G Model

OTSR-1121; No. of Pages 7 ARTICLE IN PRESS

Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx

Available online at

ScienceDirect
www.sciencedirect.com

Review article

Management of recent first-time anterior shoulder dislocations

F. Khiami ∗ , A. Gérometta , P. Loriaut
Service d’orthopédie et de traumatologie du sport du Pr Pascal-Moussellard, CHU Pitié Salpêtrière, 47-83, boulevard de l’Hôpital, 75013 Paris, France

a r t i c l e i n f o a b s t r a c t

Article history: The management of a first episode of anterior shoulder dislocation starts with an analysis of the causative
Accepted 6 June 2014 mechanism and a physical examination to establish the diagnosis. Based on the findings, the case can
be classified as simple or accompanied with complications, most notably vascular or nerve injuries. Two
Keywords: radiographs perpendicular to each other should be obtained to confirm the diagnosis then repeated after
Shoulder the reduction manoeuvres. Additional imaging studies may be needed to assess concomitant bony lesions
Anterior dislocation (impaction lesions or fractures). External reduction should always be attempted after premedication
Recurrent dislocation
appropriate for the severity of the pain. General anaesthesia may be necessary. There is no consensus
Rotator cuff
External immobilisation
regarding the optimal reduction technique, although the need for gentle manoeuvres that do not cause
pain is universally recognised. Immobilisation currently involves keeping the elbow by the side with the
arm internally rotated for 3–6 weeks depending on patient age. Vessel and nerve injuries are rare but can
cause major functional impairments. Follow-up evaluations are in order to check the recovery of normal
function, which may be more difficult to achieve in patients with concomitant lesions; and to detect
recurrent shoulder instability and rotator cuff lesions. At the acute phase, surgery is indicated only in
patients with complications or after failure of the reduction manoeuvres. Shoulder immobilisation with
the arm externally rotated and surgical treatment of the first episode are controversial strategies that are
discussed herein.
© 2014 Elsevier Masson SAS. All rights reserved.

1. Introduction followed by rehabilitation therapy. The efficacy of this treatment

Shoulder dislocation is a common reason for emergency room
visits and accounts for about 45% of all dislocations. Traumatic
shoulder dislocations are far more common than intentional and/or
non-traumatic forms, which are managed by rehabilitation ther-
apy and are not considered herein. Anterior shoulder dislocations
contribute 96% to 98% of all shoulder dislocations. The inci-
dence of first-time anterior shoulder dislocation ranges from 8 to
8.2/100,000 population/year and the prevalence is about 2% [1].
In 90% of cases, anterior shoulder dislocation affects young indi-
viduals, many of whom are athletes. The mechanism may be either
direct or indirect with a forward impulse of the elevated and exter-
nally rotated arm (e.g., during a basketball smash) or a fall on the
palm of the hand with the arm outstretched. The frequency of ante-
rior dislocation exhibits two peaks, during the second and sixth
decades, respectively. Men are affected 3 times more often than
women, and 9 out of 10 patients are 21 to 30 years of age.
The traditional treatment for anterior shoulder dislocation is
immobilisation with the arm in internal rotation for 3 to 6 weeks
remains unclear. The recurrence rate can reach 95% depending on
the risk factors, particularly patient age at the first episode. Chronic
shoulder instability can cause pain, which is often dependent on
position; require a change in sporting activities or impair perfor-
mance; and, more generally, adversely affect quality of life [1].
All the newly introduced techniques focus on preventing recurr-
ences. Immobilisation with the arm in external rotation after the
first episode has been suggested based on magnetic resonance
imaging (MRI) studies showing that external rotation increases the
amount of tension on the sub-scapularis muscle and maintains
the labrum and capsule in close contact with the glenoid. Early
arthroscopy has been advocated under the hypothesis that early
repair of the glenoid labrum and joint capsule improves healing of
these structures. The impact of these innovations on outcomes is
uncertain.
The objective of this work was to identify the points of the man-
agement of anterior shoulder dislocation for which a consensus
exists and to review recently suggested treatments.
2. Clinical diagnosis

∗ Corresponding author. Tel.: +33 1 42 17 70 49. Anterior shoulder dislocation usually occurs when abduction
E-mail address: frederic.khiami@psl.aphp.fr (F. Khiami). with external rotation of the arm produces a force that displaces

