History

Children presenting with a dislocated shoulder may relate a couple of possible mechanisms. These mechanisms occur in a number of ways and are similar to those in adults. Most commonly, the child falls on the outstretched hand, forcing the arm into abduction and external rotation, levering the humeral head out of the glenoid cavity. Activities promoting this injury include contact sports, falls from heights, fights, and motor vehicle accidents. Other mechanisms have been described, including elevation with external rotation and direct blows.

A history of prior dislocations suggests a high likelihood of anterior glenohumeral instability. Studies have shown a 70-100% recurrence rate in various population groups of patients younger than 20 years.

Physical Examination

As with physical examinations of any joint, beginning by observing the shoulder is important. Note any atrophy of the biceps, supraspinatus, or infraspinatus. Gross deformities can also suggest the direction of a dislocation.

Range of motion (ROM) of the shoulder must be tested for restriction or hypermobility. Atraumatic instability generally manifests with hypermobility of the shoulder, whereas traumatic instability typically results in bilaterally symmetric motion. Generalized joint laxity is demonstrated by extending the elbow, wrist, metacarpophalangeal (MCP), and distal interphalangeal (DIP) joints. External rotation can be increased as much as 28° or decreased as much as 14° after dislocation.

Next, the examiner manually assesses translation of the humeral head in the glenoid fossa. The humeral head is grasped in one hand, and the clavicle and scapula are stabilized in the other as the examiner pushes anteriorly and posteriorly. This is known as a shoulder drawer sign. Compared with the unaffected shoulder, the affected shoulder often demonstrates increased laxity. Remember that as much as 50% of posterior translation may be normal.

A sulcus sign is demonstrated by pulling inferiorly on the relaxed shoulder. A sulcus observed between the acromion and proximal humeral head is considered a positive finding. This finding indicates that the shoulder has multidirectional instability.

The key finding in anterior glenohumeral instability is a positive apprehension test. The arm is placed in abduction, extension, and external rotation while being stressed in anterior translation. If the patient becomes apprehensive and reports pain, this is considered a positive finding. It is important to note that pain alone does not constitute a positive apprehension test: The patient must report apprehension.

The relocation test involves placing the shoulder in the position of apprehension and applying a posteriorly directed force on the humeral head. The result is considered positive if this relieves the patient's apprehension.

The anterior release or surprise test is sensitive and specific for clinically diagnosing anterior shoulder instability.^[16]

Impingement signs must also be evaluated because as many as 10% of patients experience impingement after dislocation. Evaluate for the Hawkins sign, and perform the Neer impingement test.

