Where can I have my surgery?

Many patients have a favorite hospital. It may be their favorite because it’s close to home, their primary care physician works out of that hospital, or they’ve had a positive experience there in the past. Whatever the reason, many patients want to ensure their surgery can be done at their favorite hospital.

As an independent physician, Dr. Betsy Nolan has admitting privileges and can perform surgeries at multiple hospitals in the state of Oklahoma. While hospital choice for the patient is important, other factors may impact where your surgery takes place.

Some area hospitals have dedicated joint wards with specialized nurses and therapists who spend all of their time taking care of joint replacement patients. Specialized joint wards have a lower risk of infection since nurses are not also treating patients with major infections.

For some patients, the availability of other specialists impacts hospital choice. For example, a patient with a history of lung issues might be best treated at a hospital with a pulmonologist readily available.

Availability of certain implants can also affect hospital choice, as different hospitals may have contracts with different device companies. Most patients will select a hospital simply based on availability for when surgery best fits their schedule.

Dr. Betsy Nolan works with each patient to determine the best hospital location for their surgery. She performs surgeries at the following hospitals.

  • OU Medical Center Edmond, located at 1 South Bryant in Edmond. The specialized joint replacement ward has large rooms with pullout couches to accommodate family members or friends who wish to stay with the patient.
  • Southwest Medical Center, located at 5602 SW Lee Boulevard in Lawton. Dr. Nolan also offers clinic hours every other week in Lawton to see patients from southern Oklahoma and north Texas.
  • Surgery Center of Oklahoma, located at 9500 N. Broadway in Oklahoma City. SCO is an outpatient surgical facility that provides an upfront cost listed on their website for all procedures. Only outpatient procedures may be performed here, so patients must be healthy enough for a quick recovery. Patients who are having a procedure covered by most government insurance carriers (i.e., Medicare, Tricare) are not eligible to have their procedure done at SCO.
  • Mercy Hospital, located at 4300 W. Memorial Road in Oklahoma City. Dr. Nolan does not perform many surgeries at Mercy, but it is an option for patients who live in the area or whose primary care doctors are based at Mercy.
  • Mercy Edmond I-35, located at 2017 W. I-35 Frontage Road, is a nice, efficient, newer facility for outpatient procedures only. This facility does not do any joint replacement procedures. Patients using Tricare are not eligible to use this facility.
  • AllianceHealth Midwest, located at 2825 Parklawn Drive in Midwest City. Dr. Nolan does not perform many surgeries at this location either, but it is an option for Midwest City patients or those who prefer this hospital.

Dr. Nolan no longer goes to the VA hospital. However, she is happy to see VA patients at her clinic in Midtown or at the new Lawton location and can perform surgeries for them at one of the hospitals listed above. VA patients may continue to go to the VA for their other benefits, such as physical or occupational therapy, and use the outpatient pharmacy there.

Preparing for surgery: pre-op blood work.

It’s important to be as healthy as possible at the time of surgery, which is why a pre-operative appointment for blood work is a standard practice. Some blood tests prior to surgery are routine for all patients, while others may only be done if the patient has a history of certain medical conditions.

Your surgeon will go over your medical history with you during your appointment, but you may also need to see an anesthesiologist at the hospital’s pre-op clinic prior to surgery. Your pre-op blood work is most commonly done at this time, typically a few days to a week before surgery. At that time, you should also receive any special instructions about stopping certain medications, which medications to take on the day of surgery, any special skin prep solution to use, and not eating or drinking prior to surgery.

Here’s an overview of the most common pre-op tests we order.

Complete Blood Count (CBC) Panel

A CBC panel is done for all scheduled, non-emergency surgeries and checks four main components.