http://dx.doi.org/10.1016/j.otsr.2014.06.027
1877-0568/© 2014 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Khiami F, et al. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol
Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2014.06.027
G Model
OTSR-1121; No. of Pages 7 ARTICLE IN PRESS
2 F. Khiami et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
the humeral head anteriorly and downwards relative to the cora-
coid process (sub-coracoid dislocation). The other forms are less
common (sub-glenoid, sub-clavicular [infra-coracoid] and intra-
thoracic dislocations).
The patient supports the injured arm with the hand of the
uninjured side. Signs that suggest anterior dislocation include a
squared-off appearance of the shoulder with loss of the normal
rounded contour, bulging of the acromion, and filling of the delto-
pectoral groove. Palpation shows an empty glenoid and a bulge
in the delto-pectoral groove. The arm is abducted and cannot be
actively or passively moved into adduction.
The initial examination should include testing for injury to the
axillary nerve or brachial plexus (sensation from the point of the
shoulder to the fingers and simple motor function testing) and
blood vessels (temperature and colour of the skin over the fingers
and palpation of the distal pulses).
The findings from the physical examination should be recorded
in the patient’s medical chart.
3. Diagnostic investigations
Both an antero-posterior and a lateral radiographic view should
be obtained. The lateral view is helpful in minimally displaced dis-
locations. It shows the direction of the dislocation and can help to
detect concomitant lesions (fracture or impaction lesion). The axil-
lary view and Y view require mobilisation of the shoulder and are
therefore not appropriate. Lamy’s or Neer’s view can be obtained
without mobilisation and show the direction of the dislocation
while clearly delineating the base of the coracoid process and acro-
mial vault. Garth’s view shows any postero-superior Hill–Sachs
lesions and allows an evaluation of the anterior part of the glenoid.
Obtaining additional investigations causes unnecessary delays in
reducing the dislocation. Once reduction has been achieved, fur-
ther investigations can be obtained on a case-by-case basis to look
for concomitant lesions. Computed tomography (CT) offers the best
accuracy and sensitivity for detecting and evaluating a fracture and
for assessing the extent of impaction damage.
4. Reduction
Reduction can be considered once the patient has received
effective pain relief, as well as reassurance and information. The
patient should be comfortably settled in a quiet place. The reduc-
tion manoeuvres should be gentle and gradual to minimise muscle
spasm.
Reduction manoeuvres fall into two main categories, with many
variants, according to whether counter support on the axilla is used.
A full description of these manoeuvres is beyond the scope of this
article. Details are available in an article by Cunningham [2].
Reduction methods without counter support include the Hippo-
cratic method (simple traction along the axis of the arm); Kocher
method (slight adduction, elbow flexed at 90◦ , gradually move
the arm into external rotation then elevate the arm and rotate it
medially), which is less painful; Stimson method (the patient is
prone with the arm hanging down and a weight attached to the
wrist); Milch method (with the patient’s hands behind the head),
which may be very easy to perform even by inexperienced physi-
cians; and scapular manipulation methods (Bosley and Miles), the
Eskimo method, and self-reduction by having the patient lock the
hands around the ipsilateral knee. Among methods that use counter
support on the axilla, the most widely known are variants of the
Hippocratic method, which use a sheet (Matsen method), the oper-
ator’s fist or foot (Oribase technique with the heel in the axilla, now
discarded), or the back of a chair.
Please cite this article in press as: Khiami F, et al. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol
Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2014.06.027
Reduction can be attempted without analgesia in patients with
moderate pain. Otherwise, analgesics should be given to obtain
muscle relaxation and good participation of the patient. Various
analgesic protocols are used (inhaled or parenteral sedation or even
opiates used alone subcutaneously or with titration). Intra-articular
lidocaine injection has been reported to allow reduction in 81% of
patients and to decrease the hospital stay length and complication
rate compared to intravenous medication [3].
5. Post-reduction management
An antero-posterior radiograph should be obtained to confirm
that complete reduction has been achieved and to look for con-
comitant lesions, whose evaluation is mandatory to ensure optimal
treatment. In a study of lesions not seen on pre-reduction radio-
graphs, Kahn et al. found that 37.5% of fractures were visible only
on radiographs obtained after reduction [4].
A non-displaced fracture of the humeral head requires care dur-
ing the reduction manoeuvre to avoid disimpaction. The greater
tuberosity of the humerus or glenoid may be fractured. These frac-
tures may require surgical fixation, either immediately or on a
semi-emergent basis. The rest of the management strategy depends
on whether complications are present.
5.1. Uncomplicated dislocation: conventional conservative
treatment
After reduction, the patient should be re-evaluated for nerve and
vessel injuries as described for the initial examination. The shoulder
is usually immobilised in a swath with the elbow by the side and the
arm in internal rotation. Simple analgesics and the local application
of ice packs rapidly provide effective pain relief.
The final treatment strategy is determined based on the results
of a follow-up evaluation 5 to 8 days after the reduction. The dura-
tion of immobilisation ranges from a few days in patients older than
40 years of age to 4 to 6 weeks in young patients experiencing their
first dislocation episode. The patient should be advised about mon-
itoring the shoulder and informed about the main complications
(dominated by early recurrence despite immobilisation) [5].
5.2. Complicated dislocation
5.2.1. Neurologic complications
Neurologic complications are common but under-estimated.
Neurapraxia is usually followed by a full recovery. Tearing of nerves
is considerably less common (fewer than 4% of cases). The axillary
and supra-scapular nerves are at greatest risk for tearing. In a study
of 101 patients, De Laat et al. [6] found electromyographic evidence
of nerve injury in 45% of cases (axillary nerve, n = 37; supra-scapular
nerve, n = 29; radial nerve, n = 22; musculo-cutaneous nerve, n = 19;
and ulnar nerve, n = 8). Other studies found nerve injuries in 21% to
36% of patients, with involvement of the plexus in 12% of cases and
isolated axillary nerve injury in 8% of cases [7]. Robinson et al. [8]
found neurologic deficits in 13.5% of 3633 patients. A concomitant
rotator cuff tear or greater tuberosity fracture increases the risk
of nerve injury (relative risk, 1.9), most notably among patients
older than 60 years of age [6]. The “terrible triad” is the concomi-
tant presence in an elderly patient of shoulder dislocation, rotator
cuff tear, and brachial plexus damage. This presentation requires
prompt MRI of the shoulder and cervical spine.
Severe nerve damage mandates close monitoring and spe-
cialised management, including a baseline electromyogram within
the first 3 weeks and, if appropriate, MRI of the cervical spine to
