Shoulder Dislocation – Part Two
The conservative treatment of dislocations of the shoulder is a controversial matter in orthopaedics, with management in a sling for anything from one to six weeks. An immobilising strap may be applied around the waist but this is not universal. The arm is kept in to the side with the forearm across the abdomen (officially internal rotation and adduction) to prevent stresses to the injured areas, avoiding arm away from the body and moving it outwards (officially external rotation and abduction).
Scientific work has given a better indication of how or why these problems should be immobilised. An MRI scanning study indicated that the shoulder socket and the rim, made of fibrocartilage, are kept in the closest correct relationship by having the arm by the side and laterally rotated 35 degrees. Another study on cadavers showed that if the arm was kept in slight adduction there was a reasonable range of motion during which the two vital structures maintained close alignment. Allowing the arm to flex forward or to abduct outwards was disruptive for the rim or labrum of the socket.
The length of time someone should spend in a sling is not a matter of agreement and a typical time of 3-4 weeks for young people with a shorter time for an older patient is common. The rate of having a second dislocation was indicated to reduce in one study by having a longer time in a sling, but another study, tracking patients over ten years, showed no difference in re-dislocation rates whatever times of immobilisation were used. The physiotherapist will normally review a patient at the three to four week mark and begin rehabilitation.
Pendular exercises begin rehabilitation and due to the patient bending over and the arm hanging dependent there is less force through the shoulder, allowing the maintenance of shoulder range without inappropriate joint stresses on the capsule. Early practising of scapular movements is also taught to maintain shoulder girdle mobility and function. The physiotherapist will then progress the patient onto active assisted exercises which promote range of movement and muscle activity with the unaffected arm providing significant effort to reduce the stresses through the injured side.
Re-dislocation risk determines that external rotation should be limited and only increased as the healing process proceeds. Pushing this movement may not be wise and a loss of end range may be acceptable as it prevents the joint from going into one of its vulnerable positions, reducing the chances of a dislocation occurring again. Soft tissue healing time is around six weeks and at this time the physiotherapist will progress to muscle strengthening and full range of motion shoulder exercises.
More vigorous rehabilitation can follow if the patient has particular requirements for their shoulder function, but overhead sports are unlikely to be sensible for at least four months. If the patient is older or the greater tuberosity, a part of the humeral head which bears muscular insertions, is fractured then the prognosis is better overall. In some cases the person may have to modify their activity to avoid the risk of dislocating again, limiting overhead work, avoiding high risk sporting activities and modifying heavy work.
Overall the incidence of re-dislocation of the shoulder is around 30 percent in non-sporting people but rises to eighty-two percent in those in athletic sports. The age of the patient is however very important in determining the recurrence rate. There is a one hundred percent chance of dislocation recurrence in patients under 10 years old and only zero to 24 percent likelihood in patients who are in their forties. Surgical management may be required should a patient suffer from recurrent dislocation of the shoulder.
The timing of surgical management is not clear although early surgery after the initial dislocation may be advantageous. Studies vary but one showed that after stabilisation surgery via the arthroscope there was a four percent dislocation rate but a 94 percent repeat dislocation rate after conservative treatment. Overall it looks like the recurrence rate is higher for those patients managed by non-operative immobilisation. The level of stability given in operation was better with open surgery but arthroscopic techniques have advanced considerably and this distinction has disappeared.
Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapist in Blackpool visit his website.
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