  • White blood cells, which are your infection-fighting cells. If the count is high, that typically means there’s an infection in your body somewhere. That could mean a urinary tract infection, skin infection, or abscessed tooth, for example. Sometimes the patient isn’t even aware of the infection. If there is an infection, you’ll be treated with antibiotics to clear up the infection prior to surgery.
  • Hemoglobin and hematocrit are two separate measures of your red blood cells. Hemoglobin carries oxygen to your tissues, which is important for healing, so it’s important to have a normal level prior to surgery. Hematocrit measures the volume of red blood cells compared to total blood volume. Low hemoglobin and hematocrit typically means a patient has anemia, often due to an iron deficiency. Some blood loss occurs in any surgery, so it’s important for a patient to start with adequate blood levels. If your pre-op blood work shows anemia, you may be prescribed iron pills or other medications to help increase red blood cells before surgery.
  • Platelets are important for clotting. Any wound, including a surgical incision, needs adequate platelets to form a clot and heal the wound. If platelets are too low, a platelet transfusion can be done to increase the level prior to surgery to ensure appropriate clotting. Sometimes high platelets can be another sign of infection somewhere in the body, and low platelets often indicate liver problems, such as hepatitis or cirrhosis.

Complete Metabolic Panel (CMP)

Also known as a “chemistry” or “chem panel,” the CMP includes what most people think of as electrolytes, including sodium, potassium, calcium, and many others. These different electrolytes have different roles in the body, and an imbalance can indicate that something is going on somewhere in the body. If an electrolyte is too low, it can usually be replaced. If it’s too high, an electrolyte with an opposing function is often given to help balance the body.

Coagulation Labs

Coagulation labs include PT and PTT/INR and measure your body’s ability to stop bleeding. These make sure you don’t have an unusually high bleeding tendency. If you take blood thinners for another medical condition, it’s important to discuss that with your doctor well in advance of your surgery. Common blood thinners include Coumadin, Warfarin, Eliquis, Pradaxa, and Xarelto. It’s generally recommended to stop taking blood thinners prior to surgery, but the specific type of medication and the condition it’s treating will impact how long before surgery you’re asked to stop taking it.


A urinalysis is another test used to look at possible infection, as you do not want to undergo surgery with an infection present. If an infection is already present in your body, that bacteria will travel to the surgical site as well.

Hemoglobin A1C

This test measures glucose levels over the past several weeks and helps determine whether a person’s diabetes is well controlled. Typically, A1C should be lower than 8 prior to a scheduled surgery. Uncontrolled diabetes can increase the risk of infection and complicate the wound healing process. It’s not unusual in pre-op blood work to identify someone who is diabetic and didn’t know it. If the A1C is too high, a patient will be referred back to their primary care physician to help control the diabetes before surgery.

Chest X-Ray

Many hospitals require a chest x-ray prior to surgery to scan for public health issues like tuberculosis (TB). In older patients, the chest x-ray can also be used to show possible pneumonia, collapsed air sacs in the lungs, an enlarged heart, or hardening of the arteries, all of which can increase anesthetic risk.


An EKG, or electrocardiogram, measures the electrical activity of your heart. It’s typically done for patients over the age of 35 unless younger patients have a cardiac history or another reason to require an EKG. The test can help ensure there are no underlying cardiac issues, such as an abnormal heart rhythm or a prior heart attack the patient didn’t know about. If the EKG shows anything of concern, the patient may be referred back to their primary care physician and/or a cardiologist prior to surgery.

If you have questions about the pre-op process or want to discuss whether an existing medical condition affects your ability to have surgery, contact the Oklahoma Shoulder Center today for a consultation appointment.

Five questions to ask when choosing a shoulder or elbow surgeon.

When it comes time for any surgical treatment, it’s important to find the right doctor for you. In fact, it’s important for non-surgical treatment as well. Every patient should seek out a qualified physician who makes them feel comfortable. Here are a few things to consider when choosing a shoulder or elbow surgeon.

What specialized training do they have?

In the field of orthopaedic surgery, some physicians are generalists and some are specialists. Even among specialists, their training and experience will vary significantly, as there are no specific guidelines around what experience is required for a surgeon to advertise as a specialist.