look for lesions of the plexus (or nerve root avulsions) in patients
with very severe signs.
G Model
OTSR-1121; No. of Pages 7 ARTICLE IN PRESS
F. Khiami et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
Most neurological abnormalities resolve spontaneously. How-
ever, residual impairments may require surgery. In particular,
surgery is warranted in patients with complete and isolated loss of
axillary nerve function that does not recover within 3 to 6 months.
In a study of outcomes of 35 patients with isolated axillary nerve
injuries, most of which were tears, only 20% of patients recovered
spontaneously and the remaining 80% required surgical treatment
[9]. Kosiyatrakul et al. [10] reported that brachial plexus injuries
recovered fully in two-thirds of patients. Spontaneous recovery was
consistently good or excellent after 20 months, with the only resid-
ual impairments involving the intrinsic hand muscles, particularly
in elderly patients.
5.2.2. Vascular complications
Fewer than 1% of patients experience vascular complications.
The risk is greatest in fracture-dislocation of the humeral head
and in elderly patients with pre-existing arterial disease. Arterial
lesions include tears, thrombosis after dissection of the intima, and
pseudo-aneurysm, often along the distal third of the axillary artery.
Arterial spasm occurs in as many as 60% of patients and resolves
once the compression is lifted.
Patients with distal ischaemia should be evaluated immedi-
ately by a vascular surgeon and scheduled for routine angiography,
which should not delay the reduction. In patients with fracture-
dislocations that may require open reduction, both an orthopaedic
and a vascular surgical team should perform the procedure.
5.2.3. Concomitant fractures
A concomitant fracture complicates the management of shoul-
der dislocation by making the reduction manoeuvres more
challenging to perform. Internal fixation may be required. The most
common fracture sites are the humeral neck, greater tuberosity, and
glenoid.
5.2.3.1. Fractures of the humeral neck. These fractures must be
detected before reduction is performed. There may be a con-
comitant fracture of the greater tuberosity, which should draw
attention, as described by Hersche et Gerber [11]. Disimpaction
of the humeral head fracture is followed by avascular necrosis of
the head. Although immediate open surgery with internal fixation
before reduction of the dislocation has been advocated, the most
widely recommended strategy is attempted, gentle, closed reduc-
tion under anaesthesia, followed by conversion to open surgery if
the dislocation cannot be readily reduced. The strategy for treat-
ing the fracture is determined once reduction has been obtained,
according to the degree of displacement and age of the patient.
5.2.3.2. Fracture of the greater tuberosity. It includes:
• non-displaced fracture: conservative treatment is in order, with
radiographic monitoring to detect possible secondary displace-
ment;
• displacement of 5 mm of more after reduction: internal fixation
should be considered, particularly in patients who are young
and/or have high functional demands [12,13], although some
authors tolerate displacements of up to 10 mm;
• recurrent dislocation after reduction (intractable dislocation):
internal fixation of the greater tuberosity is mandatory to stabilise
the shoulder [14].
5.2.3.3. Fractures of the anterior glenoid. Anterior glenoid fractures
are another cause of recurrent dislocation after reduction. CT pro-
vides an accurate evaluation [location and size of the detached
fragment(s)]. Internal fixation may required irreducible dislocation
and/or to restore normal glenoid anatomy via the delto-pectoral
approach, by screw implantation. Internal fixation of comminuted
Please cite this article in press as: Khiami F, et al. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol
Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2014.06.027
3
fractures may be challenging. Creation of an abutment anterior to
the glenoid is rarely needed.
5.2.4. Irreducible dislocations
Few shoulder dislocations are irreducible after deep anaesthe-
sia with full muscle relaxation. Open reduction is only very rarely
required.
Causes of irreducibility include:
• incarceration of the humeral head in the glenoid rim;
• interposition of the torn sub-scapularis tendon [15];
• fracture of the greater tuberosity with incarceration [16];
• glenoid fracture with incarceration [17];
• interposition of the long biceps tendon, which passes behind the
humeral head as a result of a greater tuberosity fracture and pre-
vents the reduction; the tendon must be repositioned anterior to
the humeral head and the greater tuberosity stabilized by internal
fixation [18];
• a massive rotator cuff tear with incarceration [19].
5.3. Dislocation in patients older than 40 years
Shoulder dislocation in patients older than 40 years requires
special attention because rotator cuff damage is common and
increases with advancing age [20]. A careful evaluation for rotator
cuff lesions is therefore mandatory. Early MRI has been recom-
mended in patients older than 40 years, given the 35% prevalence
of rotator cuff tears in this population, with an increase over time
to over 80% after 60 years of age [21]. Whatever the case, persis-
tent functional impairment after rehabilitation therapy in a patient
without neurological abnormalities requires an evaluation of the
rotator cuff, particularly in patients older than 40 years of age. The
rotator cuff lesions vary widely. After a shoulder dislocation, ante-
rior extension of a rotator cuff tear to the sub-scapularis tendon
carries a very poor prognosis [22].
5.4. Results of conventional conservative treatment
Several case-series studies found high recurrence rates of up
to 95% (Tables 1–4). Hovelius et al. evaluated a cohort of patients
25 years after treatment with immobilisation in internal rotation
or no immobilisation and found that the shoulder was stable in
only 43% of cases [23]. Surgical stabilisation was required in only
27% of cases, but the rate of moderate-to-severe osteoarthritis
after 10 years was nearly 20%. The 60% rate of instability and 20%
rate of osteoarthritis after 10 years call into question the validity
of this treatment strategy. Furthermore, among patients who did
not experience recurrent dislocation, the proportion with forgotten
shoulder was not determined.
In all the available case-series studies, patient age at the first
dislocation episode was the main risk factor for recurrence, most
notably before 20 years of age (Tables 1–4). In patients younger
than 18 years at the first episode, the risk of recurrence within 1
year is about 77%, and only 32% have a stable shoulder 10 years later
[47]. Rowe and Sakellarides [48] reported that 87% of recurrences
occurred within the first 2 years, particularly in younger patients.
In addition to young patients, those who engage in contact
sports or athletic competitions are at high risk for recurrent
shoulder dislocation [49]. Severe impaction damage during the dis-
location is another risk factor.
Interestingly, 43% of patients in the case-series study by Hov-
elius et al. [23] had no recurrences. Thus, routine immediate
surgical stabilisation after the first episode would have resulted
in unnecessary surgery in 43% of cases.
However, absence of recurrent dislocation is not synonymous
with forgotten shoulder. Many patients have low-level pain and
G Model
OTSR-1121; No. of Pages 7 ARTICLE IN PRESS
4 F. Khiami et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx

