Review Article

Acute Traumatic Posterior

Shoulder Dislocation
Abstract
Dominique M. Rouleau, MD
Jonah Hebert-Davies, MD
C. Michael Robinson, MD

From the Department of Orthopaedic

Surgery, University of Montreal,
Sacred Heart Hospital of Montreal,
Montreal, ON, Canada (Dr. Rouleau
and Dr. Hebert-Davies), and the Royal
Infirmary of Edinburgh, Edinburgh,
UK (Dr. Robinson).
Dr. Rouleau or an immediate family
member is a member of a speakers
bureau or has made paid presentations
on behalf of Smith & Nephew; has
received research or institutional
support from DePuy, KCI, Smith &
Nephew, Stryker, Synthes, and
Zimmer; and has received nonincome
support (such as equipment or
services), commercially derived
honoraria, or other nonresearchrelated funding (such as paid travel)
from Arthrex. Dr. Robinson or an
immediate family member is a member
of a speakers bureau or has made
paid presentations on behalf of and
serves as a paid consultant to Acumed.
Neither Dr. Hebert-Davies nor any
immediate family member has received
anything of value from or has stock or
stock options held in a commercial
company or institution related directly
or indirectly to the subject of this article.
J Am Acad Orthop Surg 2014;22:
145-152
http://dx.doi.org/10.5435/
JAAOS-22-03-145
Copyright 2014 by the American
Academy of Orthopaedic Surgeons.

March 2014, Vol 22, No 3

Posterior shoulder dislocation occurs rarely and is challenging to

manage. The mechanisms of trauma are varied, which complicates
diagnosis. Missed or delayed diagnosis and treatment can have
serious deleterious effects on shoulder function. All cases of
suspected posterior shoulder dislocation require a high level of
suspicion and appropriate imaging. Identification of associated
injuries, such as fractures and rotator cuff tears, is important to guide
treatment. In the acute setting, most patients are treated with closed or
open reduction with additional soft-tissue or bony procedures.
Patients treated in a delayed fashion for persistent instability may
require additional procedures, including arthroplasty.

irst described in 1838 by Sir Astley

Cooper,1 traumatic posterior
dislocations of the shoulder represent
an unusual and challenging clinical
problem. These injuries account for
2% to 5% of all shoulder dislocations.1-3 Anterior glenohumeral
dislocation is 15.5 to 21.7 times more
common than posterior dislocation.4
Seizures, high-energy trauma, and
electrocution are associated with
a much greater risk of posterior
dislocation.1,2,5 Diagnosis is missed
or delayed in up to 79% of patients.2,3,6 The authors of one study
suggested that systematic evaluation
of AP and Velpeau radiographs in an
emergency department resulted in
dislocation being missed in only 10
of 112 patients.4
In patients who present following
seizure, electric shock, or trauma,
a high index of suspicion for posterior
shoulder dislocation should be maintained, and appropriate physical and
radiologic examinations should be
performed to confirm the diagnosis.7
This is particularly important in the
setting of seizure, in which medical
treatment combined with reduced

nociceptive sensitivity following

convulsions may make it difficult
for the treating physician to detect
the injury.8 Early identification of
these dislocations reduces morbidity
and facilitates treatment.3

Anatomy of the Shoulder

The shoulder is relatively unconstrained, allowing an extreme range
of motion. Joint stability is provided
by both static and dynamic elements,9 which allows the joint to
maintain a large degree of freedom
while remaining concentric.

Static Stabilizers
Bony congruity is achieved with the
concavity of the glenoid; this is further
increased due to asymmetric deposition
of cartilage, with the peripheral articular surface being thickest.10,11 The glenoid labrum increases the depth and
width of the joint approximately twofold.12 Loss of the labrum decreases
translational resistance by 20%.13
The three glenohumeral ligaments
are discrete capsular fibrous bands

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Acute Traumatic Posterior Shoulder Dislocation

pectoralis and latissimus dorsi muscles

overpower the weak external rotators
(ie, infraspinatus, teres minor) and
cause internal rotation of the shoulder,
displacing the humeral head superiorly
and posteriorly against the acromion
and medially against the glenoid fossa,
resulting in posterior dislocation.8,16
Adequate muscle contraction strength
of the infraspinatus and teres minor
and major can cause humeral neck
fracture. In a recent systematic review,
posterior dislocations were found to
occur after trauma in 67% of cases,
after seizure in 31%, and after electrocution in 2%.4

Figure 1

Classifications

Illustration of the dynamic and static stabilizers of the shoulder. IGHL = inferior
glenohumeral ligament, MGHL = middle glenohumeral ligament, SGHL = superior
glenohumeral ligament

that provide stability to the shoulder in

various positions. The coracohumeral
ligament and superior glenohumeral
ligament provide little anterior resistance, but they help prevent posterior
translation in the flexed, adducted,
and internally rotated shoulder.12,14
The inferior glenohumeral ligament
is the main stabilizer against posterior
dislocation. The posterior band of
the inferior glenohumeral ligament
restricts posterior displacement with
the arm in abduction12 (Figure 1).