Physicians who complete a shoulder and elbow fellowship undergo an additional year of training exclusively dedicated to shoulders and elbows, including open and arthroscopic procedures and joint replacement procedures. There are a limited number of fellowship positions available for this ultra-competitive specialty. For a list of ASES (American Shoulder and Elbow Surgeons) endorsed fellowships, please visit http://www.ases-assn.org/?p=physic-fellowships.

Are they an ASES member?

The most qualified shoulder and elbow surgeons will be those who are members of the American Shoulder and Elbow Surgeons (ASES). New members in the organization must be sponsored by two current members and must meet specific requirements, such as completing a recognized shoulder and elbow fellowship, publishing articles in relevant medical journals, presenting at conferences, and other factors that demonstrate the physician’s contributions to the field of shoulder and elbow surgery. You can search the ASES website to find a member in your area. Dr. Nolan is the only surgeon in Oklahoma to be recognized as a member of this elite group.

How many shoulder or elbow surgeries do they perform each year?

There’s research that shows that surgeons who perform a high volume of shoulder replacements each year have a lower rate of complications than surgeons who perform fewer shoulder replacements. A surgeon whose practice is focused mostly on shoulder and elbow surgery will generally perform a higher number of these types of surgeries per year and thus have more experience with the procedures. Also, they generally work with highly specialized staff who have a great deal of experience with these types of procedures.

Do you feel comfortable when meeting with them? Do you feel like they listen?

When meeting with a surgeon to talk about your concerns and questions related to your current issue or upcoming surgery, it’s critically important that you feel comfortable with them. If you’re not comfortable with your doctor, you may be less likely to keep follow-up appointments or even follow their treatment plan. Make sure to find a doctor with whom you feel you can ask all of your questions and who takes the time to address them.

Following your surgery, will you see the surgeon or will post-op care be handled solely by their staff? Are you comfortable with their approach?

Some surgeons choose to use a physician assistant (PA) as part of their patient care team, which could mean that you see a PA for part or all of your post-surgical care. While a PA is a valuable part of the surgical team, it’s important that your surgeon be directly engaged with you both before and after your surgery. If you consult with a surgeon who barely shows up to meet you before surgery and won’t be involved in your post-op care, you might be more comfortable looking for another doctor.

If you are seeking a qualified specialist for shoulder or elbow surgery or want a second opinion, contact the Oklahoma Shoulder Center today to schedule an appointment.

Three types of arthritis that impact the shoulder and elbow.

Arthritis is a group of diseases that can cause swelling, pain, stiffness, and decreased range of motion in the joints. It’s the leading cause of disability in the United States, and it can affect people of all ages. Symptoms range from mild to severe and may come and go in some patients. There are many different types of arthritis, but there are three primary categories that impact the shoulder and elbow.


Most of the time when people say arthritis, they mean osteoarthritis. It’s the normal wear and tear type of arthritis that typically affects older adults, although younger people can also have osteoarthritis. It’s a slow process that develops over years, and once it starts, it can’t be reversed.

Many people with osteoarthritis have a strong genetic predisposition. It’s not directly genetic, but it does tend to run in families. This type of arthritis primarily affects the large joints, like the hips, knees, and shoulders. Osteoarthritis of the elbow is not very common, whereas osteoarthritis of the shoulder is.

Osteoarthritis can affect multiple joints at one time. Typically, treatment begins with non-operative approaches to try and preserve the joint as long as possible. That may include cortisone injections, physical therapy, activity modification, use of assistive devices, or anti-inflammatories.

For osteoarthritis of the shoulder, steroid injections can often be effective for a while to decrease the pain and allow for continued function. In other joints, such as the knee, a viscosupplementation to inject lubricating fluid into the joint may be used, but that treatment is not FDA approved for shoulders and research hasn’t shown it to be effective for shoulders.

