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Acute posterior shoulder dislocations are severe and possibly easily missed injuries. High clinical suspicion, a properly performed physical evaluation, and the appropriate shoulder imaging are necessary in order to diagnose and manage these injuries timely and efficiently. Treatment may be closed reduction and immobilization with the arm slightly abducted and externally rotated for 4–6 weeks. The size of the humeral head defect (reverse Hill–Sachs lesion) should determine if some kind of tendon transfer or humeral head reconstruction by the use of an articular allograft is indicated. When the humeral head defect exceeds 45% of the articular surface, prosthetic replacement is considered.