Dynamic Restraints
Dynamic stabilizers include all shoulder muscles that create a concavity
compression force across the joint.
Balance between anterior and posterior forces allows the humeral head
to remain centered in the glenoid.9

146

Posterior dynamic restraints of the

shoulder include the rotator cuff, the
biceps tendon, and the deltoid.12 The
subscapularis provides the greatest
opposition to posterior translation.12
The biceps tendon increases posterior
stability, mostly in external rotation.

Mechanisms of Injury
Several different mechanisms have
been proposed for posterior dislocation. Direct high-energy trauma with
the shoulder in adduction, flexion, and
internal rotation is the most frequent
cause of posterior dislocation.2,15
Posterior shoulder dislocation may
also be caused by seizures or electrocution.8 Dislocation due to seizure is
the result of unbalanced contraction of
the shoulder muscles.16 In adduction,
internal rotation, and flexion, the

Several classification systems exist to

describe posterior shoulder dislocations, but none has been established
as a clear standard. Detenbeck17 first
separated dislocations based on type:
acute, chronic (dislocated .3 weeks),
or recurrent (traumatic or atraumatic).
Heller et al18 developed a system
based on an extensive literature review
and included different parameters:
traumatic or atraumatic, acute or
persistent, or recurrent voluntary.
Others have classified dislocations as
acute (,6 weeks) or chronic (.6
months) and have separated pure
dislocations from fracture-dislocations
(ie, any associated humeral fracture
except a reverse Hill-Sachs lesion).19
Robinson and Aderinto19 also classified humeral head defect as small
(,25%), medium (25% to 50%),
and large (.50%). Classification of
the humeral head defect is extremely
important for planning eventual surgical treatment. Classifications of
posterior recurrent instability and
atraumatic posterior instability are
beyond the scope of this article.20

Clinical Evaluation
Physical examination is particularly
important in acute posterior shoulder

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Dominique M. Rouleau, MD, et al

Figure 2

A, AP radiograph of the shoulder with the trough line visible (arrow). This is representative of the anterior humeral head
impaction. B, Axillary radiograph demonstrating posterior dislocation with a significant reverse Hill-Sachs lesion. C, AP
radiograph demonstrating the lightbulb sign (arrows).

dislocations because patients may be

unable to provide an adequate clinical
history. On visual inspection, the
shoulder often is in internal rotation,
with a prominent coracoid process and
posterior fullness in the axilla.1,3,21
Physical examination may reveal
a springy or soft end point or a block
to external rotation,1-3,21,22 as well as
the subtler sign of diminished supination of the forearm.6 Specific instability examinations such as the jerk test,
posterior load-and-shift test, or the
posterior drawer test can be useful
in patients with chronic instability.
However, these tests are rarely useful
in the acute setting.

Imaging
To minimize the risk of missing a posterior glenohumeral dislocation, the
evaluation should include standard
AP and Velpeau radiographs.1-4,21 An
axillary view is useful to evaluate
associated head impaction (ie, reverse
Hill-Sachs lesion) and glenoid rim
fractures.21 A Velpeau view is
acceptable if the patient is unable to
achieve sufficient abduction. Other
indirect signs that can be seen on
standard radiographs include the
lightbulb sign, loss of the half-moon
sign, and the trough line23 (Figure 2).
March 2014, Vol 22, No 3

CT is particularly useful for

preoperative assessment of associated fractures and quantification
of reverse Hill-Sachs impaction1,3,21,24,25 (Figure 3). Thin-slice
axial CT is the best imaging
modality for defining the humeral
head bone defect as part of the
articular surface.24
Capsulolabral and rotator cuff evaluation on MRI is essential in cases
without associated fracture7 (Figure 4).
Posterior labral lesions, such as reverse
Bankart lesions, posterior labrocapsular periosteal sleeve avulsions, and
posterosuperior tears, are found in up
to 58% of patients.26 In cases of
irreducible dislocation, MRI can
identify the responsible structure,
which most commonly is a torn rotator cuff, avulsed capsule, or biceps
tendon.26