Table 1
Recurrence rate after classical conservative treatment.

Author Level of evidence Type of treatment n Age (years) Recurrence rate (%) Secondary stabilisation (%) Follow-up (years)

Robinson et al. [24] I Conservative 252 15–35 56 2

67 5
< 30 54 2
> 30 29
Bottoni et al. [25] I Conservative 14 18–26 75 3
Lawton et al. [26] IV Conservative 70 < 16 40 >2
Deitch et al. [27] IV Conservative 32 11–18 75 >2
Rowe et al. [28] IV Conservative 313 < 20 80 5
> 40 16
> 50 12
Hovelius et al. [23] I Conservative 229 12–40 57 25
Hovelius et al. [29] I Conservative 247 12–40 48 23 10
12–22 58
30–40 14
Postacchini et al. [30] Retrospective Conservative 28 12–17 86 7
< 13 33
> 14–17 92

Table 2
Comparison of outcomes after immobilisation in internal versus external rotation.

Author Level of evidence Type of treatment n Age (years) Recurrence (%) Follow-up (months)

Itoi et al. [31] I External rotation 40 17–84 0 15

Internal rotation 30
External rotation < 30 0
Internal rotation 45
Itoi et al. [32] II External rotation 198 26 24
Internal rotation 42
Tanaka et al. [33] Prospective External rotation 11 17–26 64 24
Taşkoparan et al. [34] Prospective External rotation 16 35 (21–75) 6 24
Internal rotation 17 29 (15–68) 29
Finestone et al. [35] Prospective External rotation 27 17–27 37 33
Internal rotation 24 42
Liavaag et al. [36] Prospective External rotation 93 27 25 24
Randomised Internal rotation 95 31
Paterson et al. [37] II External rotation 25
Meta-analysis Internal rotation 40

Table 3
Comparison of outcomes after conservative treatment according to immobilisation duration.

Author Level of Type of treatment n Age (years) Recurrence rate (%) Follow-up (years)
evidence

Scheibel et al. [38] II External rotation 3 weeks 11 37 17

External rotation 5 weeks 11 30 15
Smith [39] Literature No consensus on immobilisation duration or position
review
Kiviluoto et al. [40] Prospective 1 week 53 < 30 50 1
3 weeks 22
Maeda et al. [41] Retrospective Immobilisation 0–3 weeks in internal rotation 61 14–23 85 2
Immobilisation 4–7 weeks in internal rotation 18 69
Hovelius et al. [29] Prospective Internal rotation 1 week 68 < 30 59 10
Internal rotation 4 weeks 65 67
Paterson et al. [37] II 3 weeks or more < 30 37
Meta-analysis
1 week or less 41
Robinson et al. [24] Prospective Internal rotation 4 weeks 252 15–35 67 5

Table 4
Comparison of recurrence rates after conservative treatment versus surgery.

Author Level of evidence Type of treatment n Age (years) Recurrence rate (%) Follow-up

Larrain et al. [42] Prospective not randomises Surgical 46 21 (17–27) 4 67 months

Conservative 94.5
Jakobsen et al. [43] I Surgical 37 15–39 3 2 years
Conservative 39 56
Kirkley et al. [1] II Surgical 40 23.3 18 79 months
Conservative 22.7 60
Law et al. [44] IV Surgical 38 21 (16–30) 5.2 28 months
Owens [45] IV Surgical 40 14.3 12 years
Brophy and Marx [46] Literature review Surgical 7 2 years
Conservative 46
Bottoni et al. [25] I Conservative 14 18–26 75 3 years
Arthroscopic 10 11