As arthritis progresses, an individual may be unable to complete normal daily activities or may be in so much pain that narcotic pain medications are required. At that point, when non-operative treatment is no longer giving sufficient relief, it may be time to talk to your doctor about surgical options, including joint replacement. More than 50,000 shoulder replacements are done each year in the US.

Inflammatory arthritis

There are many types of autoimmune and inflammatory arthritis, including rheumatoid and psoriatic arthritis. In this type of arthritis, the body is attacking its own cells, which causes inflammation, pain, and stiffness. Rheumatoid arthritis (the most common type of inflammatory arthritis) typically attacks the smaller joints, such as the hands and elbow. Shoulders are less commonly impacted by rheumatoid arthritis, although it is possible.

In treating inflammatory arthritis, the goal is to preserve the joints as long as possible, since this type of arthritis can affect patients at a much younger age. Most patients in this category see a rheumatologist for primary treatment with medication. Newer medications developed in the past 10 to 15 years work very well for controlling the disease and helping prevent the need for joint replacement. However, if a patient does have advanced joint destruction from inflammatory arthritis, the treatment options are usually the same as those mentioned above for osteoarthritis.

Post-traumatic arthritis

This type of arthritis is much less common, but it occurs when a fracture line extends into the joint following some sort of trauma, such as a car accident or fall. This results in incongruity of the joint line, which means the surface is uneven and does not glide smoothly against the other side of the joint. Over time, this leads to damage to the cartilage lining on both sides of the joint, and these joints develop end-stage arthritis.

Frequently, this type of arthritis is not very responsive to the conservative managements listed above in the osteoarthritis section, and patients may need surgery for definitive treatment. Also, deformities (abnormal shape of the bone) and/or bone loss from the injury can affect the surgical options, including type of implant, in these patients.

Not long ago, the most common reason for an elbow replacement was rheumatoid arthritis. Due to advancements in the medical management of rheumatoid arthritis, including medications called DMARDs (disease-modifying antirheumatic drugs), post-traumatic arthritis has become the leading reason for elbow replacements.

If you are experiencing shoulder or elbow pain and stiffness and suspect arthritis may be the cause, contact the Oklahoma Shoulder Center today to schedule an appointment.

What is impingement syndrome?

The word “impingement” covers a wide range of scenarios where something is pushing or causing pressure on another thing. In the shoulder, impingement most often refers to subacromial impingement, which affects the rotator cuff tendons beneath the acromion bone.

Impingement can cause persistent pain and affect daily activities. Symptoms are similar to rotator cuff tears, including pain when lifting the arm out to the side or overhead. That can include activities like reaching for a box of tissues behind the seat in the car, drying your hair, or reaching to get a plate out of an overhead cabinet. Impingement usually doesn’t result in weakness like a tear, but movement could be inhibited by pain.

Bone spurs in this area can also create pressure on the tendons and can eventually lead to rotator cuff tears. The shape of the acromion bone can be flat, curved, or hooked. People with more curvature in their acromion have a higher risk of rotator cuff tears as the acromion causes more wear on the rotator cuff over time.

That space around the rotator cuff tendons is relatively narrow, so any amount of inflammation in the shoulder can create pressure on the tendons and cause impingement, even in those individuals with a flat acromion. Sometimes the pain can radiate over the deltoid, but impingement pain usually stops above the elbow. If pain continues below the elbow and down into the hand, the problem likely originates in the neck rather than the shoulder area.

Impingement is usually treated with physical therapy, including specific exercises to strengthen the rotator cuff and scapular stabilizing muscles. For patients whose schedules or travel don’t allow for regular physical therapy appointments, many of the exercises can be done on your own using resistance bands, which can be rolled up and packed in a bag or suitcase.

Another treatment option is a steroid injection, which is a powerful anti-inflammatory that can help reduce swelling and pressure in the area. The steroid can take a few days to take effect, so the injection is typically done along with a local anesthetic that helps reduce the pain until the steroid can reduce the swelling.

