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Management after a first traumatic shoulder dislocation varies widely, from prolonged immobilisation to rapid mobilisation. A multidisciplinary guideline published in Acta Orthopaedica on 10 August 2026 sets out a structured pathway: confirm the diagnosis and reduction with imaging, avoid routinely prolonged immobilisation, restore function early and assess recurrence risk from the outset.
Why this guideline matters
A 20-year-old contact-sport athlete and a 65-year-old woman after a fall have different risks of recurrence, fracture, rotator cuff injury and reduction-related complications. The guideline combines orthopaedics, trauma surgery, emergency medicine, radiology, physiotherapy and patient representation. It addresses seven areas: diagnosis, reduction technique, analgesia for reduction, immobilisation, physiotherapy, recurrence risk and primary surgical stabilisation.
Imaging before and after reduction
Radiographs in at least two orthogonal views are recommended both before and after reduction. They confirm dislocation, identify associated fractures, document restored alignment and help exclude iatrogenic injury. CT is indicated when imaging remains unclear or complex bony injury is suspected. Ultrasound should not replace radiographs in this acute setting.
Reduction technique
No single technique was identified as universally best. The operator should use a familiar technique and preferably start with a gentle biomechanical method based on scapular and humeral positioning rather than substantial traction. After a failed attempt, reassess the clinical situation and possible mechanical obstacles before trying again. Rarely, reduction in the operating theatre is required.
Analgesia and sedation
Routine sedation is not required for every first reduction attempt. Analgesia should reflect the patient’s condition, team experience and emergency department resources. If an attempt without deeper sedation fails, procedural sedation with analgesia becomes the recommended first-choice approach. This recommendation largely reflects expert opinion and safety considerations because no studies met the review criteria for this question.
Immobilisation and early function
The guideline recommends approximately 1 week of relative immobilisation, using a sling mainly for comfort and pain relief. After the acute phase, early functional recovery should address rotator cuff activity, coordination and proprioception. Routinely extending immobilisation solely to reduce recurrence is not supported.
Recurrence risk and early stabilisation
Younger age and male sex are important recurrence factors, but assessment must also consider activity, contact or overhead sports, and glenoid and humeral bone defects. Discussion of primary surgical stabilisation is particularly relevant for patients under 40, contact-sport athletes and those with substantial bone loss. These factors are not automatic indications for surgery.
In the studies considered by the guideline, early arthroscopic Bankart stabilisation was associated with recurrence in approximately 8.9% versus 49% after nonoperative treatment. Return to sport was approximately 90% versus 62%. These striking figures come from selected populations and are not universal forecasts; certainty for some recommendations was low or very low.
Implications for an orthopaedic surgeon’s practice
Management should reflect the individual risk profile. Older patients require particular attention to fractures and rotator cuff injury. Young contact-sport athletes need an early discussion of recurrence and potential benefits of stabilisation. Across the pathway, key principles are radiographs before and after reduction, brief sling use and early restoration of function.
Limitations
- Many recommendations rest on low- or very-low-certainty evidence.
- No studies met the review criteria for reduction analgesia or physiotherapy, so these recommendations rely largely on expert opinion.
- Selection for primary surgery requires individual assessment rather than one age cutoff.
- The guideline addresses first-time traumatic anterior dislocation, not every form of shoulder instability.
What remains individualised
The guideline does not imply that every young patient needs surgery after a first dislocation or that 1 week of sling use suits every associated injury, such as a greater tuberosity fracture. It provides a pathway for identifying patients who need a different approach from standard nonoperative care.
References
Van Gastel ML, Hekman KMC, Boon F, Nelen SD, Schep NWL, Van der Meijden OAJ, Baden DN, Jonkergouw MAT, Huygen LE, Balemans ACJ, Griekspoor M, Derksen RJ, Van den Bekerom MPJ. Clinical practice on treatment of primary traumatic anterior shoulder dislocation: a multidisciplinary guideline. Acta Orthopaedica. 2026;97:531–537. DOI: 10.2340/17453674.2026.46434. PubMed: PMID 42573533. Full text: PubMed Central.
The article is open access under CC BY 4.0.
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Content prepared by: Tomasz Poboży - orthopaedic surgeon.