REVIEW ARTICLE
Incidence of Associated Injury in Posterior Shoulder
Dislocation: Systematic Review of the Literature
Dominique M. Rouleau, MD, MSc, FRCSC* and Jonah Hebert-Davies, MD†
Objective: Posterior shoulder dislocations are rare and often
missed. Classically associated with seizures, very little is known
about the incidence and type of associated injuries. Unfortunately, the
majority of the literature consists of incidental reports or small case
series. Our goal was to increase the strength of available data by
performing a systematic review.
Data Sources: We searched EMBASE and PubMed for the terms
‘‘posterior shoulder dislocation.’’ Our inclusion criteria were articles
in either English or French with the words ÔÕposterior’’ and
ÔÕdislocation’’ in the abstract or title. All reports of chronic cases
or instability as well as those without patient information were
excluded. Data regarding demographics, etiology, investigations,
associated injuries, treatments, and outcomes were extracted. All data
were analyzed by using SPSS 18.0 (IBM, Chicago, IL).
Results: A total of 766 articles were found of which 108 were
retained for analysis. A total of 475 patients (543 shoulders) were
compiled. Seizures were reported in 34% of cases. A majority of
dislocations (65%) had associated injuries. Fracture was most
common followed by reverse Hill-Sachs and cuff tears. In the
absence of fracture or reverse Hill-Sachs injury, the risk of cuff tear
increased nearly fivefold (odds ratio, 4.6; P = 0.016).
Conclusion: Our results suggest the amount of associated injuries
related to posterior shoulder dislocation is far greater than thought.
We propose an investigation algorithm for acute posterior shoulder
dislocations.
Key Words: posterior shoulder dislocation, Hill-Sachs, Bankart,
rotator cuff, algorithm
(J Orthop Trauma 2012;26:246–251)
Accepted for publication May 12, 2010.
From *Service d’Orthopédie, Hôpital du Sacré-Coeur de Montréal, Montréal,
Québec, Canada; and †Université of Montréal, Division Chirurgie
orthopédique, Hôpital du Sacré Cœur, Montréal, Québec, Canada.
No funds were received in support of this work.
No benefits in any form have been or will be received from a commercial party
related directly or indirectly to the subject of this manuscript.
The authors declare no conflict of interest.
Reprints: Dominique M. Rouleau, MD, MSc, FRCSC, Service d’Orthopédie,
Hôpital du Sacré-Coeur de Montréal, 5400 boul. Gouin ouest, Montréal,
Québec, Canada, H4J 1C5. (e-mail: dominique.rouleau@umontreal.ca).
Copyright Ó 2012 by Lippincott Williams & Wilkins
246 | www.jorthotrauma.com
INTRODUCTION
Posterior dislocation of the shoulder is a rare injury
accounting for approximately 2% to 5% of all shoulder
dislocations.1,2 Recognition of this injury is often difficult with
60% to 79% of posterior shoulder dislocations being missed
on initial examination.1–3 Delay between injury and diagnosis
has been reported to be as long as 10 years4 in some cases. This
can lead to significant morbidity: chronic pain, stiffness, and
functional disability.4
Suspicion of posterior shoulder dislocation must be
raised with a history of strong muscle contraction (seizure
activity, electroshock) or high-energy trauma such as motor
vehicle accident and direct or indirect trauma to the flexed,
adducted, and internally rotated shoulder.1,2,4,5 In contrast,
young athletes competing in overhead-throwing or contact
sports (eg, football, baseball, etc) tend to develop chronic
posterior glenohumeral subluxation and instability. Particular
attention should be given to the abnormal appearance of the
shoulder: internal rotation deformity, posterior fullness, and
anterior appearance of the coracoid process.1,2,4 Limitation of
external rotation and abduction of the shoulder1,2,4–6 are key
signs of the physical examination but often lead to the
incorrect diagnosis of frozen shoulder.1–4,6 Lack of supination
of the forearm has been recognized in some patients.3 In the
context of possible posterior glenohumeral dislocation,
anteroposterior and lateral radiographs in the plane of the
scapula are usually helpful,1,2,4,5 but a simple axillary view can
confirm the diagnosis, evaluate the presence of glenoid rim
fracture, and determine the approximate size of the impaction
fracture in the humeral head.4 Computerized tomography (CT)
is a useful tool in the surgical planning, allowing further
evaluation of the humeral head and glenoid fossa deform-
ities.1,2,4 Magnetic resonance imaging (MRI) can detect
posterior capsulolabral complex and rotator cuff injuries. It
can also be useful to identify the case of an irreducible
posterior dislocation (torn rotator cuff, interposed glenohum-
eral capsule or tendon of the long head of the biceps4).
Impaction fracture of the anterior humeral head (reverse Hill-
Sachs) is a characteristic injury in patients experiencing
posterior shoulder dislocation.4,5 Hawkins previously reported
that when examining plain radiographs, approximately 49% of
posterior dislocations are associated with an undisplaced
fracture of the surgical neck of the humerus, the greater
tuberosity, or the proximal part of the shaft of the humerus.4
The optimal treatment strategy is based on the general
condition and needs of the patient, the duration of the
dislocation, the size of the impression defect, the presence of
a fracture, or changes in the glenoid.1,4
J Orthop Trauma  Volume 26, Number 4, April 2012
J Orthop Trauma  Volume 26, Number 4, April 2012 Associated Injury in Posterior Shoulder Dislocation

