Shoulder Dislocations, Stabilisation & Labral Injuries

The glenohumeral joint is the most commonly dislocated major joint. Most are anterior (abduction + external rotation force); posterior dislocations are rarer and easily missed. The glenoid labrum is a fibrocartilaginous rim that deepens the glenoid socket by ~50% and stabilises the humeral head — labral injuries are divided into SLAP (superior labrum anterior-to-posterior) and non-SLAP lesions; Bankart lesions (antero-inferior labrum) accompany anterior dislocation (see below).

Anterior dislocation

• Associated lesions: Bankart lesion (antero-inferior labral tear) and Hill–Sachs lesion (posterolateral humeral-head impaction). A bony Bankart or an engaging Hill–Sachs increases recurrence risk.
• Recurrence is strongly age-dependent — very high in young athletes, lower with increasing age. Always assess axillary nerve (regimental-badge sensation) and vascular status before and after reduction, and image post-reduction.

Reduction technique

Reduce promptly — delaying beyond 24 hours increases the risk of a difficult, unstable reduction and neurovascular compromise. Pre-reduction X-ray is usual, but can reasonably be skipped and imaging done post-reduction only if the patient is under 40, has had a prior dislocation on the same side, the mechanism wasn’t high-energy trauma (no MVC, no fall from height, no assault), and the diagnosis is clinically certain — in that combination the negative predictive value for an associated fracture is 96.6%.

Analgesia first. Intra-articular lidocaine injection into the joint gives equivalent reduction success and patient satisfaction to procedural sedation, without the monitoring and recovery-time burden of sedation — a useful option where sedation resources are limited. Reserve procedural sedation (or IV/oral analgesia plus a slower technique) for a patient who doesn’t settle with intra-articular block alone.

Pick a technique to suit how the arm is presenting rather than committing to one method regardless of position — no single technique works for every patient, and being familiar with more than one avoids repeated failed attempts:

• Arm held abducted: traction-countertraction, or the FARES technique — supine, gentle axial traction with small anterior-posterior oscillations (like a handshake) while slowly abducting and externally rotating the arm. A randomised trial found FARES faster and less painful than the classic Hippocratic or Kocher methods, and it needs no assistant.
• Arm held adducted: the Cunningham technique, or gentle external rotation (±Milch).
• Traction-countertraction (an assistant applies counter-traction with a sheet around the thorax while the clinician applies in-line traction to the arm) remains the fallback when other techniques fail.

Confirm and document a full neurovascular exam — including axillary nerve sensation (regimental-badge patch) — both before and after reduction, whichever technique is used.

Posterior dislocation

Classically after seizures, electrocution, or trauma (the 3 E’s”). “The arm is locked in internal rotation and adduction (loss of external rotation); frequently missed or delayed — have a low threshold for axillary/scapular-Y views or CT. Associated with reverse Hill–Sachs lesions.

SLAP lesion (labral injury without dislocation)

• Uncommon (<5% of shoulder injuries); typically overhead throwers or a fall on outstretched hand with a tensed biceps.
• Features: a “pop” during overhead activity, vague deep shoulder pain, and weakness/fatigue with reduced athletic performance.
• Examination: the pop may reproduce on overhead ROM; Speed’s and O’Brien’s tests (both limited sensitivity/specificity).
• Investigations: X-ray normal; MRI/MR arthrogram if high suspicion.
• Management: relative rest, physiotherapy ± NSAIDs; orthopaedic review with arthroscopic repair/debridement if conservative treatment fails.

Instability examination

Apprehension test (± relocation) for anterior instability; sulcus sign for inferior/multidirectional laxity.

Rehabilitation

Goals: avoid re-dislocation, restore stability then ROM.

• Immobilise ~3 weeks (broad-arm or external-rotation sling).
• Avoid at-risk positions ~6 weeks (no external rotation beyond neutral or abduction >90° after anterior dislocation).
• Early isometric activation, then progressive ROM and strengthening; return to sport at full pain-free ROM and strength (~2 months) — the riskier the sport, the longer the rehabilitation. Recurrent instability or a structural bony lesion warrants surgical stabilisation.