 1998;69:1230-1237.

9.    Hovelius L, Olofsson A, Sandström B, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: A prospective twenty-five-year follow-up. J Bone Joint Surg Am 2008;90:945-952.

10.    Henry JH, Genung JA. Natural history of glenohumeral dislocation--revisited. Am J Sports Med 1982;10:135-137.

11.    Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg Am 1992;74:1242-1244.

12.    Postacchini F, Gumina S, Cinotti G. Anterior shoulder dislocation in adolescents. J Shoulder Elbow Surg 2000;9:470-474.

13.    Kralinger FS, Golser K, Wischatta R, et al. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med 2002;30:116-120.

14.    Hoelen MA, Burgers AM, Rozing PM. Prognosis of primary anterior shoulder dislocation in young adults. Arch Orthop Trauma Surg 1990;110:51-54.

15.    Hovelius L, Saeboe M. Arthropathy after primary anterior shoulder dislocation—223 shoulders prospectively followed up for twenty-five years. J Shoulder Elbow Surg 2009;18:339-347.

16.    Owens B, Dickens JF, Kilcoyne KG, Rue JP. Management of mid-season traumatic anterior shoulder instability in athletes. J Am Acad Orthop Surg 2012;20:518-526.

17.    Provencher M, Frank RM, Leclere LE, et al. The Hill-Sachs lesion: Diagnosis, classification, and management. J Am Acad Orthop Surg 2012;20:242-252.

18.    Griffith JF, Antonio GE, Tong CW, Ming CK. Anterior shoulder dislocation: Quantification of glenoid bone loss with CT. Am J Roent 2003;180:1423-1430.

19.    Bigliani LU, Newton PM, Steinmann SP, et al. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med 1998;26:41-45.

20.    Robinson CM, Jenkins PJ, White TO, et al. Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial. J Bone Joint Surg Am 2008;90;708-721.

21.    Chahal J, Marks PH, Macdonald PB, et al. Anatomic Bankart repair compared with nonoperative treatment and/or arthroscopic lavage for first-time traumatic shoulder dislocation. Arthroscopy 2012;28;565-575.

22.    Kirkley A, Werstine R, Ratjek A, Griffin S. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: Long-term evaluation. Arthroscopy 2005;21:55-63.

23.    Longo UG, Loppini M, Rizzello G, et al. Management of primary acute anterior shoulder dislocation: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30:506-522.

24.    Chapus V, Rochcongar G, Pineau V, et al. Ten-year follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocation in young patients. Orthop Traumatol Surg Res 2015;101:889-893.

Derek Smith, MD, FRCSC. First-time traumatic anterior shoulder dislocations in young patients. BCMJ, Vol. 58, No. 7, September, 2016, Page(s) 399-400 - WorkSafeBC.



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