Most of the time, surgery isn’t necessary for impingement alone. However, some patients with large bone spurs or those who don’t improve with non-operative treatments like physical therapy, injections, and anti-inflammatory medications may undergo an outpatient arthroscopic surgery. Through several small incisions, the surgeon can flatten the acromion bone, shave off bone spurs, and clean out the thickened bursa to relieve pressure and allow more room for the tendons.

If you are experiencing shoulder pain that affects your daily activity, contact the Oklahoma Shoulder Center today to schedule an appointment.

Orthopaedic surgery is a team effort

Guest post by Jessica Scott, PA-C, OU Medical Center Edmond

A surgical procedure, whether an outpatient surgery such as rotator cuff repair or a larger procedure such as total shoulder replacement, is very much a team effort. Here are a few of the key players in surgery, some of whom patients will meet and others whom they will not.

Pre-Operative Nurse

When a patient arrives at the hospital, a pre-op nurse will ensure they are checked in and prepared for surgery. This includes placing an IV, asking questions about health history and current medications, and other steps to prepare the patient for their procedure.

Circulator Nurse

The circulator nurse is in the operating room to document what happens during surgery, including what time the patient entered the room, when the incision was made, and any other details. The circulator nurse is not sterile, so if the surgical team needs something from outside the sterile field or outside the operating room, the circulating nurse can go get it. This is also the nurse who updates the patient’s friends or family in the waiting room about how surgery is going.


The anesthesiologist is responsible for putting the patient to sleep and controlling their pain for the procedure. They are in the room throughout the procedure to monitor the patient’s vitals, ensure they stay asleep, and help control any pain during the procedure. If the procedure is being done with a regional block, the anesthesiologist places the block prior to the procedure.

Primary Surgeon

For patients of the Oklahoma Shoulder Center, Dr. Betsy Nolan is the primary surgeon. The primary surgeon is responsible for the majority of the surgical procedure.

First Assist

The first assist is usually a resident surgeon or a physician’s assistant. Their role in surgery is to provide support in whatever way the surgeon requests support, such as holding retractors or doing suction so the surgeon can see better. The first assist also acts as another set of eyes and ears for the surgeon. They play an important role in positioning of the patient. As the surgeon focuses on a particular task, it is the first assist’s job to survey everything else happening and do what’s necessary to support the surgeon.

In many cases, the PA and/or resident also assists with taking care of the patient postoperatively if a stay in the hospital is necessary.

Scrub Techs

Scrub techs are another part of the surgeon’s support team. They assist with retraction, handing instruments to the surgeon, or anything else needed during the procedure.

Device Company Representative

For surgeries that will use an implant of some kind, a representative from the device company is also present. The representative will unpack the boxes to ensure everything meets the company’s specifications and be available to answer any specific questions related to the company’s implant or instruments.

Post-Operative Nurses & Techs

After surgery, a team of nurses and techs will care for the patient on the floor. Nurses will administer meds and monitor pain levels, nausea, and other postoperative symptoms to ensure the patient stays comfortable while recovering. Techs assist with activities like toileting and bathing, as well as checking vital signs.

X-Ray Tech

For some procedures, x-ray is required during the procedure in order to check, for instance, fracture alignment or hardware placement. An x-ray tech with a mobile x-ray machine called a c-arm comes into the operating room to take x-rays when requested by the surgeon.

Additional Support Roles

Aside from the team members directly involved in surgery and pre/post-operative care, there are additional support staff members often working behind the scenes. This category includes schedulers, medical coders, billing department staff, and hospital administrators, all of whom help ensure a smooth process for patients.

While a patient will mostly see their surgeon and pre/post-op nurses, it takes the entire team to ensure a successful surgery.

Treatment for scapular instability

Abnormal scapular (shoulder blade) motion most often occurs when compensating for another injury or pain in the shoulder area. Individuals may compensate for pain in the ball and socket joint by trying to get more motion through the scapulothoracic joint (the joint between the shoulder blade and the chest wall), which results in overuse injury to the muscles that stabilize that joint. Scapular instability can cause pain in the back of the shoulder, upper back, or even pain in the neck area that comes from the scapular stabilizing muscles, including the trapezius muscle, among others.

