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TC(1070).(05).Orthopedics Case No 146:- Recurrent Shoulder Dislocation

Recurrent Shoulder Dislocation — বাংলায় Clinical Note

Recurrent shoulder dislocation হলো shoulder joint, বিশেষ করে glenohumeral joint, বারবার socket থেকে বের হয়ে যাওয়া বা বের হয়ে যাওয়ার মতো অনুভূতি হওয়া। অধিকাংশ ক্ষেত্রে এটি anterior shoulder instability—অর্থাৎ humeral head সামনে দিকে সরে যায়। Diagnosis মূলত history + clinical instability tests দিয়ে হয় এবং MRI/CT দিয়ে labrum, capsule ও bone defect মূল্যায়ন করা হয়।

1. Definition / সংজ্ঞা

Recurrent shoulder dislocation বলতে বোঝায়—একবার shoulder dislocation হওয়ার পর একই shoulder বারবার dislocate/subluxate হওয়া, সাধারণত labrum tear, capsular laxity, glenoid bone loss বা Hill-Sachs lesion থাকার কারণে joint stability কমে যায়।

সহজ ভাষায়:
কাঁধের বল joint বারবার socket থেকে বের হয়ে যায় বা বের হয়ে যাওয়ার ভয়/অনুভূতি হয়।

2. Causes / Etiology & Pathophysiology — কারণগুলো

A. Traumatic cause — আঘাতজনিত

  1. প্রথমবার anterior dislocation
    • হাত abducted + externally rotated অবস্থায় পড়ে গেলে বা sports injury হলে humeral head সামনে বের হয়।
    • এতে anterior-inferior labrum ও capsule ছিঁড়ে যেতে পারে।
  2. Bankart lesion
    • Glenoid labrum-এর anterior-inferior অংশ ছিঁড়ে যায়।
    • Labrum socket-এর rim deepen করে; তাই labrum tear হলে shoulder unstable হয়।
  3. Hill-Sachs lesion
    • Humeral head-এর posterolateral অংশে compression defect হয়।
    • Recurrent instability-তে Hill-Sachs lesion খুব common; recurrent traumatic anterior dislocation-এ Hill-Sachs lesion 80–93% পর্যন্ত reported।
  4. Bony Bankart / glenoid bone loss
    • Glenoid rim-এর bone ভেঙে বা ক্ষয় হয়ে socket ছোট হয়ে যায়।
    • Bone loss বেশি হলে শুধু physiotherapy/Bankart repair যথেষ্ট নাও হতে পারে; Latarjet/bone block লাগতে পারে।
  5. Capsular laxity / IGHL injury
    • Inferior glenohumeral ligament complex shoulder-এর anterior stability দেয়।
    • এটি stretch/tear হলে recurrent instability হয়।

B. Patient-related risk factors

  1. কম বয়স
    • Young active male, বিশেষ করে <20 years, recurrence risk বেশি। BESS/BOA pathway-তে males under 20 years-এর recurrent instability risk প্রায় 72% বলা হয়েছে।
  2. Contact sports / overhead sports
    • Football, cricket fielding, volleyball, swimming, gym overhead press—ঝুঁকি বাড়ায়।
  3. Generalized ligament laxity
    • Hypermobile joint, Ehlers-Danlos spectrum, Beighton score high হলে atraumatic/multidirectional instability হতে পারে।
  4. Poor rehabilitation
    • First dislocation-এর পর proper immobilization + rotator cuff/scapular strengthening না করলে recurrence বাড়ে।
  5. Seizure / electric shock
    • Posterior dislocation বেশি হয়, তবে recurrent instability হতে পারে।

