Shoulder and Elbow cases Bony Bankart Hill–Sachs
A 33-year-old male presents to the ED after a fall during a soccer game. He reports significant right shoulder pain and limited ROM. An x-ray taken in the ED is shown below (Fig. 2–29).
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Figure 2–29
What is the next most appropriate step?
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Obtain an axillary view x-ray
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Recommend sling immobilization and no soccer for 1 week
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Recommend initiating gentle ROM and PT for a shoulder contusion
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Obtain an MRI to evaluate for a rotator cuff tear
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Obtain an MR arthrogram to evaluate for a labral tear
Discussion
The correct answer is (A). The ED image shown in Figure 2–29 includes only an AP view of the right shoulder. In the setting of an acute injury and pain, technicians may be hesitant to obtain additional views. A single view, however, is insufficient to diagnose either a fracture, as orthogonal views are required, or a shoulder dislocation which is best seen on an axillary view (see Fig. 2–30). Answers B and C are inappropriate as a diagnosis has not been established yet and a dislocation or fracture must be conclusively ruled out. Answers D and E may be options that are exercised in the clinic but do not represent the next step in the management of this patient.
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Figure 2–30 A: Axillary view. B: Axillary view with annotations.
Traumatic anterior instability is a common shoulder problem with an estimated incidence of 1.7%. This term encompasses both frank dislocations that require a manual reduction as well as incomplete subluxations that spontaneously reduce. It is particularly common in the young and athletic population, and it is significantly more common than other forms of instability including posterior or multidirectional instability. Understanding the natural history of anterior instability is important, as it serves as a guide to treatment. Young patients have a very high risk of recurrence; patients <20 years old have a 90% recurrence risk, between 20 and 40 years old have a 60% recurrence risk, and >40 years old have a 10% risk. Recurrent events are a predictor for arthritis and necessitate aggressive treatment, particularly in the young patient.
On evaluation, a thorough history and physical should be performed. Eliciting the mechanism and position of the arm at the time of dislocation can be helpful in determining the direction of primary instability. Anterior dislocations usually occur with the arm in an abducted and externally rotated position. If the patient presents with a nonreduced anteriorly dislocated shoulder, the arm is usually held in adduction and internal rotation; abduction of the arm is particularly limited. Prior to a reduction attempt, a thorough neurovascular examination must be performed paying close attention to the axillary nerve.
Generally speaking, treatment for first-time dislocators after the initial reduction involves conservative treatment in the form of physical therapy focusing on ROM and strengthening of the dynamic shoulder stabilizers. Some authors advocate a short duration of immobilization prior to initiating PT, although recent studies have failed to demonstrate any benefit to immobilization in either an externally or internally rotated position. After a single dislocation event, the need for surgery is often dictated by associated injuries. Glenoid bone loss >20%, a Hill-Sacks lesion >20% to 40%, a displaced fracture, an irreducible shoulder, or a large cuff tear in a young patient may be indicators for surgery. Recurrent instability after conservative management is considered a failure of treatment and is also an
indication for surgery.
Additional Questions
A 19-year-old woman presents to your clinic after a single dislocation episode that occurred during a motor vehicle accident. Her shoulder was reduced on the field.
What is the likelihood that she will have a successful outcome with nonoperative treatment?
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20%
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40%
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60%
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80%
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95%
Discussion
The answer is (A). It has been shown that traumatic dislocations in young patients have a high rate of recurrence. Patients with hyperlaxity who dislocate without a large traumatic event have a higher success rate with nonoperative treatment. Nevertheless, nonoperative treatment is still the initial modality of choice in this patient.
A 22-year-old, recreational basketball player dislocates his shoulder during a game. A reduction is performed on the field and he comes to see you in clinic 1 week later.
What will his MR arthrogram most likely show?
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Labral tear
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Rotator cuff tear
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Biceps tendon subluxation
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Hill–Sachs lesion
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ALPSA lesion
Discussion
The correct answer is (A). In a young patient, the most likely injury associated with a glenohumeral dislocation is a labral tear (see Fig. 2–31). In an older patient, >40 years old, a rotator cuff tear is more likely. Other possible associated injuries include:
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Figure 2–31 MRA demonstrating an anterior labral tear.
Bony Bankart Hill–Sachs
Humeral avulsion of the glenohumeral ligament (HAGL) Glenoid labral articular defect (GLAD)
Anterior labral periosteal sleeve avulsion (ALPSA) Fracture
Axillary nerve injury (estimated to occur 5% of the time)
These all are less common than a labral tear. Each of these injuries need to be identified and treated appropriately at the time of surgery to ensure a satisfactory outcome.