Please cite this article in press as: Khiami F, et al. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol
Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2014.06.027
G Model
OTSR-1121; No. of Pages 7 ARTICLE IN PRESS
F. Khiami et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
instability with missed shoulder instability events. Furthermore,
some patients experience residual apprehension that leads them
to limit their sporting and recreational activities, resulting in subtle
but meaningful functional impairment [1].
6. Immobilisation in external rotation
The concept of immobilisation with the arm in external rota-
tion to treat first-time shoulder dislocation was developed in the
late 1990s. External rotation is intended to put tension on the sub-
scapularis, thereby keeping the joint capsule and labrum in close
contact with the anterior aspect of the glenoid.
A study of ten fresh cadaver shoulders conducted by Itoi et al.
and reported in 1999 showed that the edges of a simulated Bankart
lesion were coapted when the arm was in external rotation [49].
In this position, the sub-scapularis muscle is under tension and
applies a force that presses the joint capsule against the neck of
the glenoid. Each shoulder was moved from internal rotation to
external rotation in 10◦ steps. The force applying the labrum to the
glenoid was greatest when the arm was in 45◦ of external rotation.
However, opposite results were obtained in cadaver studies done
to evaluate this conclusion [50]. The in vitro design is the major
limitation of these studies and probably explains the contradictory
results.
Reduction of the capsular lesion has been investigated in vivo
using MRI [51]. The arm was positioned in internal rotation then in
external rotation. Several studies demonstrated that the capsular
detachment was less marked in external rotation [52].
Hart et al. [53] used arthroscopy to assess Bankart lesion reduc-
tion in 25 patients aged 15 to 57 years after a first episode of anterior
shoulder dislocation. Reduction of the Bankart lesion was improved
in external rotation in 92% of patients. However, reduction was usu-
ally incomplete and the labrum failed to recover a fully normal
position.
Despite these somewhat promising observations, results in
terms of the recurrence rate are controversial (Table 2). Some of
the preliminary studies seem encouraging but others are far less so.
These discrepancies may be ascribable to differences in the study
populations (number of patients, mean age, nature and level of
sporting activities, observation bias, and bias related to differences
across shoulder immobilisers).
The recurrence rate increases over time and tends to become
similar to that seen after conventional treatment [35]. Adherence
is only fair and the position is poorly tolerated. Thus, no definitive
conclusions can be drawn about potential benefits from immobi-
lisation in external rotation. There is no consensus about the use
of immobilisers that maintain the arm in pure external rotation
or in external rotation and abduction, and the optimal degree of
external rotation is debated [54,55]. Combined external rotation
and abduction seems significantly less comfortable.
Conservative treatment remains widely used. In patients with
recurrent dislocation, the duration of immobilisation is short and
rehabilitation is started to prevent stiffness, particularly in elderly
patients [40]. Immobilisation in internal rotation remains the refer-
ence standard; immobilisation in external rotation generated initial
enthusiasm but has since then shown limitations. To date, there is
no scientific proof that a specific immobilisation position or dura-
tion is better over the others.
Conservative treatment is always inadequate in younger
patients, who are at greatest risk for recurrent dislocation occur-
ring early after the first episode. Furthermore, although about 40%
of patients experience no recurrences after a first episode of shoul-
der dislocation [23], many do not achieve the status of forgotten
shoulder [1].
Please cite this article in press as: Khiami F, et al. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol
Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2014.06.027
5
7. Surgery for first-time shoulder dislocation
The high risk of recurrence after conservative treatment has led
to the suggestion that surgical treatment may be in order, particu-
larly in young athletes. Numerous comparative studies support the
efficacy of surgical treatment.
Arthroscopic lavage has been suggested to eliminate the
haemarthrosis and promote normal positioning of the capsule-
labral complex on the glenoid [56]. Although this procedure proved
beneficial, the improvement was small and left a high risk of recur-
rence. Thus, arthroscopic lavage remains controversial.
The published data leave no room for doubt (Table 4): recurrence
rates are significantly lower after open or arthroscopic surgical sta-
bilisation than after any of the available conservative treatments.
Despite these results, the increasingly common use of surgery
for first-time dislocations has received criticism. It is worth recall-
ing the findings by Hovelius et al. [23]:
• 43% of patients experienced no recurrences during a 25-year
follow-up;
• in 14% of patients, the shoulder became stable over time, with two
recurrences within the first 15 years then no further recurrences
during the next 10 years;
• among patients managed non-surgically and younger than
25 years of age, half experienced no recurrences.
Thus, surgery would have been unnecessary in 30% of patients
younger than 25 years. Routine surgery in patients with first-time
