Anatomy and Pathoanatomy
Mechanisms of Injury
Signs and Symptoms
Imaging and Other Diagnostic Studies
Author’s Preferred Diagnostic Work-Up
Common Surgical Approaches
Open Anterior Approach
Open Posterior Approach
Arthroscopic Approach and Portal Placement
Recurrence of Instability
Loss of Motion
Authors’ Preferred Treatment
Controversies and Future Directions
Treatment After Initial Traumatic Anterior Dislocation
Management of Bone Loss
The Role of Open Capsulorrhaphy
Reproduced from Robinson CM, Howes J, Murdoch H, et al. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am. 2006;88(11):2326–3336.
In the emergency room, with a reduced dislocation, we prefer a true AP or Grashey view to evaluate the concentricity of the joint and signs of glenoid or proximal humerus fracture; an apical oblique or Garth view to better view a glenoid fracture; and a Velpeau or trauma axillary to clearly determine the reduction of the joint. None of these views require the patient to remove the sling. If there is any question of joint reduction, a CT scan is performed—though this is uncommon.
The evaluation of the patient with recurrent instability in the office setting requires the same views as in the acute setting, but a Stryker–Notch view is added to evaluate for the Hill–Sachs defect. If there is little concern for bone loss based on the history and radiographs, a high-resolution conventional MRI is our preferred study to not only evaluate for a capsular tear but for other pathology such as a HAGL or a rotator cuff tear. Given the high quality of current MRI scanners as well as the invasive nature and the additional cost of arthrography, MR arthrography is not routinely used.
If bone loss is a major concern, a CT scan is ordered. With the improvement of CT arthrograms, however, this may be the single ideal study, however, the quality of the imaging differs between institutions. Consideration of patient age, the additional radiation of CT scans, and the invasive nature is always considered before pursuing this study.
Last, if there is any question of the degree of bone loss, the engagement of the Hill–Sachs, the quality of tissue or the presence of other intra-articular pathology, a diagnostic arthroscopy is performed.