Associated Injuries
Isolated posterior dislocations of the
proximal humerus are rare, and associated injuries often are missed or
diagnosed in a delayed fashion.7 Historically, bony and soft-tissue injuries
were thought to occur in 49% of
dislocations,21 but a recent systematic
review indicated that up to 65% of
dislocations had associated bony or

Figure 3

Axial CT scan demonstrating severe

humeral head impaction, that is,
reverse Hill-Sachs lesion. The extent
of glenoid fracture or bone loss
dictates management.

soft-tissue injuries.7 Simple or multiple

fractures were present in 34% of
shoulders, with the most common site
being the neck (55%), followed by
the lesser (42%) and greater (23%)
tuberosities.7 Lesser tuberosity fractures are particularly important
because they influence treatment. In
these cases, it is important to enter the
joint through the fracture rather than
perform a subscapularis tenotomy.
Reverse Hill-Sachs lesions of
varying size are seen in up to 86% of

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Acute Traumatic Posterior Shoulder Dislocation

Figure 4

Axial T1-weighted magnetic

resonance arthrogram of a right
shoulder demonstrating a posterior
Bankart lesion. The rotator cuff is
also assessed on this view.

patients.26 Bone defects are common, with significant reverse HillSachs lesions found in 29% of
shoulders7 and posterior rim fracture seen in approximately 5% of
shoulders.4 The frequency and significance of these defects can
increase with delayed or chronic
presentation.5
Rotator cuff tears are found in 13%
of patients evaluated with MRI;
however, the odds ratio of finding
a tear is 4.6 times higher in the
absence of an associated fracture or
reverse Hill-Sachs lesion.7 Thus, in
the patient with a dislocation but
without concomitant fracture on
CT, a focused rotator cuff physical
examination and MRI evaluation
are strongly suggested. Nerve palsy
secondary to posterior glenohumeral
dislocation is rare, occurring in ,1%
of injuries.7 The axillary nerve is the
most commonly injured.

Management
Nonsurgical
Definitive treatment options for posterior shoulder dislocations are varied,
and the decision must be individualized to each patient. In the elderly

148

low-demand patient, chronic posterior dislocation can be tolerated provided pain is minimal and anterior
elevation is sufficient for activities
of daily living.27,28 This treatment
option has been dubbed supervised
neglect.28,29 Nonsurgical treatment
also may be appropriate in patients
with cognitive impairment or other
severe medical comorbidities.
Closed reduction can be attempted
in the presence of an acute dislocation
in an elderly low-demand patient
with a reverse Hill-Sachs lesion measuring ,20%. Recurrent dislocation
or failed reduction warrants a discussion with the patient and family
about definitive treatment. In an
active and independent patient, the
goal of treatment of acute and
chronic dislocations is to restore
shoulder stability and mobility. Isolated closed reduction is reserved for
acute posterior instability with
a reverse Hill-Sachs lesion of #20%
that is stable after reduction.
Careful imaging evaluation should
be done prior to any reduction
maneuver to avoid displacing a neck
fracture. In the presence of suspected
fracture, an urgent CT scan should be
obtained before reduction. An attempt
at closed reduction of posterior shoulder dislocation requires complete
sedation to allow gentle manipulation.
Forceful manipulations often cause
humeral head fractures, which increases the chance of osteonecrosis and
has an adverse effect on prognosis. In
a series of 112 patients, 33% of
shoulders were successfully reduced
using in-line gentle traction.4
The Stimson technique is a passive
method used to manage acute posterior dislocation without associated
neck fracture or a significantly engaged
reverse Hill-Sachs lesion. The patient is
positioned prone on a table with the
arm in abduction over the side and
with 5 to 10 lb placed in the hand.30
Muscle spasms can eventually be
overcome with the weight to allow for
spontaneous reduction.

Another method of closed reduction involves manipulating the

shoulder into adduction, anterior
flexion, and internal rotation. This is
followed by longitudinal traction
and anteriorly directed pressure on
the humeral head. As the humeral
head is felt to translate anteriorly,
progressive external rotation and
extension is done. Caution is required
at this stage because initiating rotation before humeral head translation
may cause humeral head fracture.
Residual instability following closed
reduction with the arm in the neutral
position warrants surgical management provided the patient is medically
fit to undergo anesthesia.

