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Traumatic anterior shoulder dislocations are a common problem facing the orthopaedic surgeon in practice, with an incidence rate of 1.7% in the general population. 1 They are the most frequent type of joint dislocation, accounting for almost 50% of all joint dislocations presenting to emergency departments. 2 Traditionally, initial management of anterior shoulder dislocations consists of a reduction of the glenohumeral joint, immobilisation and concomitant physical therapy to restore shoulder range of motion and strength. This traditional approach in management is being challenged, however, due to the high rate of recurrence, with reported rates as high as 92-96% in young active patients. 3 - 5 Several recent studies have compared non-operative treatment with early surgical intervention and have shown a decrease in recurrent dislocation with arthroscopic stabilisation. 6 - 11 This finding adds another level of complexity to the treatment algorithm of anterior traumatic shoulder instability.
The purpose of this review was to assimilate and present the current literature on acute anterior shoulder instability, focusing on current treatment recommendations, thus providing the clinician with an updated framework for a discussion of what to do with the first-time dislocator.
Pathology of acute dislocation
The shoulder relies on both static (osseous conformity, adhesion/cohesion, finite volume and capsular and ligamentous components such as the labrum) and dynamic (rotator cuff muscles) stabilisers to maintain joint stability through a wide arc of motion. 12 - 16 With the arm in an abducted and externally rotated position, the inferior glenohumeral complex is the primary restraint to anterior glenohumeral translation ( figure 1 ). 16 During a traumatic anterior dislocation, the anteroinferiorly displaced humeral head stretches the capsuloligamentous components, often resulting in a detachment of the anterior-inferior labrum (the classically described Bankart lesion). 17 Other findings may include bony Hill-Sachs lesions, superior labral tear from anterior to posterior (SLAP) lesions, capsular tears, rotator cuff tears and glenoid rim fractures.
Taylor and Arciero 18 studied first-time traumatic dislocations in young patients (<24 years) and found 97% had Bankart lesions, with no gross evidence of capsular injury ( figure 2 ). Eighty-nine per cent had Hill-Sachs lesions, but they were small and did not appear to have a significant effect on stability as evaluated arthroscopically. They also noted a 10% incidence of SLAP lesions...