3. Symptoms — লক্ষণগুলো

  1. Shoulder বারবার খুলে যাওয়া
    • Patient বলে: “হাত তুললেই কাঁধ বের হয়ে যায়।”
  2. Subluxation feeling
    • পুরো dislocation না হলেও shoulder “slip” করার অনুভূতি।
  3. Apprehension / ভয়
    • হাত abduction + external rotation করলে মনে হয় shoulder বের হয়ে যাবে।
  4. Pain
    • Dislocation episode-এর সময় severe pain।
    • Chronic case-এ dull ache বা activity-related pain।
  5. Clicking / catching / popping
    • Labral tear থাকলে shoulder move করার সময় click/catch হতে পারে।
  6. Weakness
    • Rotator cuff inhibition, pain বা nerve involvement-এর কারণে weakness।
  7. Reduced range of motion
    • Acute episode-এর পর movement কমে যায়।
    • Chronic case-এ patient risky position avoid করে।
  8. Numbness / tingling
    • Axillary nerve involvement হলে lateral shoulder/deltoid area-তে numbness হতে পারে।
  9. Functional limitation
    • Throwing, overhead work, dressing, sleeping posture, sports—সবকিছুতে সমস্যা হয়।

4. Clinical Diagnosis — কীভাবে clinically diagnose করবেন

Diagnosis-এর core হলো history + instability test + neurovascular examination। BESS/BOA pathway history ও examination-কে diagnosis-এর ভিত্তি হিসেবে উল্লেখ করে।

A. History — অবশ্যই জিজ্ঞাসা করবেন

  1. First dislocation কবে হয়েছিল?
  2. Mechanism: fall, sports, RTA, seizure?
  3. Direction: anterior/posterior/inferior?
  4. কতবার dislocate হয়েছে?
  5. নিজে reduce করতে পারে নাকি hospital reduction লাগে?
  6. Dominant hand কিনা?
  7. Sports/occupation: contact athlete, manual worker?
  8. Neurological symptoms: numbness, weakness?
  9. Previous physiotherapy/surgery হয়েছে কিনা?
  10. Generalized hypermobility আছে কিনা?

B. Clinical tests — specific tests

  1. Apprehension test
    • Patient supine/sitting।
    • Shoulder 90° abduct + externally rotate।
    • Positive: pain নয়, বরং “shoulder বের হয়ে যাবে” এমন ভয়।
  2. Relocation test
    • Apprehension test positive হলে humeral head posterior pressure দিলে apprehension কমে যায়।
    • Anterior instability support করে।
  3. Surprise / release test
    • Relocation pressure হঠাৎ ছেড়ে দিলে apprehension ফিরে আসে।
    • খুব carefully করতে হয়।
  4. Load and shift test
    • Humeral head anterior/posterior translation assess করা হয়।
  5. Anterior drawer test of shoulder
    • Capsulolabral laxity বোঝা যায়।
  6. Sulcus sign
    • Inferior/multidirectional instability বোঝায়।
  7. Beighton score
    • Generalized ligamentous laxity assess করতে।
  8. Rotator cuff tests
    • Jobe’s test, drop arm test, external rotation strength।
    • Older patient-এ rotator cuff tear exclude করতে হবে।
  9. Neurovascular examination
    • Axillary nerve: deltoid power + lateral shoulder sensation।
    • Radial pulse, capillary refill।
    • Brachial plexus screen।

5. Investigations — specificভাবে কী কী করবেন

1. X-ray shoulder — first-line

Views:

  • True AP / Grashey view
  • Scapular Y view
  • Axillary lateral view
    যদি painful হয়: Velpeau axillary view

Purpose:

  • Dislocation direction confirm
  • Fracture exclude
  • Hill-Sachs lesion / bony Bankart clue
  • Pre-reduction ও post-reduction X-ray করা উচিত acute dislocation-এ

2. MRI shoulder

Purpose:

  • Bankart lesion
  • Labral tear
  • Capsular injury
  • HAGL lesion
  • SLAP lesion
  • Rotator cuff tear
  • Bone edema / soft tissue injury

Recurrent instability-তে MRI/MRA গুরুত্বপূর্ণ, কারণ treatment planning-এর জন্য labrum, ligament ও bone defect identify করতে হয়।

3. MR Arthrogram — best for subtle labral pathology

Indication:

  • Recurrent instability কিন্তু routine MRI inconclusive
  • Young athlete
  • Labral/capsuloligamentous lesion suspect

4. CT scan with 3D reconstruction

Indication:

  • Recurrent dislocation with suspected bone loss
  • Bony Bankart
  • Significant Hill-Sachs
  • Pre-operative planning

Purpose:

  • Glenoid bone loss percentage
  • Hill-Sachs size
  • On-track/off-track lesion planning