Workup

Varacallo M, Musto MA, Mair SD. Anterior Shoulder Instability. Treasure Island, FL: StatPearls; 2020. [Full Text].
Dodson CC, Cordasco FA. Anterior glenohumeral joint dislocations. Orthop Clin North Am. 2008 Oct. 39 (4):507-18, vii. [QxMD MEDLINE Link].
Cox CL, Kuhn JE. Operative versus nonoperative treatment of acute shoulder dislocation in the athlete. Curr Sports Med Rep. 2008 Sep-Oct. 7 (5):263-8. [QxMD MEDLINE Link].
Bankart ASB. Recurrent or habitual dislocation of the shoulder joint. Br Med J. 1923. Dec 15:1132-1133.
DU TOIT GT, ROUX D. Recurrent dislocation of the shoulder; a twenty-four year study of the Johannesburg stapling operation. J Bone Joint Surg Am. 1956 Jan. 38-A (1):1-12. [QxMD MEDLINE Link].
Latarjet J. A propos du traitment des luxations recidivantes di l'epaule. Lyon Chir. 1954. 49:994-997.
Delorme. Die Hemmungsbander des Schultergelenks und ihre Bedeutung fur die Schulterluxationen. Arch klin Chir. 1910. 92:79-101.
Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med. 1990 Jan-Feb. 18 (1):25-8. [QxMD MEDLINE Link].
ROWE CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956 Oct. 38-A (5):957-77. [QxMD MEDLINE Link].
Kitayama S, Sugaya H, Takahashi N, Matsuki K, Kawai N, Tokai M, et al. Clinical Outcome and Glenoid Morphology After Arthroscopic Repair of Chronic Osseous Bankart Lesions: A Five to Eight-Year Follow-up Study. J Bone Joint Surg Am. 2015 Nov 18. 97 (22):1833-43. [QxMD MEDLINE Link].
Mook WR, Petri M, Greenspoon JA, Horan MP, Dornan GJ, Millett PJ. Clinical and Anatomic Predictors of Outcomes After the Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability With Combined Glenoid and Humeral Bone Defects. Am J Sports Med. 2016 Jun. 44 (6):1407-16. [QxMD MEDLINE Link].
Atef A, El-Tantawy A, Gad H, Hefeda M. Prevalence of associated injuries after anterior shoulder dislocation: a prospective study. Int Orthop. 2016 Mar. 40 (3):519-24. [QxMD MEDLINE Link].
Olds M, Ellis R, Donaldson K, Parmar P, Kersten P. Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis. Br J Sports Med. 2015 Jul. 49 (14):913-22. [QxMD MEDLINE Link].
Chalmers PN, Mascarenhas R, Leroux T, Sayegh ET, Verma NN, Cole BJ, et al. Do arthroscopic and open stabilization techniques restore equivalent stability to the shoulder in the setting of anterior glenohumeral instability? a systematic review of overlapping meta-analyses. Arthroscopy. 2015 Feb. 31 (2):355-63. [QxMD MEDLINE Link].
Bliven KCH, Parr GP. Outcomes of the Latarjet Procedure Compared With Bankart Repair for Recurrent Traumatic Anterior Shoulder Instability. J Athl Train. 2018 Feb. 53 (2):181-183. [QxMD MEDLINE Link].
Lizzio VA, Meta F, Fidai M, Makhni EC. Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability. Curr Rev Musculoskelet Med. 2017 Dec. 10 (4):434-441. [QxMD MEDLINE Link]. [Full Text].
Bigliani LU, Kurzweil PR, Schwartzbach CC. Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med. 1994. 22:578-584. [QxMD MEDLINE Link].
Delage Royle A, Balg F, Bouliane MJ, Canet-Silvestri F, Garant-Saine L, Sheps DM, et al. Indication for Computed Tomography Scan in Shoulder Instability: Sensitivity and Specificity of Standard Radiographs to Predict Bone Defects After Traumatic Anterior Glenohumeral Instability. Orthop J Sports Med. 2017 Oct. 5 (10):2325967117733660. [QxMD MEDLINE Link]. [Full Text].
Kompel AJ, Li X, Guermazi A, Murakami AM. Radiographic Evaluation of Patients with Anterior Shoulder Instability. Curr Rev Musculoskelet Med. 2017 Dec. 10 (4):425-433. [QxMD MEDLINE Link]. [Full Text].
Martins e Souza PM, Brandão BL, Brown E, Motta G, Monteiro M, Marchiori E. Recurrent anterior glenohumeral instability: the quantification of glenoid bone loss using magnetic resonance imaging. Skeletal Radiol. 2014 Aug. 43 (8):1085-92. [QxMD MEDLINE Link].
Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg Am. 1992 Sep. 74 (8):1242-4. [QxMD MEDLINE Link].
Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med. 1984 Jan-Feb. 12 (1):19-24. [QxMD MEDLINE Link].
Deitch J, Mehlman CT, Foad SL, Obbehat A, Mallory M. Traumatic anterior shoulder dislocation in adolescents. Am J Sports Med. 2003 Sep-Oct. 31 (5):758-63. [QxMD MEDLINE Link].
Hovelius L, Eriksson K, Fredin H, Hagberg G, Hussenius A, Lind B, et al. Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment. J Bone Joint Surg Am. 1983 Mar. 65 (3):343-9. [QxMD MEDLINE Link].
Wheeler JH, Ryan JB, Arciero RA, Molinari RN. Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy. 1989. 5 (3):213-7. [QxMD MEDLINE Link].
Valenti P, Maroun C, Schoch B, Arango SO, Werthel JD. Arthroscopic Trillat Coracoid Transfer Procedure Using a Cortical Button for Chronic Anterior Shoulder Instability. Arthrosc Tech. 2019 Feb. 8 (2):e199-e204. [QxMD MEDLINE Link]. [Full Text].
Budoff JE, Wolf EM. Arthroscopic treatment of glenohumeral instability. J Hand Surg Am. 2006 Oct. 31 (8):1387-96. [QxMD MEDLINE Link].
Scheibel M, Habermeyer P. Subscapularis dysfunction following anterior surgical approaches to the shoulder. J Shoulder Elbow Surg. 2008 Jul-Aug. 17 (4):671-83. [QxMD MEDLINE Link].
