Traumatic Anterior Shoulder Dislocation

Epidemiology, Diagnosis, and Treatment

Background: Traumatic anterior shoulder dislocation is the most common type of joint dislocation, with an incidence of 11 to 29 per 100 000 persons per year. Controversy still surrounds the recommendations for treatment and the available procedures for surgical stabilization.

Methods: This review is based on pertinent publications (2014–2024) that were retrieved by a selective search in the PubMed and Google Scholar databases. Meta-analyses and randomized controlled trials (RCTs) with evidence levels I and II were included.

Results: The typical injury mechanism is forcible external rotation and abduction of the arm. The diagnosis is established by x-ray, which may be supplemented by magnetic resonance imaging (MRI) for the assessment of soft-tissue structures. The indication and type of surgical treatment depends on the patient’s age, sex, activity level, and concomitant injuries. For purely soft-tissue injuries, arthroscopic Bankart repair is an established treatment, with reported significant reduction in the rate of recurrent instability after follow-up periods of up to 12 years. An accompanying bony injury of the dorsal humeral head (Hill–Sachs lesion), depending on its extent, may be an indication for the arthroscopic Remplissage procedure: this can lower the rate of recurrence, but it can also cause a postoperative restriction of external rotation. In cases of chronic instability, an arthroscopic or open Latarjet procedure and bone grafting can be performed to augment the ventral glenoid articular surface. These procedures have likewise been reported to yield low rates of recurrent instability, but also higher complication rates.

Conclusion: The treatment of shoulder dislocation should be individually tailored. Although the reported results are promising, the evidence base remains weak. Prospective studies with larger case numbers are needed so that clear treatment algorithms can be established.

Cite this as:

Goth AP, Klug A, Gosheger G, Hiort ML, Akgün D, Schneider KN: Traumatic anterior shoulder dislocation: epidemiology, diagnosis, and treatment. Dtsch Arztebl Int 2025; 122: 89–95. DOI: 10.3238/arztebl.m2024.0254

Anterior shoulder dislocation is the most common form of joint dislocation. It occurs when the humeral head separates completely from the glenoid cavity. This dislocation is usually the result of an indirect force directed to the abducted and externally rotated arm. There are numerous treatment options for this type of dislocation. The present review article provides an updated summary of epidemiology, diagnostics, and conservative and operative treatment options for traumatic anterior shoulder dislocation.

Shoulder dislocations can arise from both traumatic events as well as physiological movements without any additional use of force (habitual dislocation). This article will deal exclusively with traumatic shoulder dislocations.

Methodology

A selective search of the literature was conducted using the search engines of the databases PubMed and Google Scholar. It included meta-analyses and randomized controlled trials (RCTs) with levels of evidence 1 and 2, published between January 2014 and November 2024.

The search terms used were “anterior traumatic shoulder dislocation” OR “ventral shoulder dislocation” OR “treatment options anterior shoulder dislocation.” The last database query was performed on 11.11.2024. The results were assessed by two independent investigators.

Epidemiology

Shoulder dislocation is the most common type of joint dislocation in the human body, with an incidence of 11 to 29 per 100 000 population per year (1). Although males are disproportionately involved at 71%, the two age peaks demonstrate different gender dominance:

• The first age peak is male-dominated, occurs between the ages of 20 and 29, and at 49% predominantly represents sports injuries sustained while participating in contact sports (2).
• The second age peak is female-dominated, less pronounced, and is due to stumbling from the age of 60 (2).

Classification

Anterior shoulder dislocation is the classic direction of dislocation with a frequency of 80 to 90% (Figure 1) (3). The typical mechanism of injury is a forceful external rotation and abduction of the involved arm (2). During the dislocation process, the humeral head is forced out of the glenoid cavity. This can result in an avulsion of the anterior labroligamentous structures (so-called Bankart lesion) or in a depression fracture of the posterior humeral head (Hill-Sachs lesion) (Figure 1) (2).

Figure 1

Anterior shoulder dislocation with bony Bankart lesion, Hill-Sachs lesion of the posterior humeral head, and capsule elongation

The Matsen classification has established itself for distinguishing between atraumatic and traumatic shoulder instability (4). The mnemonic TUBS summarizes traumatic instability: T for “Traumatic”, U for “Unilateral”, B for “Bankart lesion, S for “Surgical repair”. Operative treatment is recommended for recurrent dislocations (4). The classification does not include mixed forms. Another classification system developed by Gerber distinguishes between six types of instability (5). It also makes a specific distinction with respect to posttraumatic instability between unilateral instability with (B3) and without (B2) hyperlaxity (5).