3D CT humeral head “en face view” Hill-Sachs assessment-এর জন্য খুব useful।

5. Ultrasound

Indication:

  • Older patient
  • Rotator cuff tear suspect
  • Dynamic evaluation

6. EMG/NCS

Indication:

  • Persistent deltoid weakness
  • Lateral shoulder numbness
  • Suspected axillary nerve injury

Timing:

  • Usually injury-এর 3–4 weeks পর করলে বেশি informative।

6. Differential Diagnosis

  1. Rotator cuff tear
  2. SLAP lesion without instability
  3. Adhesive capsulitis
  4. AC joint injury
  5. Cervical radiculopathy
  6. Brachial plexus / axillary nerve injury
  7. Proximal humerus fracture
  8. Posterior shoulder dislocation
  9. Multidirectional instability
  10. Septic arthritis — fever, severe pain, raised inflammatory markers থাকলে ভাবতে হবে

7. Complications — বাংলায় বুঝিয়ে

  1. Repeated dislocation
    • প্রতিবার dislocation হলে labrum, capsule ও bone damage বাড়তে পারে।
  2. Bankart lesion
    • Socket-এর labrum ছিঁড়ে গেলে shoulder বারবার unstable হয়।
  3. Hill-Sachs lesion
    • Humeral head-এ dent/defect হয়; বড় হলে glenoid rim-এ engage করে আবার dislocation ঘটায়।
  4. Glenoid bone loss
    • Socket-এর bone কমে গেলে ball ধরে রাখার ক্ষমতা কমে যায়।
  5. Post-traumatic osteoarthritis
    • বারবার injury হলে cartilage damage হয়ে ভবিষ্যতে arthritis হতে পারে।
  6. Rotator cuff tear
    • বিশেষ করে বয়স >40 হলে dislocation-এর সাথে cuff tear বেশি দেখা যায়। CPG source অনুযায়ী traumatic anterior dislocation-এর পর বয়স বাড়ার সাথে rotator cuff tear risk বাড়ে।
  7. Axillary nerve injury
    • Deltoid weakness ও lateral shoulder numbness হতে পারে।
  8. Fracture
    • Greater tuberosity fracture, glenoid rim fracture হতে পারে।
  9. Chronic pain and stiffness
    • Repeated inflammation ও fear avoidance-এর কারণে shoulder function কমে যায়।

8. Treatment / Management — Guideline-based

A. Acute dislocation episode management

  1. Emergency assessment
    • Pain control
    • Neurovascular check before and after reduction
    • X-ray
  2. Closed reduction
    • Appropriate analgesia/sedation দিয়ে gentle reduction।
    • Forceful manipulation avoid করতে হবে।
  3. Post-reduction X-ray
    • Joint reduce হয়েছে কিনা এবং fracture আছে কিনা দেখবেন।
  4. Immobilization
    • Sling usually 1–3 weeks, patient age/activity অনুযায়ী।
    • Primary anterior dislocation-এর পর 1–3 weeks immobilization ও structured physiotherapy recommended।
  5. Rehabilitation
    • Pain-free ROM
    • Rotator cuff strengthening
    • Scapular stabilization
    • Proprioception training
    • Return to sport usually strength/ROM restore হওয়ার পর

B. Recurrent case management

1. Conservative treatment — কাদের জন্য

  • Low-demand patient
  • Mild subluxation only
  • No major bone loss
  • No high-risk sports
  • Surgery unwilling/unfit

Treatment:

  • 6–12 weeks supervised physiotherapy
  • Rotator cuff + scapular stabilizer strengthening
  • Avoid abduction-external rotation risky position
  • Activity modification

2. Surgical treatment — কাদের লাগতে পারে

Indications:

  1. Young active patient with recurrent dislocation
  2. Contact athlete / overhead athlete
  3. Recurrent instability despite good physiotherapy
  4. Bankart lesion with functional instability
  5. Significant glenoid bone loss
  6. Engaging/off-track Hill-Sachs lesion
  7. Bony Bankart
  8. Revision case
  9. High-risk occupation: army, police, manual labor

Surgery options:

  1. Arthroscopic Bankart repair
    • Labrum repair + capsular tightening।
    • Soft tissue Bankart lesion, minimal bone loss হলে।
  2. Bankart repair + remplissage
    • Engaging Hill-Sachs lesion থাকলে posterior capsulotenodesis করে defect fill করা হয়।
  3. Latarjet procedure
    • Significant glenoid bone loss / off-track lesion / failed Bankart repair।
    • Coracoid transfer করে socket-এর anterior bone support বাড়ানো হয়।
  4. Open capsular shift
    • Multidirectional instability / capsular laxity।
  5. Rotator cuff repair
    • Older patient-এ associated cuff tear থাকলে।

9. Pharmacological Treatment — Bangladesh Prescription Pattern

Important: Recurrent shoulder dislocation-এর definitive treatment drug নয়। Drug দেওয়া হয় pain, inflammation, muscle spasm, post-reduction/post-operative pain কমানোর জন্য। একসাথে একাধিক NSAID দেওয়া উচিত নয়।

নীচের doseগুলো adult usual dose; renal disease, liver disease, pregnancy, elderly, peptic ulcer, anticoagulant use—এসব ক্ষেত্রে dose/choice বদলাতে হবে।

9.1 Commonly used drugs by doctors in Bangladesh

1. Paracetamol

  • Generic name: Paracetamol
  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Non-opioid analgesic
  • Bangladesh available brand examples: Ace 500 mg, Centamol 500 mg, Feva 500 mg, Fevac 500 mg, Fast XR 665 mg, Dola suspension 120 mg/5 ml. MedEx Ace 500 mg-এর therapeutic class “Non-Opioid Analgesics” হিসেবে উল্লেখ করে।
  • Adult dose: 500–1000 mg orally every 6–8 hours PRN
  • Maximum: সাধারণত 3–4 g/day; liver disease/alcohol use থাকলে কম
  • Duration: 2–5 days বা pain অনুযায়ী
  • কেন used হয়: Mild–moderate pain, post-reduction pain
  • Side effects: Nausea, rash; overdose হলে hepatotoxicity
  • Interaction: Alcohol, warfarin long-term use, other paracetamol-containing products
  • Purpose: Pain control without NSAID GI/renal risk

2. Ibuprofen

  • Generic name: Ibuprofen
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; non-selective COX inhibitor
  • Bangladesh available brand examples: Flamex 200/400 mg, Profen 400 mg, Iburex 200/400 mg, Inflam 200/400 mg, Intaflam 400 mg, Neurofen 400 mg.
  • Adult dose: 400 mg orally 2–3 times daily after food
  • Duration: 3–5 days; reassess if pain persists
  • কেন used হয়: Pain + inflammation কমাতে, acute soft-tissue pain/post-reduction pain
  • Side effects: Dyspepsia, gastritis, GI bleeding, renal impairment, edema, BP increase, bronchospasm in NSAID-sensitive asthma
  • Interaction: Anticoagulant, steroid, SSRI, ACEi/ARB, diuretic, lithium, methotrexate, other NSAIDs
  • Avoid: Peptic ulcer/GI bleed, CKD, heart failure, uncontrolled HTN, 3rd trimester pregnancy
  • MedEx note: Ibuprofen mild–moderate pain ও inflammation-associated pain-এ indicated; adult 200–400 mg dose interval 6 hours উল্লেখ আছে।

3. Naproxen / Naproxen sodium

  • Generic name: Naproxen / Naproxen sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID
  • Bangladesh available brand examples: Naproxen 500 mg, Napxon-P 250/500 mg, Naptodin 500 mg, Nasox 500 mg.
  • Adult dose: 250–500 mg orally twice daily after food
  • Duration: 3–7 days
  • কেন used হয়: Longer acting NSAID; recurrent dislocation episode-এর post-reduction inflammatory pain
  • Side effects: Heartburn, abdominal pain, nausea, diarrhea, dyspepsia, headache, dizziness, drowsiness, edema, palpitation.
  • Interaction: ACE inhibitors, diuretics, aspirin, methotrexate, warfarin, SSRI—GI bleeding/renal risk বাড়াতে পারে।
  • Avoid: CKD, active ulcer, anticoagulant high-risk patient, heart failure

