Dislocated Shoulder – When is Surgery Required and Not Required?

by Dr Gandhi Nathan Solayar FRCS (Tr&Orth)

Key Takeaways:

• In summary, not all patients require surgery following a shoulder dislocation
• Most frequent causes of shoulder dislocations is a traumatic injury that may occur following falls, sports and motor vehicle accidents.
• A dislocated shoulder is manipulated back into place by a trained doctor or orthopedic surgeon with the patient under sedation & pain medication
• Proper rehabilitation is the key regardless of the treatment method chosen

Shoulder dislocations are one of the most common injuries affecting the shoulder joint. It occurs when the arm bone (head of the humerus) comes out of its socket (the glenoid). The annual incidence (frequency of occurrence) is thought to be between 20 and 40 cases for every 100,000 people (assuming a population of 32 million, that comes up to around 8000 to 10,000 cases in Malaysia each year). It is more common in males and the younger age group (between 16 and 21 years of age).

How Dislocated Shoulder Happens: Explanation from Orthopedic Specialist Dr Gandhi Nathan Solayar

The most frequent cause of shoulder dislocations is a traumatic injury that may occur following falls, sports and motor vehicle accidents. The shoulder normally dislocates anteriorly (towards the front), bringing injuries to specific structures in the joint. These may include a Bankart lesion (torn labrum), Hill-Sachs lesions (bony depressions of the humeral head) and fractures within the joint. Between 10 and 40% of shoulder dislocations may have an associated nerve injury (the axillary nerve is most often injured, and reassuringly, most of these injuries settle with time).

Bankart Lesion following shoulder dislocation (from www.shoulder-pain-explained.com)

Non-Invasive Treatment for Joint Dislocation

Once a dislocation occurs, the priority is for immediate relocation (returning the joint into its natural position). In the majority of cases, this is performed without the need for surgery. The patient is brought to a hospital, and the shoulder is manipulated back into place by a trained doctor or orthopedic surgeon with the patient under sedation & pain medication. After confirming proper relocation (using x-rays), the arm is normally immobilized using a sling.

When opting for non-surgical treatment, the patient is advised to continue using an arm sling for some weeks. This period of immobilization allows for soft tissues around the shoulder to heal. Following this, rehabilitation begins (physiotherapy) to restore the shoulder joint’s movement and strengthen the surrounding muscles. There are many factors that affect recovery time; among them include the patient’s age, co-morbidities and pre-injury functional level.

The concern among shoulder surgeons is the re-dislocation rate following injury. Factors that influence this include the patient’s age (higher risk in younger patients), gender (higher in males), fractures and Hill-Sachs lesions. Re-dislocations rates are higher in repeat dislocations (more than two episodes of dislocations involving the same joint). In these circumstances, non-surgical methods alone may not be sufficient. Further investigations (using CT and MRI scans) may also be required.

Hill-Sachs and Bankart Lesions (from https://flawlessmotion.com)

The ideal candidate for non-surgical treatment following a shoulder dislocation would be an elderly, sedentary, non-active individual with no associated injuries (fractures). In younger, active and high functioning individuals (these may include those involved in a sporting activity or work with their hands), timely surgical management is the ideal option.

Dislocated Shoulder Treatment: Shoulder Stabilization

Historically, shoulder stabilization surgery was performed by the open method. This required a fairly large incision and releasing large muscles around the shoulder joint. These open surgeries would have resulted in large scars, prolonged recovery periods and higher rates of joint stiffness. With the advent of recent technological advancements, these open procedures are rarely performed these days (In my hands, open surgery for shoulder stabilization is done only in revision cases or in situations where there are large fractures involving the glenoid socket).

Most shoulder stabilization surgery nowadays is performed using an arthroscopic technique. This is a minimally invasive procedure (normally involving three incisions; each less than a centimetre) which allows for good visualization of the shoulder joint and appropriate fixation, allowing for restoration of normal anatomy. Routine shoulder stabilization surgery normally takes around one hour to perform and is done under general anaesthesia. The end result is aesthetically pleasing, and patients recover from surgery at a faster rate. In some of my patients, these procedures are done as day-cases where the patient returns home the same day of surgery.

Bankart Repair (Shoulder stabilization). From https://hbgmedicalassistance.com

Patient Selection for Surgical Joint Dislocation Treatment

As with most cases, patient selection is an important factor when considering someone for arthroscopic shoulder stabilization. I would strongly advise anyone with more than two dislocations of the shoulder to undergo surgery (the chances of shoulder re-dislocation is very high in this group). In cases where the patient is young (below the age of 25) and highly functional (e.g., athlete), the re-dislocation rates are lower after surgical stabilization (compared to no surgery) and therefore advisable.

Another group of patients who would benefit from early surgical intervention would be those who suffer an associated fracture or rotator cuff tear (the rotator cuff tendons are a special group of muscles that play an important role in shoulder function). These injuries are more common in elderly patients with shoulder dislocations and, if not treated, may result in long term shoulder joint dysfunction. I often advocate for early surgical repair of these structures (if torn or damaged) as this improves overall recovery, and patients have a better chance of returning to pre-injury function.

Physiotherapy is Key in Dislocated Shoulder Treatment

In summary, not all patients require surgery following a shoulder dislocation. In my practice, I would treat low-demand, sedentary and elderly individuals using conservative methods without surgery. For those patients who are young, active, having significant fractures and who have suffered more than two dislocations, I would strongly advise surgical stabilization to allow for proper restoration of joint anatomy and return to function. Proper rehabilitation is the key regardless of the treatment method chosen.

In all, counselling and consultation with the treating orthopedic specialists would help determine the best treatment method for shoulder and joint dislocation. Contact us here for more info.

About OSC:

Orthopaedic Specialist Centre (OSC) is the brainchild of four highly-experienced Malaysian orthopaedic specialists, who have come together to create an innovative centre of excellence purely focused on bone and joint care. Using their decades of experience in practice, they have embarked on a new mission for Malaysian orthopaedics. At OSC, the patient’s journey from treatment to recovery is accompanied by elevated levels of personalised expertise and empathy, in order to make a real difference to our patients’ lives. In contrast to large, faceless hospitals, OSC is a uniquely intimate medical boutique, one that puts meticulous, tailored care at the heart of the patient experience. OSC aims to redefine orthopaedic care in Malaysia, by making world-class treatment comfortable, cost-effective and attainable for the whole community. For more information, please visit www.oscortho.my