shoulder dislocation therefore constitutes overtreatment, and sur-
geons must select patients who are good candidates for early
surgery.
Although early surgery considerably diminishes the risk of
recurrence compared to conventional conservative therapy, the
outcomes are similar to those of surgery for chronic shoulder insta-
bility (Table 4). There is therefore no sound rationale for routinely
performing immediate surgery in patients with first-time shoulder
dislocation.
Kirkley et al. [1] raised the relevant issue of whether a patient
can be left to suffer from residual symptoms after a first dislocation
episode and offered stabilisation only in the event of a recurrence.
An alternative would be immediate surgical stabilisation to prevent
these “small” derangements, whose resolution would undoubt-
edly improve the functional outcomes of conservative treatment.
Kirkley et al. evaluated short-term quality of life in two groups
of patients, one treated conservatively and the other surgically.
The Western Ontario Shoulder Instability (WOSI) index was 69%
after conservative treatment and 86.3% after surgery. Early surgery
decreased the recurrence rate and improved quality of life (WOSI).
These data supporting early surgery deserve to be borne in mind.
The results of other studies [43] indicate that, in the absence
of recurrent dislocation, the proportion of patients with residual
apprehension is increased 6-fold after conservative treatment com-
pared to surgical treatment and the proportion with good function
is decreased 3-fold. Law et al. [44] reported a mean WOSI index of
83% after arthroscopic capsule-labral suturing for first-time shoul-
der dislocation. This improvement in quality of life is a major
argument in favour of early surgical treatment.
Finally, whereas surgery is superior by far over conservative
treatment, no difference has been found between conventional
surgery and arthroscopic surgery [46].
These data explain that the results of a survey showing that 35%
of British surgeons performed surgery to treat first-time shoul-
der dislocation in young individuals, with 16% of surgeons using
the arthroscopic technique. A similar survey, done 7 years later,
showed a 2-fold increase in the number of surgeons who were in
G Model
OTSR-1121; No. of Pages 7 ARTICLE IN PRESS
6 F. Khiami et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
favour of immediate surgical stabilisation, with a 4-fold increase in
the use of arthroscopy [57].
8. Conclusion
Conservative treatment is extremely controversial. The tradi-
tional immobilisation method with the arm in internal rotation has
well-documented limitations. Furthermore, the 3 to 6-week dura-
tion of immobilisation is not universally agreed on [29], and a trend
towards shorter immobilisation is emerging [58,59]. In contrast, the
need for early mobilisation in elderly patients to prevent stiffness
is widely recognised [40].
The second major issue is the very high recurrence rate after a
first episode of shoulder dislocation in young patients. The data on
this point are consistent, with recurrences in up to 95% of patients.
In addition, in the absence of recurrence, pain and apprehension
are common and may lead to a change in athletic activities or even
to discontinuation of all sports [1].
The early results of case-series studies of immobilisation with
the arm in external rotation were promising. However, longer
follow-ups showed an increase in the recurrence rate over time
[31,32,35,49]. In addition to the decline in the quality of the results
with increasing follow-up, treatment adherence was suboptimal,
as the position induced discomfort.
The development of arthroscopic techniques has encouraged
the use of surgical treatment [57]. Early surgery considerably
decreases the recurrence rate and improves the functional out-
comes. Thus, there is a current trend towards a broadening of the
indications of early surgery, regardless of the technique used, most
notably in young patients, who are at highest risk for recurrence
and residual impairments, with a 20% rate of osteoarthritis after
10 years [29].
Whether early surgery should be offered to all patients after
a first episode of anterior shoulder dislocation remains debated.
Kim et al. reported that the proportion of patients with capsulo-
labral lesions visible by MRI was 66% in a cohort of patients with
first-time shoulder dislocation and 98% in a cohort with recurrent
dislocation [60]. The group with recurrences had a 3-fold increase
in the rate of Bankart lesions and a greater number of Hill–Sachs
lesions. Progression to chronicity was associated with a significant
increase in the number and severity of impaction lesions. These
findings support greater use of surgical treatment.
Decision tools are lacking to guide surgeons in their treatment
decisions and to help patients understand the best treatment strat-
egy. At present, the only option consists of informing the patient
and family of the treatment issues and in helping them make
their decision according to their academic or occupational com-
mitments, desire to resume athletic activities and, when relevant,
schedule of competitions [24].
Disclosure of interest
The authors declare that they have no conflicts of interest con-
cerning this article.
References
[1] Kirkley A, Werstine R, Ratjek A, Griffin S. Prospective randomized clinical trial
comparing the effectiveness of immediate arthroscopic stabilization versus
immobilization and rehabilitation in first traumatic anterior dislocations of the
shoulder: long-term evaluation. Arthrosc J Arthrosc Relat Surg 2005;21:55–63.
