What is the standard follow-up and treatment protocol for a patient with a shoulder dislocation in orthopedic care?

Shoulder Dislocation Orthopedic Follow-Up Protocol

Initial Post-Reduction Management

After successful reduction of a shoulder dislocation, begin early physical therapy following a brief immobilization period, focusing on gentle mobilization and progressive strengthening to restore function while preventing recurrent instability. 1

Immobilization Duration

• For patients under 30 years of age: Immobilize for 3 weeks using complete shoulder immobilization, as this significantly reduces recurrence rates compared to 1-week immobilization (P < 0.05) 2
• For patients over 30 years of age: Immobilize for 1 week in a sling, as longer immobilization increases stiffness risk without reducing recurrence in this age group 2
• Avoid overhead pulleys during initial recovery as they encourage uncontrolled abduction that may worsen injury 1
• Standard internal rotation sling positioning is appropriate; external rotation bracing shows no significant benefit in preventing recurrent instability (37% vs 40% recurrence, p=0.41) 3

Post-Reduction Imaging Requirements

• Mandatory post-reduction radiographs must be obtained to confirm successful reduction and evaluate for fractures that may have been obscured by the dislocation 4, 5
• Post-reduction imaging should include AP views plus axillary or scapula-Y view 4
• For young patients (<35 years), obtain MRI without contrast or MR arthrography to evaluate for labral tears, capsular injuries, and bone loss that predict recurrence 6, 4
• CT without contrast may be appropriate if MRI assessment of bone loss is limited 6

Neurovascular Assessment

• Critical post-reduction neurovascular examination is mandatory, particularly evaluating axillary nerve function and vascular integrity 4
• Regular assessment for neurological deficits is essential throughout follow-up 1
• Consider CT angiography if vascular compromise is suspected, especially with associated proximal humeral fractures 4

Pain Management Protocol

• First-line: Acetaminophen or ibuprofen if no contraindications exist 1
• Intra-articular corticosteroid injections demonstrate significant pain reduction effects 1
• Subacromial corticosteroid injections may be beneficial when pain relates to subacromial region injury or inflammation 1
• For spasticity-related shoulder pain, botulinum toxin injections into subscapularis and pectoralis muscles may be beneficial 1

Rehabilitation Protocol

Early Phase (Post-Immobilization)

• Begin early physical therapy immediately after immobilization period to restore function and prevent complications 1
• Focus on gentle stretching and mobilization techniques, especially increasing external rotation and abduction 1
• Educate healthcare staff, patients, and family on correct positioning and handling of the affected arm to prevent further injury 1

Progressive Phase

• Progressive strengthening of shoulder muscles, particularly the rotator cuff, is essential 1
• Neuromuscular re-education may be necessary if nerve injury is present 1
• Functional electrical stimulation (FES) may be considered to improve shoulder lateral rotation 1

Protective Measures

• Consider shoulder strapping or sling to prevent trauma during recovery 1
• Monitor for signs of complex regional pain syndrome (shoulder-hand syndrome), which may require early intervention with oral corticosteroids 1

Surgical Considerations and Referral Criteria

• Surgical intervention should be considered for patients with neurological deficits suggesting nerve involvement 1
• Patients with recurrent instability (second documented dislocation or multiple subluxations severe enough to request surgical stabilization) require surgical evaluation 3
• For fracture-dislocations: Type I injuries (anterior dislocation with greater tuberosity fracture) can undergo reduction under sedation with 94% success rate; Type II injuries (surgical neck fracture with/without greater tuberosity fracture) should have reduction under general anesthesia to avoid fracture propagation 7
• All posterior dislocations with any fracture should undergo reduction under general anesthesia 7

Follow-Up Imaging Strategy

• Limit follow-up imaging to what will change management decisions 1
• CT scan may be indicated to better characterize associated fractures 1
• MRI should be considered if concerns exist about soft tissue injuries or neurological involvement 1

Critical Pitfalls to Avoid

• Never overlook associated rotator cuff tears, especially in patients over 40 years or with high-energy trauma mechanisms 4
• Do not delay reduction attempts, as delays increase neurovascular complications 4
• Avoid inadequate immobilization duration in young patients (<30 years), as this significantly increases recurrence risk 2
• Do not miss posterior dislocations by relying on AP views alone—always obtain axillary or scapula-Y views 4, 5
• Recognize that manual laborers experience more recurrences than office workers and may require more aggressive preventive strategies 2

Age-Specific Recurrence Risk

• Highest recurrence risk occurs in patients under 30 years (significantly higher than older patients, P < 0.001) 2
• Thirteen percent overall recurrence rate at 1-year follow-up, with most occurring in patients under 30 2
• Residual stiffness encountered more often in patients over 30 years than younger patients (P < 0.001) 2