The most common visible sign of fatigue or imbalance of the scapular stabilizing muscles is called winging, where the shoulder blade looks like it pops out when raising the arms overhead. This typically occurs because of weakness in the muscles surrounding the shoulder blade, although it can also occur due to a nerve deficit.

Physical therapy is the most common treatment for pain or winging due to scapular instability, as it helps strengthen the specific muscles that stabilize the scapula. Many shoulder surgery post-operative physical therapy plans include exercises for scapular stabilization, since many patients will use the scapulothoracic joint more in order to compensate for pain and limited motion following surgery. Physical therapy to strengthen the surrounding muscles is important to address this secondary problem, which often occurs after surgery. The link below demonstrates some of the exercises that may be helpful.

When recovering from surgery or healing from a fracture, scapular instability can be a frustrating hurdle to overcome in the healing process. It can also be confusing for patients, as the pain may occur in a different location than where the issue actually occurs, as in patients who experience neck pain or upper back pain.

When an underlying issue, such as arthritis, contributes to scapular instability, it’s important to see a specialist who can treat the primary problem and reduce the need for compensation when rotating the shoulder. A combination of treating the primary problem and working with a physical therapist to strengthen the surrounding muscles can help reduce pain and improve overall shoulder function.

If you experience pain in the back of the shoulder or uncomfortable popping of the shoulder blade, contact the Oklahoma Shoulder Center for an appointment.

Fractures of the elbow and shoulder

There are many types of fractures that can occur to the shoulder or elbow, all of which differ in terms of severity, treatment, and recovery. Lots of fractures occur in older patients who have osteoporosis, but patients of any age can suffer a fracture in the right circumstances.

Orthopaedic surgeons classify fractures based on the number of parts fractured, the direction of displacement, whether or not there is an associated open skin injury, whether or not the fracture line extends into the joint itself, and more. Shoulder and elbow fractures can be evaluated through x-rays and sometimes a CT scan, if needed.

For a typical patient, it’s not important to understand the classification systems, but they help physicians be able to better discuss the injury with other doctors and the other members of your care team. It also helps with providing diagnostic and treatment-related information, as not all fractures are created equal.  

In general, treatment of fractures depends on bone quality overall, how well the bone is expected to heal, and potential future repercussions of that injury, such as risk of future arthritis when a fracture goes into a joint and makes the joint incongruent. Many fractures heal on their own with immobilization, while others can be repaired through surgical use of plates and screws, pins, or wires. In some cases, replacement of a portion of the joint or the entire joint may be required.

Fractures of the elbow

Distal humerus fractures most often occur from a fall from standing or a slight elevation, such as a step or two. This often occurs in patients with osteoporosis and results in lots of fragments. Treatment usually requires surgery and the use of pre-contoured plates attached with screws that hold the fragments in correct alignment in order to allow the arm to heal in correct alignment. This is especially helpful in allowing motion earlier to avoid stiffness in the elbow.

Radial head fractures are common and often occur when falling, such as off a bike, onto an outstretched hand. If the injury results in only two fragments and minimal displacement, treatment is to immobilize the elbow in a sling for a week or two and then start early physical therapy. If there are more fragments or greater displacement, surgery to repair the fracture with screws or a radial head replacement (different than a total elbow replacement) may be required.

Olecranon fracture occurs in the bony tip of the elbow and typically needs to be repaired with screws, pins, or wires. Because the triceps attaches to the point of the elbow, it can create a gap that doesn’t allow new bone to form, thus the need for surgical treatment.


Coronoid fracture can occur alone or in combination with elbow dislocation and/or ligament injury. A simple tip of the coronoid fracture may not require treatment beyond temporary immobilization, but more complex coronoid injuries that include ligament injury will likely require surgery. The terrible triad of the elbow is a coronoid fracture combined with radial head fracture and dislocation.

