BANKART LESION

BY DR LC MULUNGWA10 SEPTEMBER 2011

24 yrs old male soccer player.Playing as a goalkeeper-first choice for a semi-professional club.Complaining of R shoulder pain for 3/52.Aggravated by activity and relieved by rest.

Had a shoulder dislocation prior that 2/12.Reduced and given pain killers, arm sling for 2/52(GP). Attended physio for 3/52 then returned full activity.Pain started after two matches incr. In intensity after each activity.

PAST HISTORY OF INJURIES

No history of recurrent shoulder dislocations.

EXAMINATION

Local examination: Right shoulder.No joint deformity on inspection.Active and passive movements (Arm elevation, internal-external rotation) all restricted due to tenderness.

AC joint exam good.Hawkins/Kennedy test negative.Anterior drawers/Apprehession test positive.Rotator cuff tests negative.

ASSESMENTClinical:-Glenohumeral instability. -Labral tear.Individual-concerned about the time will spent out of the game.

-his position in the team. -continue participating in sport.

Contextual-coach more worried about his position

INVESTIGATION1) X-RAY-Labral tears

PLAN

Consulted Orthopaedic surgeon for Arthroscopy and repair. Referred to physio for a rehabilitation . Psychologist. NSAIDS-DICLOFENAC.

Follow-up was done after 6/52-active strengthening started.Continue with rehabilitation further 8/52. Review done –good range of motion in all direction achieved.RTS recommended after training with the team for 2/52.After 2/52 he started the game and maintained his position.

DISCUSSIONAnatomy 3 Bones

HumerusScapulaClavicle

3 JointsGlenohumeralAcromioclavicularSternoclavicular

1 “Articulation”Scapulothoracic

ScapulaGlenoidAcromionCoracoidSubscapular fossaScapular spineSupraspinatus fossaInfraspinatus fossaGreat scapular notchSuprascapular notch

Anteroinferior labral tear of glenoid.Might be due to inferior glenohumeral ligament tear.15% follows ant. Dislocation (G.Ansede et al,BJSM 2011;45;70-72). Often accompanied by Hill-Sachs lesion-compression fracture of humeral head posteriorly.

Perthes lesion is a variation of Bankart lesion-non displaced tear of the anteroinferior labrum held in position by an intact medial scapular periosteum.ALPSA-similar to Perthes lesion except labrum is displaced. (Neviaser TJ, Arthroscopy 1993;9:17).

Bankart Clinical EvaluationOccurs following traumatic dislocation.May have clicking or popping with shoulder motion. Symptoms- Sense of instability, Catching sensation, Shoulder achingApprehension Test and Relocation Test or Load and shiftEvaluate axillary nerve function

Bankart Associated Injuries / Differential DiagnosisHill-Sachs lesionSLAP RTC Tear Shoulder Instability HAGL lesion ALPSA Perthes lesion GLAD lesion: glenolabral articular disruption: nondisplaced anterior labral tear associated with articular cartilage injury

Bankart ComplicationsRecurrent instability / failure Infection Stiffness CRPS Nerve injury: Axillary nerve, Brachial plexus Fluid Extravasation: Chondrolysis: though to be related to heat from electo cautery or radiofrequency probes used during capsular release or capsular shrinkage. Hematoma Chondral Injury / arthritis

INVESTIGATIONS X-RAY-A/P,Lateral and axillary view.(generally normal). CT scan is best to evaluate bony anatomy and should be considered for the recurrent dislocator suspected of having a large Hill-Sachs or bony Bankart lesion. MRI arthrogram.ARTHROSCOPY.

TREATMENT

Conservative managementArthroscopic repair techniques: (Sugaya H, JBJS 2006;88Am:159), (Millett PJ, Arthroscopy 2008)

Consider primaryAnterior instability repair for hightly athletic young (<25y/o) patients with MRI confirmed Bankart lesions. Bony Bankart Lesion:-If >25% of the glenoid is involved in a bony-Bankart lesion (anterior rim fracture) the joint will be unstable without ORIF of the bony lesion, or bone grafting the defect. (Bigliani LU, AJSM 1998;26:41)

Bankart Follow-up CarePost-Op:Shoulder immobilizer. Begin pendelum ROM, elbow/wrist/hand exercises immediately. 7-10 Days: continue shoulder immobilizer for 4-6weeks. Start Physical therapy, active assist and active ROM; No external rotation past 40 degrees for 6 weeks.

6 Weeks: discontinue shoulder immobilizer. Progress with strengthening exercises. 3 Months: Progess with ROM and strengthening, start sport specific training. 6 Months: Return to sport if patient has full ROM, near full strength and no apprehension

Outcomes 90% excellent or good results, 10% recurrent instability . Average ASES score = 92 of 100 points. Patient satisfaction = 8.9 on a 10-point visual analog scale. (Carreira DS, AJSM 2006;34:771). 11% recurrence for collision/contact athletes (Mazzoca AD, AJSM 2005;33:52).

TAKE HOME MESSAGE

Check associated injuries/PathologyPsychological intervention plays integral part.Communication best in management