shoulder joint dislocation is the most common joint dislocation in the emergency department ( 8 to 17 cases/100  000 inhabitants / year ) . in 95% of cases , the upper end of the humerus is pushed out of the joint socket in a forward direction , usually as a result of a low - energy accident . the shoulder joint has the greatest range of motion of all the joints in the human body ; for this reason it is the most unstable joint . once a dislocation has occurred , the shoulder is more susceptible to re - dislocation . in the literature , traumatic dislocation may cause damage to the soft - tissues surrounding the shoulder joint and sometimes to the bone . in the classical bankart lesion , the separation of the anterior capsule and the labrum from the glenoid rim occurs ; sometimes it can be accompanied by a glenoid rim fracture ( bony - bankart ) . associated lesions such as humeral avulsion of the glenohumeral ligaments ( hagl ) , extended labral detachment , rotator cuff tendon tears and impaction fractures of the humeral head ( hill - sachs lesion ) can also occur . the treatment for shoulder dislocation , which aims at restoration of a fully functioning , pain - free and stable shoulder , includes either conservative ( non - surgical ) or surgical management . both are generally preceded by closed reduction of the acute dislocation ( figs 1 and 2 ) . subsequent conservative management usually requires a period of rest , generally involving immobilisation of the arm in a sling , for three to six weeks , followed by a supervised physiotherapy and rehabilitation programme . operative management , which may involve open or arthroscopic surgery , incorporates soft - tissue reconstructions ( repair of labral detachment with or without capsular shift ) and/or bony procedures ( e.g. transfer of the coracoid process ) and is usually followed by a supervised physiotherapy programme . left shoulder fracture - dislocation before reduction . left shoulder fracture - dislocation after reduction . even though the literature is currently unclear about the best procedure to use after the first shoulder dislocation , the available data support primary surgery in young adults ( usually male ) engaged in highly demanding physical activities ( military personnel and athletes ) . in 2008 , hovelius and saeboe also demonstrated that shoulders that suffer only a single dislocation are at risk for arthropathy and identified different risk factors .. considering conservative management , it is still debated whether to immobilise the shoulder in internal or external rotation . handoll et al did not find any difference in recurrence rate ; in a recent update of his systematic review , the authors did not report any difference between these two strategies in terms of healing and return to sports . this kind of immobilisation can reduce the labrum back to a more anatomical position . however , these results have proven difficult to reproduce in later studies . one review addresses all surgical versus all non - surgical treatments , showing increased recurrence in the non - surgical group . furthermore , kirkley and wintzell reported a delayed re - dislocation in the surgical group . with regard to surgical treatment , there are no significant differences in terms of re - dislocation rates between open and arthroscopic repair . during the last decade , a marked shift from open shoulder stabilisation to arthroscopic surgery has occurred . the latarjet procedure ( open and arthroscopic ) ( figs 3 and 4 ) is a well - recognised and accepted technique for surgical treatment of anterior instability associated with significant bone defects . the procedure , performed in the  beach - chair position , involves transfer of the horizontal limb of the coracoid process along with the conjoint tendon to the anterior glenoid rim for reconstruction of the glenoid bone loss . the procedure was first described by latarjet in 1955 and several modifications have evolved thereafter . recently , lafosse and boyle described an arthroscopic technique for this procedure giving a safe and reproducible coracoid fixation to the deficient anterior glenoid . lateral view of laterjet procedure . for the bankart procedure ( performed arthroscopically ) , the lateral decubitus position is the predominant position for the operation . in the systematic review by frank et al , lower recurrence rates were noted using the lateral decubitus in comparison with the supine decubitus position , with no differences in terms of functional outcome and return to sport . an analysis of the technical aspects of the arthroscopic bankart procedure , as performed in the united states , shows that three portals are usually used for working portals , three anchors are preferred and these are generally single - loaded and have a bio - composite structure . no differences in re - dislocation rates have been reported with absorbable or non - absorbable implants . a simple suture configuration is used ; anterior portal viewing , trans - subscapularis approach and additional posterior anchors or capsular sutures are infrequently used . hiemstra et al reported no difference in rotational strength after open or arthroscopic surgery but the overall strength is decreased compared with the contralateral shoulder . only one randomised controlled trial reported better functional and disability scores after arthroscopic repair compared with open surgery . a systematic review analysed the differences between arthroscopic stabilisation after the first episode of dislocation compared with stabilisation after recurrent instability and reported no difference in dislocation recurrence or complication rate , although the studies were not entirely comparable with regard to different surgical techniques and rehabilitations protocols . early mobilisation favourably affects pain and functional recovery in the first months but it does not affect recurrence rate or functional results at final outcome ( table 1 ) . recurrence rate and range of motion for any procedure ns , no statistically significant difference in redislocation rate ; na , not available for all first - time dislocators , non - operative management is favoured at our institution . this is particularly the case for those with multi - directional instability or those with soft - tissue laxity . those with multi - directional instability with recurrent and debilitating laxity may be treated with open capsular shifts . conservative measures are often much preferred in older patients or younger patients that are not actively engaged in overhead activities , which may include baseball , hurling or pull - ups . however , younger more active patients are known to have a higher recurrence rate . in fact , at the united states military academy , 85% of patients who had a shoulder dislocation went on to have some type of instability event within nine months . these patients are subject to rigorous daily physical training and may not necessarily reflect the average adult population . it showed that only one - third of patients experienced later instability . despite a recent trend towards immediate stabilisation in first - time dislocators , we believe that , given the findings of sachs et al , immediate surgery on all first - time dislocators may subject many patients to surgery who would not have any future instability . the latest update of the biggest study on first - time dislocators suggests that , although more than 50% of young ones tended to recur , treating all patients surgically is almost certainly overtreatment . it is important to note that complication rates have not been considered in this study . wait and see approach and good communication between surgeon and patient about when to treat is probably the best option . 5 ) . for these reasons , we will always try physical therapy and activity modification for the vast majority of our patients initially . watch and wait , strict surveillance and immediate re - evaluation in case of recurrence are the best options in deciding whether to perform surgery or not . no benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article .
shoulder joint dislocation is the most common joint dislocation seen in the emergency department.traumatic dislocation may cause damage to the soft - tissues surrounding the shoulder joint and sometimes to the bone . 
 the treatment , which aims at restoration of a fully functioning , pain - free and stable shoulder , includes either conservative or surgical management preceded by closed reduction of the acute dislocation.conservative management usually requires a period of rest , generally involving immobilisation of the arm in a sling , even though it is still debated whether to immobilise the shoulder in internal or external rotation.operative management , with no significant differences in term of re - dislocation rates between open and arthroscopic repair , incorporates soft - tissue reconstructions and/or bony procedures and is recommended in young male adults engaged in highly demanding physical activities.at our institution , non - operative management is favoured particularly for patients with multi - directional instability or soft - tissue laxity . 
 conservative measures are often preferred in older patients or younger patients that are not actively engaged in overhead activities . 
 immediate surgery on all first - time dislocations may subject many patients to surgery who would not have had any future subluxation.for these reasons , initially we will always try physical therapy and activity modification for the vast majority of our patients.cite this article : efort open rev 2017;2:35 - 40.doi : 10.1302/2058 - 5241.2.160018 .