4. Aceclofenac

  • Generic name: Aceclofenac
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; COX inhibitor
  • Bangladesh available brand examples: Acenac 100 mg, Acepro 100 mg, Aclopain 100 mg, Aclovix 100 mg, Ceclofen 100 mg, Fenaaf 100 mg.
  • Adult dose: 100 mg orally twice daily after food
  • Duration: 3–5 days
  • কেন used হয়: Trauma-related pain ও inflammation; MedEx aceclofenac trauma pain/inflammation-এ indicated বলে।
  • Side effects: Dyspepsia, abdominal pain, nausea, rash, urticaria.
  • Interaction: Lithium, digoxin, diuretics, anticoagulants, methotrexate—monitoring প্রয়োজন।
  • Avoid: Peptic ulcer, GI bleed, severe renal/cardiac/hepatic impairment, NSAID-induced asthma

5. Etoricoxib

  • Generic name: Etoricoxib
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • Bangladesh available brand examples: Etorix 60/90 mg, Aroxia 60 mg, Espana 120 mg, Etoricoxib 60/90/120 mg.
  • Adult dose: 60 mg once daily after food; severe short-term pain/post-op pain-এ 90 mg once daily may be used
  • Duration: 3–5 days; post-operative acute pain হলে shortest possible course
  • কেন used হয়: Pain + inflammation; GI intolerance risk থাকলে কিছু doctor COX-2 selective option হিসেবে দেয়
  • Side effects: Dyspepsia, edema, BP rise, headache, dizziness; CV risk may increase
  • Interaction: Warfarin/anticoagulant, ACEi/ARB/diuretic, lithium, methotrexate, aspirin
  • Avoid: Ischemic heart disease, stroke history, uncontrolled hypertension, severe renal/hepatic disease
  • MedEx note: Etorix 60 mg page-এ OA dose 30–60 mg daily এবং post-operative dental pain dose 90 mg daily maximum 3 days উল্লেখ আছে।

6. Diclofenac

  • Generic name: Diclofenac sodium / Diclofenac potassium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; non-selective COX inhibitor
  • Bangladesh available brand examples: Clofenac 50 mg, G-Diclofenac 50 mg, G-Diclofenac IM 75 mg/3 ml, Fengel SR 100 mg.
  • Adult oral dose: 50 mg orally 2–3 times daily after food
  • IM option: 75 mg IM stat/once daily for very acute severe pain, hospital/clinic setting only
  • Duration: Oral 2–5 days; IM repeated unnecessaryভাবে avoid
  • কেন used হয়: Severe acute pain, post-reduction inflammatory pain
  • Side effects: Epigastric pain, nausea, vomiting, diarrhea, dyspepsia; rare serious GI bleeding/peptic ulcer/perforation।
  • Interaction: Lithium, digoxin, anticoagulant, cyclosporine, methotrexate, diuretics, other NSAIDs/steroids।
  • Avoid: Peptic ulcer, GI bleeding, CKD, heart disease/high CV risk, anticoagulant use, pregnancy last trimester

7. Tizanidine — only if painful muscle spasm

  • Generic name: Tizanidine hydrochloride
  • Therapeutic category: Muscle relaxant
  • Pharmacological class: Centrally acting skeletal muscle relaxant; alpha-2 agonist
  • Bangladesh available brand examples: Relentus 2 mg, Tizan 2 mg, Tizanac 2 mg, Sirdalud 2 mg. MedEx Relentus 2 mg ও other tizanidine brands দেখায়।
  • Adult dose: 2 mg orally at night or 2 mg 2–3 times daily
  • Duration: 2–5 days only if spasm prominent
  • কেন used হয়: Painful muscle spasm কমাতে; dislocation-এর definitive treatment নয়
  • Side effects: Sleepiness, fatigue, dizziness, dry mouth, hypotension, nausea, transaminase rise.
  • Interaction: Ciprofloxacin ও fluvoxamine contraindicated; alcohol/benzodiazepine/sedative দিলে sedation ও hypotension বাড়ে।
  • Avoid: Severe hepatic impairment, hypotension-prone patient, driving/operating machinery

