Can I refer a 14-year-old patient with recurrent shoulder dislocations to an orthopedic surgeon before obtaining a Magnetic Resonance Imaging (MRI)?

Management of Recurrent Shoulder Dislocations in a 14-Year-Old Patient

Yes, you should refer a 14-year-old with recurrent shoulder dislocations directly to an orthopedic surgeon without first obtaining an MRI. 1

Rationale for Direct Orthopedic Referral

The American Academy of Pediatrics specifically identifies "children and adolescents with sports injuries, such as anterior cruciate ligament tears, meniscal tears, cartilage injuries, ankle instability, or shoulder instability" as patients who may be best cared for by a pediatric orthopedic surgeon 2. Recurrent shoulder dislocations clearly fall within this category of shoulder instability.

Current evidence supports this approach for several key reasons:

1. High Recurrence Risk in Adolescents: Adolescents have an extremely high risk of recurrent dislocations after initial injury:

   • Up to 92% recurrence rate in adolescents aged 14-17 years 3
   • Some studies report recurrence rates as high as 100% in skeletally immature patients 4

2. Surgical Consideration: Many adolescents with recurrent dislocations ultimately require surgical intervention:

   • Up to 50% of adolescents with traumatic dislocations eventually need surgical stabilization 4
   • Early surgical consultation allows for timely intervention decisions

3. Imaging Protocol: The orthopedic surgeon can order the most appropriate imaging studies based on their clinical assessment:

   • Standard radiographs are typically the first imaging obtained 1
   • The surgeon may order MRI, MR arthrography, or other advanced imaging based on specific clinical findings 2, 1

Imaging Considerations

While MRI is valuable for assessing shoulder pathology, it's not necessary before orthopedic referral:

• The American College of Radiology recommends standard radiographs as the initial imaging modality for shoulder pain 2, 1
• MRI is excellent for evaluating soft tissue injuries but is best ordered by the specialist who will be managing the condition 2
• MR arthrography is considered the gold standard for detecting labral tears, particularly in patients under 35 years 1

Management Algorithm

1. Initial Evaluation:

   • Confirm history of recurrent dislocations
   • Obtain standard radiographs (anteroposterior views in internal and external rotation, axillary or scapula-Y view) 1
   • Assess for obvious deformity, neurovascular compromise, or associated injuries

2. Immediate Management:

   • Pain control with NSAIDs as first-line medication if no contraindications 1
   • Local cold therapy for pain relief 1
   • Temporary immobilization for comfort

3. Referral:

   • Direct referral to pediatric orthopedic surgeon with radiographs
   • Expedite referral given the high recurrence risk in this age group

4. Follow-up:

   • Initial follow-up should occur within 1-2 weeks after initiation of treatment 1
   • Clinical reassessment at 6 weeks to evaluate progress 1

Common Pitfalls to Avoid

1. Delaying Specialist Referral: Waiting for MRI before referral may delay appropriate treatment, especially given the high recurrence risk in adolescents.

2. Underestimating Recurrence Risk: The recurrence rate following initial dislocation is extremely high in adolescents (up to 92-100%), making specialist evaluation crucial 3, 4.

3. Overlooking Surgical Indications: Early surgical consultation is particularly important for adolescents with traumatic dislocations, as they often require surgical stabilization 4.

4. Inappropriate Imaging: While MRI provides excellent soft tissue detail, the orthopedic surgeon should determine which advanced imaging studies are most appropriate based on their clinical assessment 2, 1.

By referring directly to an orthopedic surgeon, you ensure the patient receives timely specialist evaluation and appropriate management for this condition that carries significant risk of recurrence and long-term complications in adolescents.