BY DR LC MULUNGWA 10 SEPTEMBER 2011 BANKART LESION BY DR LC MULUNGWA 10 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.

ASSESMENT Clinical:-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

INVESTIGATION 1) X-RAY-Labral tears

Consulted Orthopaedic surgeon for Arthroscopy and repair. 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.

DISCUSSION Anatomy 3 Bones Humerus Scapula Clavicle 3 Joints Glenohumeral Acromioclavicular Sternoclavicular 1 “Articulation” Scapulothoracic

Scapula Glenoid Acromion Coracoid Subscapular fossa Scapular spine Supraspinatus fossa Infraspinatus fossa Great scapular notch Suprascapular 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 Evaluation Occurs following traumatic dislocation. May have clicking or popping with shoulder motion. Symptoms- Sense of instability, Catching sensation, Shoulder aching Apprehension Test and Relocation Test or Load and shift Evaluate axillary nerve function

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

Bankart Complications Recurrent 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 management Arthroscopic 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 Care Post-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 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/Pathology Psychological intervention plays integral part. Communication best in management