Despite abundant literature on posterior dislocation, test and the incidence of injuries with the chi-square test. The
small case series are still widely published despite low level of significance was established at 0.05.
scientific content and limited new information. The purpose of
this study is to conduct a systematic review of the current
literature to summarize and extract incidence of associated RESULTS
injuries, like fractures, rotator cuff tears, and reverse Hill- Study inclusion is outlined in Figure 1. From the initial
Sachs lesions. Also, this review helps to describe the etiology, list of 766 articles identified, only 106 were retained for data
risk factors for associated injuries, and functional outcome. extraction after evaluation7,11–115 All studies were of thera-
peutic Level IV and were published between 1964 and 2009.
Of these studies, 81 were case reports (as defined by less than
five patients) and 25 were case series (more than five patients).
MATERIALS AND METHODS There were 477 patients (547 shoulders) with 90 women
We searched both MEDLINE and EMBASE databases (19%). Average age of these patients was 41.1 years (range,
with the terms ‘‘posterior’’ and ‘‘shoulder dislocation’’ to find 17–75 years). In 70 cases, the dislocations were bilateral.
all relevant studies. Only articles with abstracts in either In 133 cases (24%), the initial diagnosis of posterior
English or French and including human adult (17 years or dislocation was missed. Seizure was a common cause present
older) subjects were considered. All articles referring to in 186 instances (39%). For diagnostic purposes, 441 patients
anterior dislocation were excluded. The remaining abstracts had x-rays information reported, 158 underwent CT scanning,
were evaluated for inclusion. All chronic dislocations series, and 50 had an MRI.
defined as greater than 1 month, were excluded. Reports
referring to traumatic posterior instability without actual
traumatic dislocation were also excluded. The included articles
were all obtained and evaluated by two different authors.
Studies containing no patient demographic data or found to
match previous exclusion criteria were not retained. Finally, all
the remaining references were crosschecked to find any
missing relevant articles.
Both authors analyzed all articles for data extraction. A
predetermined set of data was established (Table 1) and each
article was examined. Data entry was compared between both
lists and any discrepancies (ie, patients with multiple
associated fractures that had only been included in one
category) were settled with a consensus review. All results
were then compiled and analyzed using statistical software
(SPSS Version 18.0, Chicago, IL).

Statistics
Descriptive data were obtained by weighted mean, in
which each study influences the mean according to the relative
number of patients included. When information was available
in the article, individual patient information was entered
instead of the group average (ie, incidence percentages and
age). The means between groups were tested using Student t

TABLE 1. Predetermined Data Collected in a

Systematic Review
Age
Sex
Number of patients (shoulders)
Presence of seizures
Radiologic investigations
Number/type of fracture
Reverse Hill-Sachs presence
Cuff pathology
Surgical treatment/type
Complications
Functional outcome
FIGURE 1. Study flow chart.