Owens BD, Harrast JJ, Hurwitz SR, Thompson TL, Wolf JM. Surgical trends in Bankart repair: an analysis of data from the American Board of Orthopaedic Surgery certification examination. Am J Sports Med. 2011 Sep. 39 (9):1865-9. [QxMD MEDLINE Link].
Arciero RA, Spang JT. Complications in arthroscopic anterior shoulder stabilization: pearls and pitfalls. Instr Course Lect. 2008. 57:113-24. [QxMD MEDLINE Link].
Larrain MV, Montenegro HJ, Mauas DM, Collazo CC, Pavón F. Arthroscopic management of traumatic anterior shoulder instability in collision athletes: analysis of 204 cases with a 4- to 9-year follow-up and results with the suture anchor technique. Arthroscopy. 2006 Dec. 22 (12):1283-9. [QxMD MEDLINE Link].
Westerheide KJ, Dopirak RM, Snyder SJ. Arthroscopic anterior stabilization and posterior capsular plication for anterior glenohumeral instability: a report of 71 cases. Arthroscopy. 2006 May. 22 (5):539-47. [QxMD MEDLINE Link].
Iizawa N, Yoneda M, Yamada S, Mizuno N, Goto K, Iwashita S, et al. Benefits of bone graft augmentation to arthroscopic Bankart repair for recurrent anterior shoulder instability with glenoid bone loss. Knee Surg Sports Traumatol Arthrosc. 2019 Oct 30. [QxMD MEDLINE Link].
Plath JE, Henderson DJH, Coquay J, Dück K, Haeni D, Lafosse L. Does the Arthroscopic Latarjet Procedure Effectively Correct "Off-Track" Hill-Sachs Lesions?. Am J Sports Med. 2018 Jan. 46 (1):72-78. [QxMD MEDLINE Link].
Ranne JO, Kainonen TU, Lehtinen JT, Heinonen OJ. Modified arthroscopic latarjet procedure with coracoid exteriorization for treatment of anterior glenohumeral instability. Arthrosc Tech. 2013. 2 (4):e361-5. [QxMD MEDLINE Link]. [Full Text].
Ali J, Altintas B, Pulatkan A, Boykin RE, Aksoy DO, Bilsel K. Open versus Arthroscopic Latarjet Procedure for the Treatment of Chronic Anterior Glenohumeral Instability with Glenoid Bone Loss. Arthroscopy. 2019 Dec 20. [QxMD MEDLINE Link].
de Beer JF, Roberts C. Glenoid bone defects--open latarjet with congruent arc modification. Orthop Clin North Am. 2010 Jul. 41 (3):407-15. [QxMD MEDLINE Link].
Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000 Oct. 16 (7):677-94. [QxMD MEDLINE Link].
Woodmass JM, Wagner ER, Solberg M, Hunt TJ, Higgins LD. Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability. JBJS Essent Surg Tech. 2019 Jul-Sep. 9 (3):e31. [QxMD MEDLINE Link].
Edwards TB, Walch G. The Latarjet procedure for recurrent anterior shoulder instability: rationale and technique. Oper Techn Sports Med. 2012 Mar. 20 (1):57-64.
Bessière C, Trojani C, Carles M, Mehta SS, Boileau P. The open latarjet procedure is more reliable in terms of shoulder stability than arthroscopic bankart repair. Clin Orthop Relat Res. 2014 Aug. 472 (8):2345-51. [QxMD MEDLINE Link].
Young AA, Maia R, Berhouet J, Walch G. Open Latarjet procedure for management of bone loss in anterior instability of the glenohumeral joint. J Shoulder Elbow Surg. 2011 Mar. 20 (2 Suppl):S61-9. [QxMD MEDLINE Link].
Iordens GI, Van Lieshout EM, Van Es BC, Schep NW, Breederveld RS, Patka P, et al. Outcome after modified Putti-Platt procedure for recurrent traumatic anterior shoulder dislocations. Strategies Trauma Limb Reconstr. 2013 Nov. 8 (3):141-7. [QxMD MEDLINE Link].
Puskas GJ, Giles JW, Degen RM, Johnson JA, Athwal GS. Humeral head reconstruction for Hill-Sachs defects: a biomechanical comparison of 2 fixation techniques for bone grafting. Arthroscopy. 2014 Jan. 30 (1):22-8. [QxMD MEDLINE Link].
Park MJ, Tjoumakaris FP, Garcia G, Patel A, Kelly JD 4th. Arthroscopic remplissage with Bankart repair for the treatment of glenohumeral instability with Hill-Sachs defects. Arthroscopy. 2011 Sep. 27 (9):1187-94. [QxMD MEDLINE Link].
Nourissat G, Kilinc AS, Werther JR, Doursounian L. A prospective, comparative, radiological, and clinical study of the influence of the "remplissage" procedure on shoulder range of motion after stabilization by arthroscopic Bankart repair. Am J Sports Med. 2011 Oct. 39 (10):2147-52. [QxMD MEDLINE Link].
Zuckerman JD, Matsen FA 3rd. Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg Am. 1984 Feb. 66 (2):175-80. [QxMD MEDLINE Link].

Media Gallery

Y-view radiograph of the right shoulder shows anterior dislocation of the humeral head relative to the glenoid fossa
Upper - Type I superior labrum anterior posterior lesion. Lower - Type II superior labrum anterior posterior lesion.
Upper - Type III superior labrum anterior posterior lesion. Lower - Type IV superior labrum anterior posterior lesion.

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Author

Amin H Afsari, DO General Orthopedic and Hand/Upper Extremity Surgeon, Lakeshore Medical Clinic

Amin H Afsari, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Osteopathic Association, American Society for Surgery of the Hand, American Osteopathic Academy of Orthopedics

Disclosure: Nothing to disclose.

Coauthor(s)

Alexander W Nielsen Medical College of Wisconsin

Disclosure: Nothing to disclose.

Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Sections Anterior Glenohumeral Instability
Overview
Presentation
Workup
Treatment
Media Gallery
References

Anterior Glenohumeral Instability Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

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