Diagnostic investigations

Diagnosis involves case history, clinical examination, and imaging studies. When taking the history, mechanism of injury, previous dislocations, and patient activity level are decisive for further therapy planning (6). Clinical examination includes assessment of peripheral circulation, sensory and motor function since axillary nerve injury is possible after dislocation. This may be apparent in the form of reduction of strength on abduction and external rotation with hypesthesia of the lateral side of the shoulder (6).

Another important examination is to test stability, by applying the apprehension test for instance (Figure 2). A level 2 cohort study of this test demonstrated an association with a later risk of recurrence in the presence of a positive test results with an odds ratio (OR) of 4.29 (95% confidence interval: [1,13; 16,27]) (7).

Figure 2

Apprehension test

A detailed assessment of the rotator cuff is crucial, given that the incidence of associated injury is around 30% and increases with advancing age (8). Testing rotator cuff function starts with an assessment of the supraspinatus muscle using the Starter or Jobe test. Next, the posterosuperior components of the rotator cuff are checked (infraspinatus and teres minor muscles) for Hornblower’s sign. A positive Lift-off test is an indication of a subscapularis muscle tear (6).

Hyperlaxity is defined as joint play beyond the normal range of motion. This is evident at the shoulder as excessive translation of the humeral head against the glenoid (2). Hyperlaxity is considered a risk factor for recurrent dislocation and should be assessed using standard scores, such as the Beighton score (9).

Diagnostic investigation before and after reduction is achieved primarily by X-ray imaging to detect any major bony injuries (for example, disarticulation fracture) and associated injuries (including, amongst others, a bony Bankart lesion/Hill-Sachs lesion) as well as to document the dislocation itself and subsequent successful reduction. An orthograde view of the glenoid fossa is essential to detect posterior shoulder dislocation (10).

X-ray imaging should be obtained in at least two planes: anterior-posterior and a Y view. This should be supplemented by a third axial view, although this is often not possible due to pain (11).

A computed tomography (CT) scan is indicated for radiological evidence of fractures of the glenoid or humeral head and is particularly recommended in the event of recurrence (10).

Ultrasound of the shoulder joint is a dynamic and cost-effective examination, for which reason it is gaining in importance especially in times of short resources. It allows assessment of both Hill-Sachs lesions as well as the integrity of the rotator cuff (8).

A possible Bankart lesion and other associated injuries can be assessed by magnetic resonance imaging (MRI) (2). However, other studies have shown that injury to the anterior labrum is better detected by MRI arthrography (sensitivity 89% and specificity 95%) than by conventional MRI (sensitivity 48% and specificity 91%) (12).

Associated injuries and instability

The two most common injuries associated with traumatic shoulder dislocation are the Bankart lesion, which is reported in the literature as having an incidence of 18 to 100%, and the Hill-Sachs lesion, which is detected in 58 to 83% of all traumatic first-time shoulder dislocations and in 70 to 95% of all recurrent dislocations (Figure 1) (13).

Bankart lesion

A Bankart lesion can be a purely soft-tissue injury or a combined bony injury to the anteroinferior glenoid with avulsion of the anteroinferior labrum (13). A meta-analysis from 2022 demonstrated an increased rate of Bankart lesions in recurrent shoulder dislocations in comparison with first-time dislocations (85% versus 71%; p <0.01) (13).

Capsule elongation

There is increasing discussion about the impact of capsule elongation as an associated injury: In a recent postmortem study, Nolte et al. found that a first-time shoulder dislocation results in a mean increase in joint capsule elongation of 3.5% (p <0.01) (14). Weakening of static stabilizers, i.e., injury to the glenoid labrum, the joint capsule, the glenohumeral ligaments, the humeral head, and the glenoid, and elongation of the attached glenohumeral capsule can promote recurrent dislocations (15). Combination injuries involving labrum and capsule show an overall higher risk of recurrent dislocation than capsule or labral injuries alone (15).

Other potential injuries associated with anterior shoulder dislocation include a SLAP lesion (avulsion of the biceps tendon anchor complex at the anterosuperior glenoid) and an anterosuperior labral tear (an anterior labrum periosteal sleeve avulsion or ALPSA lesion), where the labrum is displaced medially and rotated inferiorly but still has bony attachment to the glenoid by the elevated periosteum (16).