Surgical
Open Reduction
Following unsuccessful closed reduction, open reduction can be done
through either an anterior or a posterior approach. The approach is determined based on preoperative planning.
Isolated open reduction can be successful in acute dislocations with
reverse Hill-Sachs lesions measuring
,20%.
An anterior approach is done via
a standard deltopectoral incision,
where the humeral head lies deeper than
usual. Initially, the rotator interval is
opened to allow the introduction of
a finger into the glenohumeral joint to
aid in manual reduction of the shoulder.
In cases in which the shoulder is not
reducible through an open rotator
interval alone, a formal arthrotomy is
necessary. Management of the subscapularis is crucial and is dictated by
associated fractures. The two options
are peeling of the subscapularis and
lesser tuberosity osteotomy. In the setting of persistent posterior dislocation,
locked internal rotation limits access to
the subscapularis. The long head of the
biceps is useful in identifying the lateral
margin; frequently, the subscapularis
tendon lies beneath the conjoined
tendon.

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Dominique M. Rouleau, MD, et al

mended to prevent contact between

the grafted zone and the glenoid.

Figure 5

formed approximately 1 cm deep to

the bicipital groove in the sagittal
plane. A second cut is made from the
rotator interval in the coronal plane
from the reverse Hill-Sachs lesion
medially to the groove laterally. This
cut is possible only if the rotator
interval is open. Careful manipulation
of the lesser tuberosity is required to
prevent fragmentation.

Posterior Open Bankart Procedure

Irreducible posterior shoulder dislocations or persistent instability after
closed reduction without a significant
reverse Hill-Sachs lesion (#20%) can
be managed with a posterior approach
to achieve reduction, followed by
posterior Bankart repair33 (Figure 7).
A posterior longitudinal incision is
made medial to the deltoid border in
line with the posterior joint. Inferior
dissection must be done carefully to
prevent injury to the axillary nerve.
The deltoid is lifted with a retractor,
after which the infraspinatus is visualized and transverse tenotomy is
performed in line with the capsule.
The posterior labrum and capsule are
repaired in a standard fashion. Alternatively, the approach can be done
through a longitudinal split between
the infraspinatus and teres minor. This
approach allows excellent exposure
of the labrum complex without posterior tendon tenotomy. The interval
between these muscles is not always
obvious. Typically, it can be found
2 cm inferior to the scapular spine. It is
harder to see the separation at the
tendinous portion, and a longitudinal
tenotomy is usually necessary. Alternatively, on palpation, the humeral
head is usually felt deep to the infraspinatus, whereas the inferior portion
of the teres minor feels soft on
palpation.

Anterior Approach and Bone

Grafting
Significant acute reverse Hill-Sachs
lesions (20% to 40%) can also be addressed with disimpaction and bone
grafting or allograft (Figure 6). The
ideal patient for these techniques is
young, with good healing potential.
Following fracture disimpaction, an
iliac crest bone graft can be inserted
under the cartilage for support.32
Postoperative use of an external
rotation splint for 4 weeks is recom-

Arthroscopic Posterior Bankart

Repair
Arthroscopic posterior Bankart repair
is an option for acute reducible dislocations with little or no humeral head
impaction (,20%) and with persistent instability. The arthroscope is
introduced through the anterior portal, and a posterolateral portal is used
for suture anchor placement. A posterosuperior portal is used for suture
management. The posterior portion of
the acromion may prevent vertical

A, Axial (top) and AP (bottom) illustrations of a shoulder with a reverse Hill-Sachs

lesion. The AP view illustrates a modified McLaughlin procedure, which is done
through a transsubscapularis approach. B, Axial (top) and AP (bottom)
illustrations of the shoulder following suture of the subscapularis tendon into the
defect with the help of suture anchors and subsequent repair of that approach
through the tendon.

The McLaughlin Procedure

For patients with reverse Hill-Sachs
lesions of #20% and with persistent
instability following reduction, the
subscapularis can be either lifted off
the lesser tuberosity and transposed
into the defect with transosseous sutures after reduction as originally
described by McLaughlin2 or sutured
into the bed of the defect.31 The circumflex vessels are preserved inferiorly by maintaining a small sleeve of
tendon attached to its original site.
Modified McLaughlin Procedure
In the presence of a significant reverse
Hill-Sachs lesion (20% to 40%), the
lesser tuberosity can be osteotomized
to access the joint and eventually
transposed to the bone defect after
joint reduction.21 This is known as
the modified McLaughlin procedure
(Figure 5). The osteotomy is perMarch 2014, Vol 22, No 3

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Acute Traumatic Posterior Shoulder Dislocation

Figure 6

A, Axial CT scan of a left shoulder with significant humeral head impaction. B, Axial CT scan of the same patient 3 months
after an allograft was implanted into the deficit. C, Axial CT scan of a different patient with a similar injury 3 months after
fracture disimpaction.