8. Tramadol — severe acute pain only

  • Generic name: Tramadol hydrochloride
  • Therapeutic category: Opioid analgesic
  • Pharmacological class: Centrally acting synthetic opioid; weak μ-opioid agonist + serotonin/noradrenaline reuptake inhibition
  • Bangladesh available brand examples: Anadol 50 mg, Dolonil 50 mg, Dolorex 50 mg, Lucidol 50 mg, Tranal 50 mg, Utramal 50 mg, Winpain 50 mg, Xtrapel 50 mg, Zydol 50 mg.
  • Adult dose: 50 mg orally every 6–8 hours PRN
  • Maximum: 400 mg/day; elderly/renal/hepatic impairmentে কম
  • Duration: 1–3 days only
  • কেন used হয়: Severe pain after reduction/surgery when paracetamol/NSAID inadequate
  • Side effects: Nausea, vomiting, dizziness, sedation, constipation, dependence, respiratory depression, seizure risk
  • Interaction: SSRI/SNRI/TCA/MAOI → serotonin syndrome/seizure risk; benzodiazepine/alcohol → respiratory depression; other opioids/sedatives
  • Avoid: Uncontrolled epilepsy, severe respiratory depression, substance dependence risk
  • Note: Routine recurrent dislocation pain-এ first-line নয়।

9. PPI gastroprotection — NSAID দিলে high-risk patient-এ

  • Generic name: Omeprazole / Pantoprazole / Esomeprazole
  • Therapeutic category: Anti-ulcerant, gastroprotection
  • Pharmacological class: Proton Pump Inhibitor
  • Bangladesh available brand examples:
    • Omeprazole: O-20 20 mg, O-40 40 mg, Omegut 20/40 mg, Prazole 20 mg, Prevas 20/40 mg.
    • Pantoprazole: Pantonix 40 mg, Pantogut 40 mg, Pantolok 20/40 mg, Pantopan 20 mg.
    • Esomeprazole: Maxpro 20/40 mg, Nexum 20/40 mg, Sergel 20/40 mg.
  • Adult dose:
    • Omeprazole 20 mg once daily before breakfast, or
    • Pantoprazole 40 mg once daily before breakfast
  • Duration: NSAID course চলাকালীন; high-risk হলে 1–2 weeks
  • কেন used হয়: NSAID-induced gastritis/ulcer risk কমাতে; Pantonix page NSAID-induced ulcer indication উল্লেখ করে।
  • Side effects: Headache, diarrhea/constipation, nausea; long-term useে hypomagnesemia, B12 deficiency, infection risk
  • Interaction: Clopidogrel interaction concern বেশি omeprazole/esomeprazole-এ; warfarin/phenytoin monitoring; long-term unnecessary use avoid

9.2 Bangladesh doctors commonly prescribe — practical list

Recurrent shoulder dislocation episode/post-reduction pain-এর জন্য Bangladesh clinical practice-এ সাধারণত prescription pattern এমন হতে পারে:

  1. Paracetamol 500 mg
    • Pain control-এর first-line।
    • Mild pain হলে NSAID ছাড়াই দেওয়া যায়।
  2. One NSAID only
    • Aceclofenac 100 mg BD or
    • Ibuprofen 400 mg TDS or
    • Naproxen 500 mg BD or
    • Etoricoxib 60 mg OD or
    • Diclofenac 50 mg BD/TDS
    • Purpose: pain + inflammation কমানো।
    • একই সাথে দুইটা NSAID দেওয়া যাবে না।
  3. PPI
    • Omeprazole 20 mg OD / Pantoprazole 40 mg OD
    • Purpose: NSAID-induced gastritis/ulcer prevention, especially high-risk patient।
  4. Tizanidine 2 mg
    • Muscle spasm থাকলে short course।
  5. Tramadol 50 mg
    • Severe pain হলে short course only; routine নয়।

