Shoulder injury

Post traumatic shoulder luxation
Short Summary

31 years old healthy man, a month ago, during a soccer match, had a trauma of the right shoulder and was diagnosed with right glenohumeral luxation.
The Emergency Room orthopedist reduced luxation, and during the first days of the event, the patient treated pain, of modest importance and bearable. At present, the day pain has completely disappeared reappearing a bit at night and affecting mainly the forearm.
3 weeks later the patient decided to carry out a right shoulder MRN which showed characteristics of Hill Sachs lesion and Bankart lesion.
The patient points out that he is a lawyer, therefore with little exposure to traumas, but, being 31 years old, he would like to avoid the risk of luxations recurrence, with further damage of tissues as a result of regular sport activities (e.g. jogging) or of ordinary movements (e.g. wearing a jacket or sneezing, etc.).
 

Patient's Questions

1) The conservative treatment carried out till today is correct?
2) Do you deem it necessary to wear the brace for 4 or 5 weeks? If the brace is worn for 5 weeks, does the patient run the risk of suffering from too much shoulder rigidity?
3) In order to avoid the luxation from becoming relapsing, do you deem it necessary or useful to carry out a surgical operation or, based on the clinical picture described, the rehabilitation therapy is to be considered sufficient?
4) Do you think that lesions highlighted from the MRN could, with the passing of time, gain a complete recovery?
5) If a rehabilitation therapy is necessary, which kind do you suggest?
6) If a surgical operation is needed which are the centers of excellence in Italy?
 

Medical Background

31 years old male without any significant notable pathology in anamnesis.
A month ago, during a soccer match, the patient had a trauma at the right shoulder level, therefore, he immediately went to the Emergency Room , where the medical staff placed a diagnosis of “Right glenohumeral luxation.”
The Emergency Room orthopedist reduced luxation, after local anesthesia, asking the patient to return the following day for a follow-up examination. The day after a conservative treatment was prescribed to the patient who had to wear a brace (Gibaud Ortho) for 5 week.
During the first days of the event, the patient treated pain, of modest importance and bearable, taking Tachipirina 1000 twice a day. At present, the day pain has completely disappeared reappearing a bit at night and affecting mainly the forearm.

3 weeks later the patient decided to carry out a right shoulder MRN, with the following medical report:
“A depression of the anatomical profile of the posterolateral region of the humeral head is appreciable with signs of subcortical medullary edema, as for Hill-Sachs lesion. Concomitant alteration of signal with characteristics of hyper-intensity of the anterior inferior glenoid lip, as for Bankart lesion: at the basal assessment, however, it is not possible to stage the fibrocartilage lesion nor define the associated capsular ligament lesions, therefore an integration through arthro-MR examination is advised.
The supraspinatus and infraspinatus muscle tendons don’t show solutions of continuity or avulsion symptoms; the tendon tissue structure is homogenous.
No effusion of the deltoid subacromial bursa. Normal muscle trophism of the supraspinate and the deltoid. Findings within normal limits for the subscapularis muscle tendon.
The long head tendon of the brachial biceps muscle starts in the reflection pulley; the insertion of the biceps anchor is intact.
Presence of intraarticular effusion of moderate importance with distension of axillary and subscapularis-subcoracoid recess in presence of hypointense nucleus placed in the most declivous area.”
 

Expert's Opinion

Below are answers to the questions:
1) The conservative treatment carried out till today is correct?
Yes. The shoulder had closed reduction of a traumatic glenohumeral dislocation, anterior, with postoperative sling immobilization for five weeks.

2) Do you deem it necessary to wear the brace for 4 or 5 weeks? If the brace is worn for 5 weeks, does the patient run the risk of suffering from too much shoulder rigidity?
There are differences of opinion regarding the need to immobilize the shoulder after dislocation. It is standard practice to immobilize for 4-6 weeks, but there is not much difference in re-dislocation rate if the shoulder is or is not immobilized. The risk of loss of motion is very small, though.

3) In order to avoid the luxation from becoming relapsing, do you deem it necessary or useful to carry out a surgical operation or, based on the clinical picture described, the rehabilitation therapy is to be considered sufficient?

The chance of recurrent dislocation is in the range of 40%, regardless of therapy or not. I would not recommend surgery now, though, because the risk of not having another dislocation, on the other hand, is in the range of 60%. The level of activity (such as sports) is one of the important factors that will affect the re-dislocation rate.

4) Do you think that lesions highlighted from the MRN could, with the passing of time, gain a complete recovery?
The Bankart and Hill-Sachs lesions demonstrated on the MRI are typical findings after traumatic shoulder dislocation. They typically do not heal spontaneously. The Bankart lesion could be repaired surgically, but this should be done only if the shoulder has recurrent instability (dislocations). The shoulder function can return completely to normal and have no further problem, though, even if the lesions do not heal.

5) If a rehabilitation therapy is necessary, which kind do you suggest?
Pendulum exercise, elastic band (Theraband), resistance exercises to regain strength. However, no matter how strong the shoulder is, the shoulder can accidentally re-dislocate (when the patient did not expect a force and when the muscles were not contracted). Avoid overhead weight lifting with the weights behind the head (in other words, be careful of excessive extension of the shoulder in the overhead abducted externally rotated position).

6) If a surgical operation is needed which are the centers of excellence in Italy?
Where in Italy? Dr. Alex Castagna in Milan trained in USA with Dr. Steven Snyder. He is good, but there are others.
 

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