Figure 7

Illustration of the skin landmarks

used in the posterior approach
(represented by the dashed line)
used to manage irreducible posterior
shoulder dislocation or persistent
instability after closed reduction in
the absence of a significant reverse
Hill-Sachs lesion. Access to the joint
is achieved either through
infraspinatus tenotomy or between
the infraspinatus and the teres minor.

positioning of suture anchors, and the

surgeon must have at the ready
a variety of suture passers to accommodate the anatomy in this area.
Arthroplasty
In the presence of massive humeral head
impaction (.40%) in patients aged

150

,55 years or in patients who are

not good candidates for graft incorporation, hemiarthroplasty is a good
option to address both instability
and the articular surface deficit.33
In order to prevent postoperative
dislocation, the humeral head must
be positioned in normal retroversion (#20). In more severe cases
of residual instability, the posterior
labrum can be repaired before
prosthesis implantation. Through
an anterior approach, the humeral
head is excised and the humeral cut
is oriented parallel to the glenoid,
leaving 1 to 2 cm of joint space to
visualize the posterior labrum. Use
of a laminar spreader and gentle
lateral traction can improve visualization. In a right shoulder, the
first glenoid anchor is positioned at
the 7-oclock position and the second at the 9-oclock position.
The anchor is placed at the edge of
the cartilage at a 45 angle to the
joint surface. A free 2/3 circular
needle is usually sufficient to pass
the anchor suture through the posterior labrum and capsule. Following repair of the labrum, the
hemiarthroplasty can be performed
as usual. A treatment algorithm is
shown in Figure 8.

Rehabilitation
Regardless of management type, the
shoulder is braced in 20 of external
rotation and abduction for 4 weeks to
aid healing of the posterior capsule.
Pendulum exercises and elbow range
of motion three times per day are
encouraged. At 4 weeks, unlimited
progressive range of motion is initiated
as well as isometric posterior rotator
cuff strengthening. Noncontact sports
are allowed 3 months after reduction or
surgery, and contact sports are permitted 4 to 6 months postoperatively.

Results
Approximately 18% of patients experience recurrent instability in the first
year following acute posterior dislocation.4 Risk factors for recurrence are
age ,40 years, seizure, and large
reverse Hill-Sachs lesion (.1.5 cm3).
Persistent functional impairment has
been noted 2 years after the initial
trauma, even without recurrent instability.4 Activities that require significant internal rotation may be
particularly difficult.
Typically, patients with persistent symptoms present with either

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Dominique M. Rouleau, MD, et al

Figure 8

Treatment algorithm for the surgical management of acute posterior shoulder dislocation.

subjective or objective posterior

instability and a painful shoulder.
On physical examination, apprehension is seen with the shoulder in
adduction and forward elevation.
Most patients will present additional
symptoms with a posteriorly directed
translational force of the humerus.
Compensatory scapular winging can
be seen with anterior shoulder elevation.9 For these patients, imaging
should include magnetic resonance
arthrography of the shoulder. Treatments include all modalities of nonsurgical treatment as well as surgical
management of refractory cases. PosMarch 2014, Vol 22, No 3

terior capsular plication and posterior

Bankart repair have been reported to
improve both function and pain.34

Summary
Posterior shoulder dislocation is a relatively uncommon pathology, with
several typical modes of presentation.
Dislocation often goes undiagnosed in
the acute setting in patients who present following seizure, electric shock, or
high-energy trauma. Thus, particular
attention is required to diagnose the
injury in these patients. Imaging stud-

ies should always include an axillary

or equivalent radiograph. CT and
MRI are both useful to diagnose
associated injuries, which are much
more frequent than previously
thought. Treatment is individualized
to each patient based on timing
of presentation, size of the reverse
Hill-Sachs lesion, and the presence of
associated injuries (ie, fracture, rotator
cuff tear, glenoid bone loss). Younger
patients are treated with soft-tissue
management with or without a bony
procedure, whereas older patients
may require arthroplasty to maintain
stability.

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Acute Traumatic Posterior Shoulder Dislocation

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