by Todd C. Battaglia, MD, MS, FAAOS, DAL
Traumatic shoulder dislocations, like many other injuries, have different consequences and concerns in younger persons versus older individuals. These differences greatly affect how we manage such injuries.
First, when an orthopedic surgeon uses the term "shoulder dislocation," we are specifically referring to an event in which the main ball and socket of the shoulder joint become disengaged - that is to say that the ball slips out of the socket. (This is very different from another injury often called a "shoulder separation," which involves a sprain of the ligaments of the smaller collarbone joint at the top of the shoulder.)
The first priority of any shoulder dislocation is to relocate the joint. This may occur at the emergency room and require the use of anesthesia or sedation to relax the patient. Sometimes, a patient’s shoulder will dislocate and then spontaneously relocate when they move the arm themselves. And occasionally, particularly for those of us who cover athletic contests, we may be able to relocate the shoulder right at the field. Regardless, once the shoulder is put back in place, initial treatment involves use of a sling, ice, pain medicine, and restriction of activities. It is at that point that further treatment options diverge depending on the patient.
Younger individuals, particularly athletes in their teenage and college years, often dislocate as the result of a significant trauma - football, wrestling, skiing. Typically, in these individuals the structural damage that occurs is a stretching and tearing of the cartilage and ligaments which hold the shoulder in place. These structures often never heal fully on their own and accordingly, these individuals are at a fairly high risk for recurrent dislocations. In fact, for an 18-year-old football player who suffers his first shoulder dislocation, the likelihood that he will have another dislocation may be as high as 70 to 90%, particularly if he continues to play contact sports.
Because of this, there is a trend in the orthopedic world to address these individuals with surgery to repair and tighten the injured structures. Whether or not such surgery should be offered or recommended after a patient’s first dislocation is controversial, but surgery certainly becomes increasingly appropriate for any young patient who has had multiple dislocations. The surgery that is performed for this problem depends on the specific amount and type of damage, but can involve arthroscopic (camera) surgery, or open surgery through larger incisions to reconstruct and repair major tears or bone injuries that occur.
Older individuals on the other hand, especially those in their 60s and older, more often suffer a dislocation as a result of a low-energy trauma such as a slip and fall. And for these persons, the typical damage that occurs can be very different than that seen in younger patients. Older patients are actually much less likely to have recurrent instability or future problems with additional dislocations. But on the other hand, fractures are much more common in older individuals, largely because of the decreased bone strength that occurs with aging. And tendon injuries, particularly to the rotator cuff, are very common as well. These rotator cuff tendons attach directly to the ball of the shoulder joint, and when that ball dislocates, the tendons simply do not have the stretch and flexibility to accommodate, and accordingly, they can quite easily tear. Therefore, if an older individual requires a surgery after a shoulder dislocation, it is typically either for a fracture or, most commonly, for a rotator cuff tear.
Obviously, not every patient with a shoulder dislocation fits neatly into one of these two categories. Shoulder dislocations can occur at any age, and patients can fall anywhere on the spectrum between these two extremes. Ultimately, appropriate treatment of a shoulder dislocation depends not only on the patient's age and the type of structural damage that has occurred, but on numerous other factors including the patient's overall health, activity level, occupation and hand dominance. Every patient who suffers a shoulder dislocation should be evaluated by an orthopedic surgeon; the correct treatment decision can only be made through detailed conversation between the patient and their orthopedist.