10. Prevention — কীভাবে recurrence কমাবেন

  1. Proper first-time management
    • Correct reduction, post-reduction X-ray, sling, early follow-up।
  2. Structured physiotherapy
    • Rotator cuff strengthening
    • Scapular stabilizer strengthening
    • Proprioception training
    • Closed-chain shoulder control
    • Gradual return to sport
  3. Risky position avoid
    • Abduction + external rotation position avoid until rehab complete।
  4. Contact sport delay
    • Pain-free full ROM, near-normal strength, negative apprehension test না হওয়া পর্যন্ত return নয়।
  5. Recurrent episodes ignore না করা
    • বারবার খুললে MRI/CT করে Bankart, Hill-Sachs, glenoid bone loss evaluate করতে হবে।
  6. Young athlete হলে early orthopedic referral
    • Young active patient-এ recurrence high; early stabilization discussion দরকার।
  7. Seizure control
    • Seizure-related dislocation হলে neurologist management essential।
  8. Hypermobility থাকলে long-term strengthening
    • Joint laxity থাকলে lifelong shoulder conditioning দরকার।

Overview / Summary

Recurrent shoulder dislocation সাধারণত anterior instability due to Bankart lesion, Hill-Sachs lesion, capsular laxity বা glenoid bone loss। Diagnosis clinical—apprehension/relocation/load-shift tests—আর MRI/MRA/3D CT treatment planning-এর জন্য গুরুত্বপূর্ণ। Drug shoulder stabilize করে না; drug শুধু pain/inflammation/spasm control করে। Definitive prevention হলো rehab + risk modification, আর high-risk/recurrent structural lesion থাকলে surgical stabilization।

Actionable Plan / Steps

  1. Acute dislocation হলে: ER/orthopedic setup → neurovascular exam → X-ray → closed reduction → post-reduction X-ray।
  2. Recurrent case হলে: MRI shoulder ± MR arthrogram; bone loss suspect হলে 3D CT।
  3. Pain management: Paracetamol ± one NSAID; high-risk হলে PPI; severe pain হলে short-course tramadol only.
  4. Physiotherapy: minimum 6–12 weeks supervised rotator cuff + scapular program।
  5. Orthopedic referral: young active patient, contact athlete, repeated dislocation, Bankart/Hill-Sachs/glenoid bone loss, failed physiotherapy।
  6. Surgery consideration: Arthroscopic Bankart repair, remplissage, Latarjet—lesion type ও bone loss অনুযায়ী।

Reference List

Textbooks

  1. Apley & Solomon’s System of Orthopaedics and Trauma, latest edition — Shoulder instability/dislocation chapter.
  2. Campbell’s Operative Orthopaedics, latest edition — Recurrent anterior shoulder instability, Bankart repair, Latarjet procedure.
  3. Rockwood and Green’s Fractures in Adults, latest edition — Shoulder dislocation and associated fractures.
  4. DeLee, Drez & Miller’s Orthopaedic Sports Medicine, latest edition — Athletic shoulder instability.

Guidelines / Pathways

  1. BESS/BOA Patient Care Pathway: Traumatic Anterior Shoulder Instability, 2015. DOI: 10.1177/1758573215585656.
  2. CSM / Academy of Orthopaedic Physical Therapy Shoulder Instability Clinical Practice Guideline handout, 2019.
  3. Management of Primary Anterior Shoulder Dislocations: Narrative Review, Sports Medicine – Open, 2019. DOI: 10.1186/s40798-019-0203-2.

Peer-reviewed Articles with DOI

  1. Brownson P, Donaldson O, Fox M, et al. BESS/BOA Patient Care Pathways: Traumatic anterior shoulder instability. Shoulder & Elbow. 2015;7:214–226. DOI: 10.1177/1758573215585656.
  2. Hasebroock AW, Brinkman J, Foster L, Bowens JP. Management of primary anterior shoulder dislocations: a narrative review. Sports Medicine – Open. 2019;5:31. DOI: 10.1186/s40798-019-0203-2.
  3. Baudi P, Righi P, Bolognesi D, et al. Imaging of the unstable shoulder. The Open Orthopaedics Journal. 2017;11:882–896. DOI: 10.2174/1874325001711010882.
  4. Robinson CM, Howes J, Murdoch H, Will E, Graham C. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. JBJS Am. 2006;88:2326–2336. DOI: 10.2106/JBJS.E.01327.

Md.Rafiqul Islam Lipu,Date:-23-06-2026 Tuesday,Time:-11-41-12 Am

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