Fractures of the shoulder

Proximal humerus fracture is a fracture of the upper part of the arm bone, the third most common joint fracture after wrist and hip. Most can be treated non-operatively, although it depends on the fracture pattern.

Scapula fractures can occur in the blade part of the shoulder. Most are non-operative, but some may require surgery if they extend into the socket part of the shoulder joint or if they cause instability of the shoulder. Scapular fractures are not common and require a significant amount of trauma to occur, such as a motorcycle accident.  

Glenoid fractures (the socket part of the shoulder joint) can cause the joint to be uneven, can lead to arthritis, and can cause the ball to fall out of the socket. Surgical treatment is generally recommended if they are displaced to prevent long-term consequences.

Clavicle fractures are relatively common and treatment depends on age, activity demands, and how displaced they are. The clavicle remodels well even up to the early 20s, and many heal on their own in older patients as well. For patients who do manual labor or lots of overhead work, repairing the clavicle surgically may be recommended.

A type of fracture that occurs between the shoulder and elbow is a humerus fracture, which is the shaft part of the arm. It can be associated with radial nerve injury, especially if the fracture occurs in a spiral pattern at the groove where the nerve is normally located and traps the nerve. Most humerus fractures only require a sling and physical therapy.

If you experience pain in your shoulder or elbow that may be the result of a fracture, contact the Oklahoma Shoulder Center today to schedule an appointment.

Dislocations of the shoulder and elbow

The shoulder is the most commonly dislocated joint in the body. The shoulder joint has the most motion of any joint, which also means it has the least inherent natural stability of any joint. Joints like the hips and knees are more about supporting body weight rather than performing the range of activities that utilize the arm and shoulder, so they have less motion overall than the shoulder.

For most patients, shoulder dislocations occur through some type of trauma—a fall, car accident, or sports injury—where the arm is in a vulnerable position and then an applied force pops the shoulder out of place. More than 90% of dislocations are anterior, meaning the ball comes out to the front of the socket. Such injuries usually occur when the arm is in a position of abduction and external rotation, such as throwing a ball overhead.

The second most common type is posterior dislocation, or to the back of the socket. This type accounts for about 9% of dislocations and is frequently associated with seizure disorders where the patient’s muscles tighten during a seizure and push the shoulder to the back.

Less than 1% of shoulder dislocations are inferior dislocations that occur when the patient’s arm is straight up overhead with force applied. This type of injury might occur in surfers hit by a wave or if someone’s arms were up and pinned against a wall. It’s an uncommon but dangerous injury because a nerve or vascular injury can occur along with this particular type of dislocation.

Once a dislocation has occurred with trauma once, it can become a recurring problem that happens with a lesser amount of trauma in the future. In some patients with multiple dislocations, the shoulder can begin to dislocate during their sleep without any trauma.

In most cases, a first-time shoulder dislocation is treated non-operatively by immobilizing the shoulder in a sling for a week or two followed by physical therapy to restore motion and help balance the muscles for better stability. Therapy is also commonly used to treat partial dislocations, called subluxations, where the joint feels like it might come out but doesn’t go all the way.

Once a dislocation becomes recurrent, surgery is generally required. Although the specific type of surgery will vary depending on the type of dislocation and which structures have been torn or damaged, most can be done arthroscopically. Some patients have inherent hyperlaxity of their tissues, where joints naturally move farther than they should. If it becomes symptomatic, it usually responds to physical therapy. A small number of these patients may require stabilization by surgically tightening the capsule around the joint.

Elbow dislocations are much less common than shoulder dislocations, but the elbow can go out any direction. The most common type of dislocation, a posterior dislocation, is caused by a fall on outstretched hands. Typical treatment for elbow dislocation is immobilization in a sling for a week or two. Because elbows are not as prone to recurrent dislocation or instability as shoulders are, no further treatment is generally needed. In cases where an elbow dislocation is accompanied by certain types of fractures and/or ligament injuries, however, urgent surgery may be needed to stabilize the elbow.

