Shoulder and Elbow cases shoulder instability

A 24-year-old, male athlete sustains an anterior shoulder dislocation. His MRI is shown in Figure 2–32.

 

 

 

Figure 2–32

 

Which of the following ligaments is injured?

1. Anterior band of the inferior glenohumeral ligament

2. Posterior band of the inferior glenohumeral ligament

3. Superior glenohumeral ligament

4. Coracohumeral ligament

5. Middle glenohumeral ligament

 

Discussion

The correct answer is (A). The MRI demonstrates an HAGL lesion. The MR arthrogram shows fluid extending down the medial humerus and is indicative of an HAGL. Most commonly, with an anterior dislocation, the anterior band of the inferior glenohumeral ligament is torn. With a posterior dislocation, the posterior band is torn creating a reverse HAGL. The ligament tends to tear off the humeral side. These are important injuries to identify as arthroscopic labral repair and capsular shift may be unsuccessful without concomitant repair of the HAGL lesion. Many authors advocate an open approach to repair an HAGL lesion.

A sophomore, high school wide receiver presents to your clinic at the beginning of his football season. He reports a dislocation event after being tackled; his shoulder was “put back in place” by the on-field athletic trainer. A CT scan taken in the hospital today is shown (Fig. 2–33). He has been recruited by numerous colleges, plans to play at a division 1 school, and is very eager to return to the field.

 

 

 

Figure 2–33

 

What is the best treatment option for this patient?

1. Bracing, PT, and return to play this season once patient can tolerate sports specific drills

2. Bracing, PT, and sit out for the remainder of the season

3. Latarjet procedure

4. Magnuson–Stack procedure

5. ORIF of anterior glenoid

 

Discussion

The correct answer is (E). A large bony fragment (>20%) makes the failure rate with nonoperative treatment (Answers A, B) unacceptably high. This question is meant to illustrate the challenges associated with treating an in-season athlete and highlighting the indications for surgery after a first time dislocation event. Typically, early in a season, providers will initiate an aggressive PT program and try and return athletes to the field within a few weeks so that they can play out the remainder of the season. Towards the end of the season, when there is insufficient time to rehab a patient, one may choose early surgery so that the patient has maximal time to recover prior to the next season. In this case, even though the

patient is extremely motivated to return to the field and has only sustained a single dislocation event, the large bony Bankart lesion behooves surgical treatment. The best option for him would be to have early surgery and have a maximal amount of time to prepare for his senior season. A Latarjet procedure (Answer C) is used for patients with recurrent anterior instability and significant glenoid bone loss, and the Magnuson–Stack procedure (Answer D) is a largely historic procedure that was used for recurrent anterior instability.

 

Objectives: Did you learn...?

 

The common presentation of a patient with shoulder instability?

 

 

The concomitant injuries that frequently occur with a shoulder dislocation? The treatment options for first time dislocators?

 

The challenges associated with treating an in-season athlete?