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Rouleau and Hebert-Davies
In total, 65% of cases had associated injuries. A
breakdown of these injuries can be seen in Table 2. Fractures
were present in 185 cases (34%) with many being at multiple
sites. The most common fracture was neck fracture (101)
followed by lesser tuberosity (78) and greater tuberosity (43).
Other fractures (humerus diaphysis, scapula, clavicle, or any
other fracture) were present in 33 patients. Figure 2 illustrates
a posterior Bankart fracture on CT scan. The reverse Hill-
Sachs lesion was identified in 160 cases (29%). The prevalence
in the 158 patients (181 shoulders) having undergone CT scan
evaluation was 45. This rate, 25%, is similar to that which was
found in the total study population and thus we consider the
true incidence to be comparable.
Rotator cuff tear was present in only 13 shoulders (2%);
however, the total number of patients undergoing rotator cuff
imagery was limited. Only 50 shoulders underwent MRI and
for 48 shoulders, cuff status was described during the
operation. The total rate in these patients is then 13%, which
is probably closer to the actual incidence. Open surgery was
performed in 238 cases and arthroscopic surgery in nine cases.
The most common procedure was open reduction and internal
fixation, although in most reports, the specific fracture type
requiring fixation was not indicated. Other common proce-
dures included the McLaughlin surgery and its modifica-
tions4,7 and hemiarthroplasty.
Average follow-up was 40.0 months and was very
variable among different studies (range, 1–180 months.) The
Constant score was available in 66 cases and the average score
was 87 (range, 46–97). Further functional outcomes were too
variable across the different studies to be compiled.
Statistical analysis about risk factors for associated
injuries revealed that in the absence of fracture or reverse Hill-
Sachs injury, the risk of cuff tear increased fivefold (odds ratio,
4.6; P = 0.016) Also, the group of patients with reverse Hill-
Sachs lesion was older than the group without (50 year old
average vs 34 years old, P = 0.008).
TABLE 2. Results Including Demographics and
Associated Injuries
Data No.
Patients 477
Shoulders 547
Bilateral 14.6%
Women 90 (19%)
Average age (years) 41.1
Fracture type
Neck 18.5%
Lesser tuberosity 14.3%
Greater tuberosity 7.8%
Other 6.0%
Reverse Hill-Sachs total 29%
Reverse Hill-Sachs with computed tomography scan* 25%
Rotator cuff tear 2%
Rotator cuff tear with magnetic resonance imaging/surgery† 13%
*n = 158.
†n = 98.
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J Orthop Trauma  Volume 26, Number 4, April 2012
FIGURE 2. Illustration of associated posterior Bankart fracture
after closed reduction of the dislocation. In our review, it was
present in three cases.
DISCUSSION
Traumatic posterior glenohumeral dislocation remains
a rare but severe injury. This systematic review illustrates the
high incidence of associated bone and soft tissue injuries.
When compared with anterior dislocations, the incidence of
fracture is increased. Two large series of anterior shoulder
dislocations published in 2004 and 2005 found an incidence of
fracture of 26% and 21% respectively8,9 compared with the
34% in our analysis. We found an increased incidence of
reverse Hill-Sachs lesions with increasing age, which is likely
secondary to progressive osteopenia as showed by Emond
et al8 for anterior dislocation and fracture incidence. Younger
individuals have less chance for bone impaction injury. Also,
the actual number of missed dislocations is quite higher;
however, in this review, we have excluded all chronic
presentations. Incidence of rotator cuff tears in our study
seems to be lower for posterior dislocation than anterior
dislocation. However, this conclusion is drawn knowing that
only a small number of series had MRI or surgical evaluation.
One reason for this could be that posterior dislocation creates
less inferior displacement and less pulling force on the
superior and posterior cuff. The increased chance of rotator
cuff tear in the absence of fracture or Hill-Sachs may be
explained by the decreased pull of the cuff muscles on the
humeral head during spontaneous reduction. The force with
which the humeral head impacts on the glenoid rim with a torn
cuff is possibly less violent, causing less reverse Hill-Sachs
and by extension less humeral neck fractures. However, the
position of the arm at the moment of impact (ie, more
adduction) could also explain this phenomenon and there is no
biomechanical data to confirm either possibility. The acute or
chronic nature of cuff tears included in our study could not be
obtained.
Although our study focused solely on primary traumatic
posterior dislocation, literature concerning posterior shoulder
instability adds to our understanding of these pathologies.
These articles were excluded from our study because their
focus was on subacute and chronic instability; however,
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J Orthop Trauma  Volume 26, Number 4, April 2012 Associated Injury in Posterior Shoulder Dislocation

several conclusions can be drawn. Bradley et al reported

a prospective series of 100 shoulders with posterior instability
of which 53% had been traumatic. All patients participated in
competitive sports. In the patients with traumatic instability,
66% had reverse Bankart-type injuries. These patients were
chronic cases and were treated after an initial physical therapy
regimen and thus the study was excluded from our database. In
2005, Bottoni et al reported on 31 shoulders operated on for
traumatic posterior shoulder instability. All patients were
operated on more than 1 month after initial presentation and
thus the article was excluded from our study. Reverse Bankart
lesions, posterior rim fracture, or rim calcification was found
in 97% of shoulders; however, a more detailed incidence was
not mentioned. In 2005, Provencher et al reported on 33
patients with posterior instability with 91% having traumatic
injuries. However, there were no documented dislocations.
Radiologic abnormalities included 52% of posterior labral
tears, one reverse Hill-Sachs lesion, and a partial supraspinatus
tear. Patients were treated arthroscopically with restoration of
stability in 88% of cases.Our study has several limitations
primarily as a result of the weakness of available literature,
which is typical of a rare pathology. No prospective study was
found and no therapeutic trial is available. Despite this,
a significant number of papers on posterior dislocation were
found, demonstrating the interest and concern about this injury
in the orthopaedic community. An ideal situation would have
been to combine the original databases from each series, but FIGURE 3. Treatment algorithm of acute posterior shoulder
the number of studies and timespan between each of them dislocation.
made this impossible.
For future development about acute posterior shoulder
Recommended Investigation Algorithm for dislocation, a multicentered prospective prognostic study
Acute Posterior Dislocation would bring more information on treatment choice and
After analyzing these results, we propose an algorithm functional outcome. An eventual subgroup of patients with
of investigation for acute posterior shoulder dislocations worse outcome could then be identified and surgical treatment
(Fig. 3). To avoid displacement of a humeral neck fracture, tailored according to results. Awareness by primary care
which is present in one in five patients, we recommend physicians, radiologists, and even of orthopaedic surgeons has
a mandatory CT scan before a trial of closed reduction for to be maintained by continuous teaching.
posterior dislocation. A humeral neck fracture is a strong
argument for open reduction because of the high risk of
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