Hill-Sachs lesion

A Hill-Sachs lesion is a bony depression on the dorsal humeral head secondary to a dislocation event. Depending on the position and extent of the Hill-Sachs lesion, the glenoid can slip into the Hill-Sachs lesion when the arm is externally rotated, resulting in instability which can cause the humeral head to easily slip back out of the glenoid fossa. In previous years, numerous studies have examined the effect of a Hill-Sachs lesion on recurrent instability and established the concepts of on-track (Figure 3) and off-track Hill-Sachs lesions (Figure 4) (17, 18).

Figure 3

On-track Hill-Sachs lesion with an associated bony Bankart lesion

Figure 4

Off-track Hill-Sachs lesion with an associated bony Bankart lesion

The off-track lesion is a defect in the humeral head which is larger than the area of contact between the humeral head and the glenoid (Figure 4). Here, there is a risk that the Hill-Sachs lesion will result in recurrent dislocation on external rotation of the arm when the humeral head slides off the glenoid. The off-track Hill-Sachs lesion is therefore a risk factor for redislocation (18).

There are a number of known risk factors for the development of an off-track lesion: Delgado et al. showed that age (under 20 years) at the time of the first dislocation event (OR 2.67, [1.2; 5.99], p <0.05) poses an increased risk for the development of an off-track lesion (18). Furthermore, the risk of an off-track lesion increases with each dislocation event by the 1.2 fold [1.025; 1.14], p <0.01). An interval of more than two years between the initial dislocation and surgery was identified as further risk factor (OR 2.42, [1.176; 4.608], p = 0.01) (18).

Initial therapeutic measures

The initial steps for suspected shoulder dislocation should include radiologic imaging studies before attempting reduction, as described above. If the affected person is not in pain, then an attempt at reduction may be made. There are various methods available for this which cannot be described in this article. They can be found, for example, in Echtermeyer et al. (2). A meta-analysis of the different reduction techniques was conducted by Dong et al. and shows that traction-countertraction methods are less painful than leverage methods (19).

The affected person should be positioned as comfortably as possible until reduction can be performed – supporting the arm in a sling can also contribute to pain relief until the reduction attempt.

Treatment

The goals of treatment are a stable shoulder joint with unrestricted range of motion and powerful functional capacity in everyday life as well as prevention of recurrent dislocation events. Treatment strategy depends on prognostically relevant factors such as patient age and activity level, the type of instability, and potential associated injuries. Treatment can be conservative or surgical, with immobilization after reduction being the first therapeutic step (2).

Position of immobilization

There is some controversy concerning the ideal position of immobilization (20, 21, 22). In a prospective study in 2003 involving 42 patients, Itoi et al. showed that redislocation rate was 0% in external rotation and 30% in internal rotation (20). An RCT conducted later found no significant difference in redislocation rate after immobilization in external rotation (31%) versus internal rotation (25%, p = 0.36) (21).

Notwithstanding these results, a meta-analysis by Hurley et al. from 2021 demonstrated that immobilization in external rotation results in a significant reduction of the redislocation rate (22.2% versus 33.4%, p = 0.02). An even more significant difference in redislocation rate was shown in patients between the ages of 20 and 40 years (12.1% versus 31.4%, p <0.01), which prompted the recommendation to provide immobilization in external rotation to patients under 40 years of age and conventional immobilization to patients over 40 (23).

Duration of immobilization

Following a recommendation of the S2-guideline “First-time Shoulder Dislocation”, immobilization can be provided for three to four weeks (24). The guideline is currently under review; the latest version is due for publication at the end of January 2025. A meta-analysis by Paterson et al., however, demonstrated no significant difference in redislocation rate and various durations of immobilization (≤ 1 week 41%, ≥ 3 weeks 37%, p = 0.52, [0.97; 2.45]) (25).

Conservative management

A conservative treatment approach may be considered for patients aged 30 and over with traumatic first-time shoulder dislocation. This involves initial immobilization and a specialized physiotherapeutic rehabilitation program. If in this case recurrent dislocation or signs and symptoms of instability due to subluxation arise despite at least six months of conservative management, then the indication for surgical stabilization is recommended (2). The risk of recurrent dislocation declines with increasing age. It is 24% in the fifth decade of life and 14% in the sixth decade (26).

Patients classified as Type B3 according to the Gerber classification system (unilateral instability with hyperlaxity) can benefit from a conservative treatment approach (1).

