The treatment of primary anterior shoulder dislocations

The treatment of primary anterior shoulder dislocations is complex and challenging. The goal of treatment is to achieve a stable, pain-free shoulder with a full range of motion. The currently available evidence on the outcomes of nonsurgical treatment and immediate surgical stabilization conflicts; decision making must also take into account patient-specific variables, including age, occupation, functional demands, sports participation, physical characteristics, and compliance. Although recurrence rates after anterior shoulder dislocation are difficult to pinpoint, abundant data indicate that the shoulder is more vulnerable to instability after a first traumatic dislocation. Relatively young patient age at the time of injury is the most consistent and significant prognostic factor for recurrent instability. Male gender is independently predictive of recurrent instability. Most recent studies have not identified sports participation or a type of sports activity as correlated with the risk of recurrent instability. Nonsurgical treatment typically involves closed reduction, a period of immobilization, and physical therapy for strengthening the rotator cuff and scapular stabilizers. The evidence for this treatment strategy is largely anecdotal, and the literature on its efficacy is inconclusive. Several recent studies suggested that immobilization of the shoulder in external rotation after a primary traumatic anterior shoulder dislocation may decrease the risk of recurrent instability more than conventional sling immobilization. The limited evidence available from randomized, controlled trials supports early surgical stabilization of a first traumatic anterior dislocation in high-risk young adults who engage in demanding physical activities. Although different outcome tools were used, the reported recurrence rates and functional outcomes consistently and significantly favored surgical treatment over nonsurgical treatment in this population of young, active patients. Early or prophylactic stabilization is not advisable unless the patient has a high risk of recurrence.