[2] Cunningham NJ. Techniques for reduction of anteroinferior shoulder disloca-
tion. Emerg Med Australas 2005;17:463–71.
[3] Cheok CY, Mohamad JA, Ahmad TS. Pain relief for reduction of acute anterior
shoulder dislocations: a prospective randomized study comparing intravenous
sedation with intra-articular lidocaine. J Orthop Trauma 2011;25:5–10.
[4] Kahn JH, Mehta SD. The role of post-reduction radiographs after shoulder dis-
location. J Emerg Med 2007;33:169–73.
Please cite this article in press as: Khiami F, et al. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol
Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2014.06.027
[5] Robinson CM, Kelly M, Wakefield AE. Redislocation of the shoulder during the
first six weeks after a primary anterior dislocation: risk factors and results of
treatment. J Bone Joint Surg Am 2002;84–A:1552–9.
[6] De Laat EA, Visser CP, Coene LN, Pahlplatz PV, Tavy DL. Nerve lesions in primary
shoulder dislocations and humeral neck fractures. A prospective clinical and
EMG study. J Bone Joint Surg Br 1994;76:381–3.
[7] Pasila M, Jaroma H, Kiviluoto O, Sundholm A. Early complications of primary
shoulder dislocations. Acta Orthop Scand 1978;49:260–3.
[8] Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with
traumatic anterior glenohumeral dislocations. J Bone Joint Surg Am 2012;94:
18–26.
[9] Alnot JY, Liverneaux P, Silberman O. [Lesions to the axillary nerve]. Rev Chir
Orthop Reparatrice Appar Mot 1996;82:579–89.
[10] Kosiyatrakul A, Jitprapaikulsarn S, Durand S, Oberlin C. Recovery of brachial
plexus injury after shoulder dislocation. Injury 2009;40:1327–9.
[11] Hersche O, Gerber C. Iatrogenic displacement of fracture-dislocations of the
shoulder. A report of seven cases. J Bone Joint Surg Br 1994;76:30–3.
[12] Platzer P, Kutscha-Lissberg F, Lehr S, Vecsei V, Gaebler C. The influence of dis-
placement on shoulder function in patients with minimally displaced fractures
of the greater tuberosity. Injury 2005;36:1185–9.
[13] George MS. Fractures of the greater tuberosity of the humerus. J Am Acad
Orthop Surg 2007;15:607–13.
[14] Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open
reduction and internal fixation of two-part displaced fractures of the greater
tuberosity of the proximal part of the humerus. J Bone Joint Surg Am
1991;73:1213–8.
[15] Connolly S, Ritchie D, Sinopidis C, Brownson P, Aniq H. Irreducible anterior
dislocation of the shoulder due to soft tissue interposition of subscapularis
tendon. Skeletal Radiol 2008;37:63–5.
[16] Ilahi OA. Irreducible anterior shoulder dislocation with fracture of the greater
tuberosity. Am J Orthop 1998;27:576–8.
[17] Mihata T, Doi M, Abe M. Irreducible acute anterior dislocation of the shoul-
der caused by interposed fragment of the anterior glenoid rim. J Orthop Sci
2000;5:404–6.
[18] Inao S, Hirayama T, Takemitsu Y. Irreducible acute anterior dislocation of the
shoulder: interposed bicipital tendon. J Bone Joint Surg Br 1990;72:1079–80.
[19] Vichard P, Bellanger P, Watelet F. Irreducible shoulder dislocation caused
by interposition of the rotator cuff. Apropos of 2 cases. Acta Orthop Belg
1981;47:113–22.
[20] Murthi AM, Ramirez MA. Shoulder dislocation in the older patient. J Am Acad
Orthop Surg 2012;20:615–22.
[21] Rumian A, Coffey D, Fogerty S, Hackney R. Acute first-time shoulder dislocation.
Orthop Trauma 2011;25:363–8.
[22] Rapariz JM, Martin-Martin S, Pareja-Bezares A, Ortega-Klein J. Shoulder dislo-
cation in patients older than 60 years of age. Int J Shoulder Surg 2010;4:88–92.
[23] Hovelius L, Olofsson A, Sandström B, Augustini B-G, Krantz L, Fredin H, et al.
Nonoperative treatment of primary anterior shoulder dislocation in patients
forty years of age and younger. a prospective twenty-five-year follow-up. J
Bone Joint Surg Am 2008;90:945–52.
[24] Robinson CM, Howes J, Murdoch H, Will E, Graham C. Functional outcome and
risk of recurrent instability after primary traumatic anterior shoulder disloca-
tion in young patients. J Bone Joint Surg Am 2006;88:2326–36.
[25] Bottoni CR, Wilckens JH, DeBerardino TM, D’Alleyrand J-CG, Rooney RC,
Harpstrite JK, et al. A prospective, randomized evaluation of arthroscopic sta-
bilization versus nonoperative treatment in patients with acute, traumatic,
first-time shoulder dislocations. Am J Sports Med 2002;30:576–80.
[26] Lawton RL, Choudhury S, Mansat P, Cofield RH, Stans AA. Pediatric shoulder
instability: presentation, findings, treatment, and outcomes. J Pediatr Orthop
2002;22:52–61.
[27] Deitch J, Mehlman CT, Foad SL, Obbehat A, Mallory M. Traumatic anterior shoul-
der dislocation in adolescents. Am J Sports Med 2003;31:758–63.
[28] Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am
1956;38–A:957–77.
[29] Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary
anterior dislocation of the shoulder in young patients. A ten-year prospective
study. J Bone Joint Surg Am 1996;78:1677–84.
[30] Postacchini F, Gumina S, Cinotti G. Anterior shoulder dislocation in adolescents.
J Shoulder Elb Surg Am 2000;9:470–4.
[31] Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I, et al. A new
method of immobilization after traumatic anterior dislocation of the shoulder:
a preliminary study. J Shoulder Elb Surg Am 2003;12:413–5.
[32] Itoi E, Hatakeyama Y, Sato T, Kido T, Minagawa H, Yamamoto N, et al.
Immobilization in external rotation after shoulder dislocation reduces the
risk of recurrence. A randomized controlled trial. J Bone Joint Surg Am
2007;89:2124–31.
[33] Tanaka Y, Okamura K, Imai T. Effectiveness of external rotation immobiliza-
tion in highly active young men with traumatic primary anterior shoulder
dislocation or subluxation. Orthopedics 2010;33:670.
