What is the immediate care for a patient with a repeat shoulder dislocation that has relocated spontaneously?

Immediate Care for Repeat Shoulder Dislocation with Spontaneous Relocation

For a patient with a repeat shoulder dislocation that has spontaneously relocated, immediate care should focus on pain management with NSAIDs, local cold therapy, and gentle range of motion exercises, followed by progressive rehabilitation to prevent future dislocations. 1

Initial Management

1. Pain Management:

   • First-line medication: NSAIDs (if no contraindications) 1
   • Alternative: Acetaminophen for pain relief if NSAIDs are contraindicated 1
   • Local cold therapy for pain relief and to reduce inflammation 1

2. Immediate Assessment:

   • Standard radiographs including anteroposterior views in internal and external rotation, and axillary or scapula-Y view to rule out fractures and assess shoulder alignment 1
   • Note that normal X-rays do not rule out soft tissue injuries such as labral tears 1

3. Early Mobilization:

   • Evidence suggests that conventional shoulder immobilization in a sling offers no benefits for preventing recurrence 2
   • Consider avoiding immobilization altogether, as duration of immobilization does not affect re-dislocation rates 2

Rehabilitation Protocol

Phase 1 (Initial 1-2 weeks):

• Pain control measures
• Gentle range of motion exercises
• Patient education on proper positioning
• Isometric exercises for muscle reactivation if pain-free 1

Phase 2 (Progressive Rehabilitation):

• Progressive ROM exercises
• Light strengthening exercises focusing on rotator cuff and periscapular muscles
• Scapular stabilization exercises 1

Phase 3 (Advanced Rehabilitation):

• Progressive resistance training
• Advanced scapular stabilization
• Sport or activity-specific training 1

Follow-up Schedule

• Initial follow-up: 1-2 weeks after treatment initiation to assess response 1
• Clinical reassessment: 6 weeks to evaluate progress 1
• Rehabilitation progress evaluation: 3 months 1

Important Considerations

• High Recurrence Risk: The overall recurrence rate for shoulder dislocations is approximately 50%, but rises to 88.9% in the 14-20 year age group 2

• Surgical Consultation: Consider referral for surgical consultation if:

  • Patient is under 30 years of age
  • Participates in high-demand or contact sports
  • Evidence of significant Hill-Sachs lesion or Bankart tear on imaging
  • No improvement after 3 months of appropriate rehabilitation 1

• Imaging for Persistent Symptoms: If symptoms worsen or do not improve by 3 months, consider advanced imaging:

  • MR Arthrography (gold standard, especially for patients under 35)
  • Standard MRI without contrast (highly effective with optimized equipment)
  • CT Arthrography (if MRI is contraindicated) 1

Special Considerations for Recurrent Dislocators

• Patients with recurrent dislocations often have increased glenoid bone loss compared to first-time dislocators 3
• Specific muscle training programs focusing on rotator cuff and deltoid strengthening have shown effectiveness in reducing recurrence in most patients 4
• For young patients with recurrent dislocations, surgical stabilization may be necessary, as multiple dislocations can lead to further soft-tissue and bony injury 5

Common Pitfalls to Avoid

• Prolonged immobilization: Evidence suggests it does not reduce recurrence rates and may delay rehabilitation 2
• Overlooking bone loss: Recurrent dislocators are more likely to have bony Bankart lesions that may require surgical intervention 3
• Neglecting muscle strengthening: Weakness of rotator cuff muscles is common in patients with recurrent dislocations and should be specifically addressed 4
• Delaying surgical consultation for high-risk patients (young, athletic, multiple dislocations) can lead to worse outcomes 5