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Introduction
  • Commonly referred to as a reverse Bankart lesion
  • Epidemiology
    • demographics
      • may occur in all athletes due to trauma
      • most commonly occur in 
        • football linemen (blocking)
        • weightlifters (bench press) 
  • Pathophysiology
    • mechanism
      • usually from a posteriorly directed force with arm flexed, adducted, and internally rotated
  • Associated injuries
    • Kim lesion
      • is an incomplete and sometimes concealed avulsion of posterior labrum
Anatomy
  • Posterior labrum
    • function
      • helps create cavity-compression and creates 50% of the glenoid socket depth
      • provides posterior stability
    • anatomy
      • composed of fibrocartilagenous tissue
      • anchors posterior inferior glenohumeral ligament (PIGHL)
  • See complete Glenohumeral joint anatomy 
Presentation
  • Symptoms 
    • shoulder pain
    • sense of instability
    • mechanical symptoms (clicking, popping) with range of motion
  • Physical exam
    • posterior joint line tenderness
    • provocative tests
      • Posterior Load and Shift
      • Jerk test
        • subluxation with posteriorly applied force while arm is in flexion and internal rotation
      • Kim test
        • subluxation with posteriorly applied force as arm is dynamically adducted by examiner
Imaging
  • Radiographs
    • recommended views
      • complete shoulder series
    • findings
      • are often normal
  • MRI 
    • diagnostic study of choice
    • intra-articular contrast (MRI arthrogram) increases sensitivity for labral pathology
Treatment
  • Nonoperative
    • NSAIDs, PT
      • indications
        • first line of treatment
      • technique
        • rotator cuff strengthening and periscapular stabilization
  • Operative
    • posterior labral repair with capsulorrhaphy 
      • indications
        • extensive nonoperative management fails
      • technique
        • both open and arthroscopic techniques can be used
        • probing of posterior labrum is required to rule out a subtle Kim lesion 
Complications
  • Axillary nerve palsy
    • posterior branch of the axillary nerve is at risk during arthroscopic stabilization 
      • travels within 1 mm of the inferior shoulder capsule and glenoid rim
        • is at risk during suture passage at the posterior inferior glenoid
  • Overtightening of posterior capsule
    • can lead to anterior subluxation or coracoid impingement
 

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Questions (2)

(OBQ12.268) A 27-year-old male bodybuilder presents to the office with vague, deep shoulder pain and weakness with his bench press. His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. Radiographs are normal, and an MRI arthrogram is shown in Figure A. Which of the following is the most likely etiology of his complaints? Review Topic

QID:4628
FIGURES:
1

Pectoralis major rupture

24%

(423/1735)

2

Supraspinatus partial thickness tear

1%

(25/1735)

3

SLAP lesion

10%

(166/1735)

4

Tendonitis of the long head of the biceps

2%

(35/1735)

5

Posterior labral tear

62%

(1083/1735)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The clinical presentation and MRI are consistent with a Posterior labral tear.

Posterior labral tears are commonly seen in individuals that have repeated posteriorly-directed stress across their glenohumeral joint (football linemen, bodybuilders). These patients will often present with ill-described pain deep in their shoulder joint, along with decreases in shoulder strength. Focused shoulder examinations, such as the Jahnke Jerk Test or Push-pull test, can elicit pain from posterior labral tears; however, the sensitivity and specificity of these tests remain under question.

Mair et al. reviewed the outcome of posterior labral injuries in nine athletes who underwent arthroscopic repair with a bioabsorbable tack after failure of conservative management; all were able to return to contact sports. They note that posteriorly applied forces can result in a shear-type vector that can cause posterior labral tears without capsular injury.

Bradley et al. reviewed 91 athletes with unidirectional recurrent posterior shoulder instability that were treated with an arthroscopic posterior capsulolabral reconstruction. They found that significant improvements in stability, pain, and function at a mean of 27 months postoperatively. Eighty-nine percent of the patients were able to return to their sport.

Figure A shows an axial MRI arthrogram of the shoulder with a posterior labral tear and an associated paralabral cyst. Illustration A is another axial shoulder MRI arthrogram cut showing a posterior labral tear (red arrow) and an associated paralabral cyst (yellow arrows).

Incorrect Answers:
Answer 1-4: The MRI does not show evidence of injury to his pectoralis major, supraspinatus tendon, superior labrum, or long head of his biceps.

ILLUSTRATIONS:

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(OBQ11.152) A 20-year-old college football offensive lineman undergoes arthroscopic right shoulder surgery for the injury shown in Figure A. Post-operatively he complains of burning pain in the region marked in yellow on Figure B. Which of the following nerves was most likely injured during the procedure? Review Topic

QID:3575
FIGURES:
1

Radial

0%

(6/1909)

2

Upper subscapular

0%

(1/1909)

3

Lower subscapular

1%

(22/1909)

4

Suprascapular

0%

(9/1909)

5

Axillary

98%

(1866/1909)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The posterior branch of the axillary nerve travels within 1mm of the inferior capsule of the glenohumeral joint and can be injured with suture passing devices during posterior-inferior labral repairs. The superior-lateral brachial cutaneous nerve and the nerve to the teres minor always arise from the posterior branch. Injury can lead to teres minor weakness on external rotation and sensory symptoms in the lateral arm in the region marked by yellow in Figure B.

Figure A shows an axial image of the shoulder with a posterior-inferior labral tear off of the glenoid with a small fragment of bone.

Ball et al traced the course of the axillary nerve in cadaveric shoulders and noted that the posterior branch of the axillary nerve has an intimate association with the inferior aspects of the glenoid and shoulder joint capsule, which may place it at particular risk during capsular plication or thermal shrinkage procedures.

Esmail et al used intraoperative nerve monitoring to identify axillary nerve position, capsule thickness, and provide real-time identification of impending nerve injury and function during shoulder thermal capsulorrhaphy. The use of intraoperative nerve monitoring altered the heat application technique in 4 of 11 patients and may have prevented nerve injury.

Illustration A shows the sensory distribution of the axillary nerve. Illustration B shows an arthroscopic image (viewing from anterior while in the lateral decubitus position) following repair of this posterior-inferior labral tear.

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