[34] Taşkoparan H, Kılınçoğlu V, Tunay S, Bilgiç S, Yurttaş Y, Kömürcü M. Immo-
bilization of the shoulder in external rotation for prevention of recurrence in
acute anterior dislocation. Acta Orthop Traumatol 2010;44:278–84.
[35] Finestone A, Milgrom C, Radeva-Petrova DR, Rath E, Barchilon V, Beyth S, et al.
Bracing in external rotation for traumatic anterior dislocation of the shoulder.
J Bone Joint Surg Br 2009;91:918–21.
[36] Liavaag S, Brox JI, Pripp AH, Enger M, Soldal LA, Svenningsen S. Immobiliza-
tion in external rotation after primary shoulder dislocation did not reduce
G Model
OTSR-1121; No. of Pages 7 ARTICLE IN PRESS
F. Khiami et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
the risk of recurrence: a randomized controlled trial. J Bone Joint Surg Am
2011;93:897–904.
[37] Paterson WH, Throckmorton TW, Koester M, Azar FM, Kuhn JE. Position and
duration of immobilization after primary anterior shoulder dislocation: a sys-
tematic review and meta-analysis of the literature. J Bone Joint Surg Am
2010;92:2924–33.
[38] Scheibel M, Kuke A, Nikulka C, Magosch P, Ziesler O, Schroeder RJ. How long
should acute anterior dislocations of the shoulder be immobilized in external
rotation? Am J Sports Med 2009;37:1309–16.
[39] Smith TO. Immobilisation following traumatic anterior glenohumeral joint dis-
location: a literature review. Injury 2006;37:228–37.
[40] Kiviluoto O, Pasila M, Jaroma H, Sundholm A. Immobilization after
primary dislocation of the shoulder. Acta Orthop Scand 1980;51:
915–9.
[41] Maeda A, Yoneda M, Horibe S, Hirooka A, Wakitani S, Narita Y. Longer immo-
bilization extends the “symptom-free” period following primary shoulder
dislocation in young rugby players. J Orthop Sci 2002;7:43–7.
[42] Larrain MV, Botto GJ, Montenegro HJ, Mauas DM. Arthroscopic repair of acute
traumatic anterior shoulder dislocation in young athletes. Arthrosc J Arthrosc
Relat Surg 2001;17:373–7.
[43] Jakobsen BW, Johannsen HV, Suder P, Søjbjerg JO. Primary repair versus conser-
vative treatment of first-time traumatic anterior dislocation of the shoulder:
a randomized study with 10-year follow-up. Arthrosc J Arthrosc Relat Surg
2007;23:118–23.
[44] Law BK-Y, Yung PS-H, Ho EP-Y, Chang JJH-T, Chan K-M. The surgical out-
come of immediate arthroscopic Bankart repair for first time anterior shoulder
dislocation in young active patients. Knee Surg Sports Traumatol Arthrosc
2008;16:188–93.
[45] Owens BD, DeBerardino TM, Nelson BJ, Thurman J, Cameron KL, Taylor DC,
et al. Long-term follow-up of acute arthroscopic Bankart repair for initial
anterior shoulder dislocations in young athletes. Am J Sports Med 2009;37:
669–73.
[46] Brophy RH, Marx RG. The treatment of traumatic anterior instability of the
shoulder: nonoperative and surgical treatment. Arthrosc J Arthrosc Relat Surg
2009;25:298–304.
[47] Mather 3rd RC, Orlando LA, Henderson RA, Lawrence JTR, Taylor DC. A
predictive model of shoulder instability after a first-time anterior shoulder
dislocation. J Shoulder Elb Surg Am 2011;20:259–66.
Please cite this article in press as: Khiami F, et al. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol
Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2014.06.027
7
[48] Rowe CR, Sakellarides HT. Factors related to recurrences of anterior dislocations
of the shoulder. Clin Orthop 1961;20:40–8.
[49] Itoi E, Hatakeyama Y, Urayama M, Pradhan RL, Kido T, Sato K. Position of immo-
bilization after dislocation of the shoulder. A cadaveric study. J Bone Joint Surg
Am 1999;81:385–90.
[50] Limpisvasti O, Yang BY, Hosseinzadeh P, Leba T, Tibone JE, Lee TQ. The effect
of glenohumeral position on the shoulder after traumatic anterior dislocation.
Am J Sports Med 2008;36:775–80.
[51] Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I, Sato K. Position of
immobilization after dislocation of the glenohumeral joint. A study with use of
magnetic resonance imaging. J Bone Joint Surg Am 2001;83-A:661–7.
[52] Chetouani M, Ropars M, Marin F, Huten D, Duvauferrier R, Thomazeau H, et al.
useful to assess labral reduction following acute anterior shoulder dislocation?
Orthop Traumatol Surg Res 2010;96:203–7.
[53] Hart WJ, Kelly CP. Arthroscopic observation of capsulolabral reduction after
shoulder dislocation. J Shoulder Elb Surg Am 2005;14:134–7.
[54] Handoll HHG, Hanchard NCA, Goodchild L, Feary J. Conservative management
following closed reduction of traumatic anterior dislocation of the shoulder.
Cochrane Database Syst Rev 2006:CD620049.
[55] Drasler E. Position and duration of immobilization after primary anterior
shoulder dislocation: a systematic review and meta-analysis of the literature:
Paterson WH, Throckmorton TW, Koester M, Azar FM, Kuhn JE. J Bone Joint Surg
Am 2010;92:2924–33. J Emerg Med 2011;40:609.
[56] Wintzell G, Haglund-Akerlind Y, Nowak J, Larsson S. Arthroscopic lavage com-
pared with nonoperative treatment for traumatic primary anterior shoulder
dislocation: a 2-year follow-up of a prospective randomized study. J Shoulder
Elb Surg 1999;8:399–402.
[57] Boone JL, Arciero RA. First-time anterior shoulder dislocations: has the standard
changed? Br J Sports Med 2010;44:355–60.
[58] Smith GCS, Chesser TJS, Packham IN, Crowther MAA. First time traumatic
anterior shoulder dislocation: a review of current management. Injury
2013;44:406–8.
[59] Malhotra A, Freudmann MS, Hay SM. Management of traumatic anterior shoul-
der dislocation in the 17- to 25-year age group: a dramatic evolution of practice.
J Shoulder Elb Surg Am S 2012;21:545–53.
[60] Kim D-S, Yoon Y-S, Yi CH. Prevalence comparison of accompanying lesions
between primary and recurrent anterior dislocation in the shoulder. Am J Sports
Med 2010;38:2071–6.