Surgical treatment

Indication for surgery

Surgical treatment is recommended for young physically active men in particular since they have a clearly higher risk for persistent instability after traumatic first-time dislocation than women (men 70.4% versus women 37.5% in the 5-year follow-up, p <0.01). Particularly men under 20 years of age had a higher redislocation rate at 80.2% than men over 25 years at 39.75% (Table 1) (27).

Table 1

Risk factors for recurrent dislocation

In a prospective trial with an average follow-up of 32 months (15 to 45 months), Arciero et al. showed a recurrence rate of 80% for conservative treatment and of 14.3% for surgical management (p <0.01) (28).

Other studies also returned similar results in their cohorts of young men. Here, DeBerardino et al. demonstrated a recurrence rate after surgical treatment of 12% (27). A further study by Kirkley et al. showed a recurrence rate for conservative treatment of 47% and of 15.9% for surgical management (p = 0.03) (29, 30). Another relevant risk factor and indication for surgical management is the presence of an off-track Hill-Sachs lesion (18).

Surgical treatment options

Surgical stabilization is usually achieved arthroscopically, although it can be performed as an open surgical procedure, depending on the patent’s history and defect size.

The arthroscopic Bankart repair reattaches the anterior labral complex to the glenoid (6). This showed a significant reduction of the instability rate in comparison with conservative treatment (31). However, there was residual instability in around 11.9% of patients (32). The Bankart plus procedure involves interposition of a bone matrix for smaller glenoid defects. No recurrence was found in the shorter term follow-up of 12 months (33).

The remplissage procedure is used for larger Hill-Sachs lesions, where augmentation is achieved using the posterolateral capsule (17). The long-term recurrence rate is 5.85% over 15 years (34). Temporary restriction of external rotation often returns to normal after two years (35). The arthroscopic Latarjet procedure involves transfer of the coracoid process to the glenoid for stabilization (Figure 5). Long-term persistent instabilities of 6.2% are reported. Serious complications such as nonunion are possible but rare (1.3 %) (36, 37).

Figure 5

Latarjet procedure with transfer of the coracoid process to the anterior glenoid rim as a therapeutic option for a glenoid defect and chronic traumatic shoulder instability

As an open surgical procedure, the Latarjet repair is employed primarily for chronic traumatic anterior shoulder instability (38). Long-term, it produces stable results with a redislocation rate of around 6%, often at the cost, however, of reduced external rotation (39, 40). The open Bankart procedure carries a higher risk of nerve injury, infection, and shoulder stiffness, but offers a comparable long-term recurrence rate of 11% (6, e1). A bone block transfer is employed for chronic shoulder instability with substantial glenoid defects. A bone graft (allograft or autograft) is used and can be inserted either open surgically or arthroscopically (e2, e3).

Long-term data reveal redislocation rates of 4 to 7%, although there is an increased risk of osteolysis and complications involving the donor site (e4, e5).

Table 2 provides a short overview of the most relevant literature. Table 3 offers a detailed list and comparison of the various surgical procedures.

Table 2

Meta-analyses on the treatment of anterior shoulder dislocation

Table 3

Overview of the most important surgical procedures with information about indication, implementation, results, complications, and long-term outcome

Treatment of children

There is no difference in initial therapeutic measures between children and adults. Timely reduction, if necessary under general anesthesia, should be undertaken to achieve rapid pain relief. There are differences in key steps of further management, however, which cannot be presented in this article. More information on this subject is available, for example, in the article “Traumatic Shoulder Dislocation in the Child” by Christoph Röder and Ralf Kraus (e6).

Conclusions

Dislocation of the shoulder is one of the most common joint dislocations of the body, with men being more often affected than women. A distinction in diagnosis is made between habitual and traumatic shoulder dislocation. Among the possible associated injuries, the Bankart lesion and Hill-Sachs lesion are of particular concern. A further subdivision of the Hill-Sachs lesion into the off-track and on-track lesion is just as necessary for risk assessment of recurrent dislocation and further management decisions as consideration of other concomitant injuries, the patient’s age, and sporting demands.

Conflict of interest statement

The authors declare that no conflict of interests exists.

Manuscript received on 24 August, 2024, revised version accepted on 17 December, 2024

Translated from the original German by Dr. Grahame Larkin

Corresponding author:
Dr. med. Anna Patricia Goth

BG Trauma Hospital

Department for Trauma and Orthopedic Surgery

Friedberger Landstrasse 430, 60389 Frankfurt am Main

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