40 HOW TO TREAT: SHOULDER INSTABILITY
40 HOW TO TREAT: SHOULDER INSTABILITY
16 MAY 2025 ausdoc. com. au
Table 1. Injuries that may be associated with a shoulder dislocation
Associated injuries
Bankart lesion
Bony Bankart lesion
Hill – Sachs lesion
Reverse Hill – Sachs lesion
Greater tuberosity fracture
Rotator cuff tears
Detail
Avulsion of the labrum
Fracture of the anterior inferior glenoid
Chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim in anterior dislocation
Chondral impaction injury in the anteromedial humeral head secondary to contact with the glenoid rim in posterior dislocation
Associated with anterior dislocation in patients older than 50
Increase after age 40
PAGE 38 the arm. An assistant may be helpful for applying countertraction with a towel or similar around the athlete’ s torso and pulling in the opposite direction. Once the arm is abducted, the humeral head will often reduce. The arm can then be placed in adduction( see figure 13).
Perform a post-reduction neurological assessment, with particular focus on axillary nerve function. Also examine for weakness in shoulder abduction and check for loss of sensation over the posterolateral aspect of the shoulder.
Carefully evaluate patients presenting in their 30s and older with a shoulder dislocation for a tear or an avulsion fracture of the rotator cuff. Perform an X-ray, and if concerned, an ultrasound. If there are no tendon injuries or fractures, patients over 40 can be managed non-operatively as the shoulder becomes tighter with advancing age and recurrence rates are low.
In younger patients( 17-40 years) recurrence rates after traumatic instability are high. 9
Non-operative care
This is indicated when the patient declines surgery or access to good surgical management is not available.
If immobilisation is considered, place the arm in external rotation using an external rotation pillow or brace for three weeks, both for day and night. Placing the shoulder in external rotation will force the Bankart lesion to re-appose to the glenoid neck. 10 Do not use a traditional sling. 11 Placing the arm in internal rotation will open the Bankart lesion and increase recurrence rates.
Figure 6. Bony Bankart lesion. 3D volume rendering CT of a large avulsed anteroinferior glenoid bony fragment( outlined by arrows) using surface rendering and subtraction of humeral head that will be treated by surgical fixation.
Surgical repair
The ease and technology for repairing Bankart lesions has advanced significantly. 12 The detached labrum can be reattached using suture anchors; these lodge in bone and the attached sutures can be passed through the labrum and capsule to reattach it to the anterior and inferior glenoid margins. The procedure can be performed arthroscopically
Figure 7. Schematic illustration of Hill – Sachs lesion.
Courtesy of Shoulderdoc. co. uk