It’s also possible to dislocate either end of the clavicle, commonly called the collarbone. At the sternoclavicular joint (the end of the collarbone in the center of your chest), it can dislocate to the front or the back. If the collarbone comes out to the front when dislocated, it generally doesn’t require surgery. However, if it dislocates to the back, which is much less common, it can be stuck under the sternum and pointing into the trachea, esophagus, and vessels as they come out of the heart to supply blood to the rest of the body and return blood from the rest of the body to the heart. When a clavicle dislocation to the back occurs, surgery is generally required to decrease risk to these vital structures.

The distal clavicle area of the shoulder typically separates, rather than dislocates. A distal clavicle separation is common in sports that may involve a direct hit on the top of the shoulder, such as football or soccer. While it can result in a cosmetic deformity from one end of the collarbone appearing more prominent, most of these injuries don’t require surgery and don’t cause any particular disability.

If you have experienced one-time or recurrent dislocation of the shoulder or elbow, contact the Oklahoma Shoulder Center today for more information and to schedule an appointment.

Can I go hunting after a shoulder replacement?

When working with patients who need a total shoulder replacement or reverse shoulder replacement, many patients ask if they will be able to hunt following their surgery. Other patients ask about returning to golf or other physically active hobbies. Still others have more questions about their ability to continue in a job that requires physical labor. Not many patients ask us whether they can return to riding a motorcycle, although we have an answer for that as well.

So what activities can you do (and not do) after a shoulder replacement?

When it comes to hunting, we advise patients to proceed with caution following their surgery but that they can still hunt. Certain types of guns can have a pretty decent kick, and the shoulder takes most of that impact. At this point in time, there’s no specific research to measure how that impact affects a replacement shoulder joint over time though. Dr. Nolan hopes to do a future study on the impact of hunting on shoulder replacement to fill that research gap, but for now, we simply don’t know what the impact is.

In the absence of research showing negative impact on shoulder implants, there’s no specific reason to avoid hunting once fully healed from surgery. Dr. Nolan has seen many patients who returned to hunting following their shoulder surgery, and these patients have not developed any implant-related issues over time.

Potential risk doesn’t just come from shotguns, as some handguns still kick and create pressure on the shoulder. Yet some professions, such as police officers, must regularly pass shooting qualifications and meet certain physical standards to continue in their job.

Other jobs that could be impacted by a shoulder replacement include those that require heavy lifting, especially overhead lifting. Some patients with physically demanding jobs choose to take a non-operative treatment approach to manage shoulder pain until they reach retirement age and can pursue replacement. Others who can’t avoid shoulder replacement any longer may need to change positions or request accommodations following surgery.

For golfers, there are no restrictions on returning to regular activity once fully recovered from surgery. However, most patients can expect full recovery to take about six months. There’s no research addressing whether tennis has an impact on replacement shoulder joints. If you played tennis prior to your surgery, you are likely fine to return to playing after recovery. But if you are picking up a new sport after surgery, it’s best to stick with lower impact sports overall that put less stress on your shoulder.

One category of activities we advise against following shoulder replacement surgery is any hobby or activity that could result in falling, such as riding a motorcycle, horseback riding, skiing, or even climbing ladders. Any fall can result in a significant injury, such as dislocating the shoulder, fracturing the area around the implant, or even breaking the implant. Revision surgeries to repair a damaged joint that has already been replaced are harder on the patient than the original surgery, and the outcomes are often not as good as the primary surgery. Thus, we advise people to avoid any activities that could result in a fall or accident that may cause damage to the shoulder.

Ultimately, all joint replacements surgeries are designed to help the individual with activities of daily living, or ADLs. More research is needed to determine how well joint replacements hold up to higher levels of activity over time, but until that research can be completed, remaining active while exercising reasonable caution is the best approach.